Alan M. Preston, Sc.D.
Professor, Texas Health and Science University, Austin, TX
How can a government improve a healthcare system? The answer to that question is what I have heard from students over a number of years when such a broad question is asked in such a manner. Their answer was: “It depends.” And they are right! It does indeed depend! When policymakers say we need “healthcare reform,” what does that mean? Healthcare is an all-encompassing word. And in this hyper-politicized world we live in, what exactly do we want to improve and why should we improve it?
Recently, a university professor made a strong point to say that the healthcare system in the United States (U.S.) needs a lot of work and is a terrible system. Of course, I had to ask the 2.5 trillion-dollar question: what exactly is wrong and why did she think we had a terrible system? She told me that our [the U.S.] healthcare system ranks 37 when compared to other healthcare systems in the world. Imagine, we spend 2.5 trillion dollars on healthcare every year, yet we only rank 37th in the world. How can that be?
When one looks at a “quality” measure to assess the quality of healthcare, does that metric really tap quality of care received in the U.S.? On the other hand, is the metric so far off in tapping quality it would be like using a thermometer to measure the height of a person? Obviously, that would be the wrong instrument to measure height. I was told that the World Health Organization (WHO) was her source and, thus, a reliable source. As an informed healthcare scientist, needless to say, I was skeptical. I looked at the report and, just as I thought, the first sentence of the report is quite telling: “Evidence that other countries perform better than the U.S. in ensuring the health of their populations is a sure prod to the reformist impulse.”
This is revealing from the start from a couple of perspectives. One is that there has been a long-standing agenda by WHO to pressure the U.S. into a single payer system and the WHO continues to support that agenda. Whether there is a single payer or multiple payers, the patient outcome may be improved for the delivery of quality healthcare to compliant patients.
The source of financing can have an impact on outcomes; however, going from a competitive payer system to a monopolistic payer system run by the government is a political desire. In addition, whether we have a single payer or multiple payers will not make Dr. Smith treat his patient with better or worse care per se. Most doctors and caregivers treat patients the same regardless of which payer is attached to the patient. They do not say, “Well, since Joe is with Blue Cross (BCBS) and not Humana, let’s give Joe worse care because BCBS is not paying us enough.”
In addition, the report indicates that their ranking is based on the following:
- contributing to critical social objectives;
- improving health, and citing infant mortality rate (IMR);
- reducing health disparities;
- protecting households from impoverishment due to medical expenses; and
- providing responsive services that respect the dignity of patients.
As we can see by the list, there is not a direct measure of “true quality” care. The list is largely about social objectives. It may be okay to have some social objective; however, it is a far cry from a direct measure of what is happening in a doctor’s office or a hospital.
It is important to acknowledge that the WHO does a lot of good in many of the 191 countries where they provide assistance to countries for their citizens. Thus, I am in no way condemning the wonderful contributions of the WHO organization around the world. I also rely on the plethora of data the WHO produces every year and they should be commended for those activities. My very narrow criticism is WHO and governments that tend to politicize healthcare reform under the guise that the reform will improve care; when all too often it makes healthcare more expensive, bureaucratic and challenging for those who provide it and those who attempt to receive it.
Going back to the WHO list, the first one on the list is about contributing to critical social objectives. What does that mean? Who decides what a critical social objective is? In addition, how does that improve the care given by a doctor? Was the doctor not providing a procedure because some critical social objective is not being met? My guess is the critical social objective is really about free care (socialized medicine). Yet, we as a nation are already spending 2.5 trillion dollars per year on healthcare, of which most is financed by private employers and the federal government for programs such as Medicare, Medicaid, Tricare, the Veterans Administration (V.A.), etc. According to the WHO, that is not good enough; we need more free “social programs” in order to be considered a nation providing quality healthcare. My view is that every nation needs to decide how their country is organized economically and then implement a system that embraces the respective sovereign nation’s economic identity.
Improving health is number two on the list. Again, in what area do we improve health? One metric they use to show how poor the U.S. is in healthcare outcomes is IMR. I love it when people cite this as the sole reason our healthcare system in the U.S. is deplorable; it is the classic use of a thermometer to measure the height of a person. It seems obvious to me, but many actually think that IMR is a good “proxy” metric that represents the “quality” of healthcare in the U.S. That is simply not the case. Here is what the WHO report indicates about IMR:
“Despite the claim by many in the U.S. health policy community that international comparison is not useful because of the uniqueness of the U.S., the rankings have figured prominently in many arenas. It is hard to ignore that in 2006, the U.S. was number one in terms of healthcare spending per capita but ranked 39th for infant mortality.” http://www.nejm.org/doi/full/10.1056/NEJMp0910064
This was the drumbeat of the Democratic Party in passing the Patient Protection and Affordable Protection Act (PPACA), affectionately called Obamacare. It was the main talking point for all Democrats attempting to get their constituents to embrace such a major reform. Yet seven years later, are we doing better in the healthcare outcome of IMR? No, we have slipped down a bit to 58! Obviously, the PPACA did little to improve the world rankings of the U.S. regarding IMR. To be fair, however, I do not think we should indict the PPACA because, as I indicated supra, IMR is a poor measure of quality performance. Likewise, we should not pass sweeping healthcare reform legislation based on a faulty premise that somehow the U.S. is terrible when compared to other countries when it comes to healthcare quality when the sole metric (IMR) for coming to such a conclusion fails to tap quality of healthcare.
In 1935, IMR was a reasonable measure of how effective our healthcare system, and, in particular, doctors and hospitals were in mitigating the impact of IMR in the U.S. due to the quality of care the mother received. The infant mortality rate in the U.S. in 1935 was 55.7 per 1,000 live births. In 2000, it went down to 6.9 percent, which was a decline in IMR of 3.1 percent per year from 1935 to 2000. In 2016, according to the CIA World Fact Book, IMR is now at 5.87 percent. Much of the gains were indeed because of improvements in our healthcare system. However, 6.9 percent of improvements will need to come from the individual, and all the money in the world to improve the IMR at the healthcare system level will not produce significant gains as we have observed in the past. Thus, using IMR as a metric to judge the U.S. on our healthcare system quality is no longer an appropriate measurement.
First, for a baby to become an IMR statistic two events must occur: the baby must be born, and then, within 12 months, the baby must die. The two most important determinants of infant survival are birthweight and length of gestation. In 2006, the mortality rate for low birthweight (<2,500 grams) infants was 55.4 deaths per 1,000 live births. And for very low birthweight (<1,500 grams), the IMR is about 240 per 1,000 live births or about 24 percent of those babies die during the first year of life. In 1960, about 75 percent of very low birthweight babies died in the first year of life. Most of the improvement was indeed due to medical advancements. We can now save the mother and the baby by performing c-sections and incubating the baby. However, these complicated procedures are not foolproof, and for every 100 mothers on whom we attempt these delicate procedures, we save about 80 percent of the babies and their mothers. Thus 20 percent are not successful and add to the IMR statistics.
Furthermore, the U.S. is a very diverse nation. The diversity happens to be one of the drivers to a higher IMR. If we compare whites to blacks in IMR rates, there are stark differences. Those differences are not due to a poor quality healthcare system. In 2007, the black IMR was 13.2 percent, while the white IMR was 5.6 percent. And when we measure the largest driver of IMR, it happens to be Sudden Infant Death Syndrome (SIDS). SIDS, maternal complications of pregnancy, unintentional injuries and placental complications, together account for 62.1 percent of all infant deaths in 2007. And a majority of SIDS happens between months five and nine, a time that the baby is not in a hospital system nor in the care of a physician.
Blaming the healthcare system for what may appear to be an unpreventable accidental death while babies are in the care of their parents is an inappropriate indictment on the tremendous quality of care the U.S. delivers every day to our citizens as well as many foreign visitors. Thus, if people really think they get better care in Italy, ranked number two by the WHO or Greece ranked 14 or Costa Rica ranked 36, then I suggest they fly there to get their high quality care. Yet it is remarkable that heads of state in most of the countries from ranking 1 to 36 all come here to the U.S. when they have a serious healthcare condition. Why is that? Because the U.S. has the best quality of healthcare in the world! Nevertheless, the WHO is not measuring quality of healthcare; they are measuring how close we are to socialized medicine and a socialized country. On that metric, I wish we were closer to 191 as opposed to 37. The U.S. has a unique history in the founding of this great country called the U.S. Constitution and the Bill of Rights. As an independent capitalistic sovereign country, we should maintain our sovereignty and not be influenced by what other countries are doing if it does not fit the American tradition or identity.
Another point about “rankings” is that many people look at a number and simply hear that number from an organization like WHO and come to a quick conclusion without ever giving it a second thought about how they came to such a conclusion or worse, what their agenda may be. We all too often just swallow the Kool-Aid and repeat it over and over. In my due diligence in the purchase of a hospital, I wanted to see the incidence rates of certain diseases to assess the likelihood of admissions by disease. I came across this chart. (See Figure 1).
Now as you can see, there are two things worth noting. One is there is a steady decline in the incidence of prostate cancer. Does the WHO look at outcomes like this when comparing “quality” of care in the U.S.? No! There should be metrics that tap quality of healthcare and unfortunately, the U.S. is not receiving the accolades from the WHO because the WHO is politicizing the world “quality” rankings based on social agendas and not on direct quality measures. There seems to be a blatant disregard for improved outcomes by disease as appropriate quality metrics, which is a major flaw in attempting to “measure” the quality of healthcare.
The third item on the list has to do with the comment of the WHO regarding “reducing health disparities.” If we want to reduce “disparity” then we might want to consider deporting those citizens that are causing the “averages” to look bad (those who have poor IMR) when we are compared to a “homogeneous” country like Sweden. Obviously, that would be a ridiculous suggestion though it would decrease disparities. We are the most diverse nation on the planet and as such, if you want to compare apples to apples and not oranges, then an adjustment is warranted to deal with the outliers like age differences between nations as well, since age is an independent risk factor.
The fourth point on the list focuses on protecting households from impoverishment due to medical expenses in a country. The U.S. achieves this objective by offering Medicaid to the poor. In addition, we provide subsidies to those who do not meet poverty benchmarks as defined by the federal government, but could have incomes up to 400 percent of the Federal Poverty Level. Thus for a family of four, they would be eligible for a subsidy if they made around $100,000 dollars per year. How many countries are considering people “poor” who make $100,000 per year?
Last on the list is providing responsive services that respect the dignity of patients. In our capitalistic system, the U.S. provides strong protections regarding individual freedom and liberty; therefore, we should rank as one of the best countries in the world in protecting the dignity of patients.
Thus, when we look at how the U.S. ranks in “quality” as defined by the WHO, we are not performing well compared to other countries. Yet, if one were to look at the advances in medical care, prescription drugs, medical equipment and treatment centers, availability of healthcare providers, we lead the world in providing the best care. One would not know that by looking at the rankings of the WHO. Anyone who has traveled the world knows which country offers unparalleled quality in healthcare. That is the U.S. by a long shot, regardless of how the WHO ranks the U.S.! In conclusion, when comparing the quality of healthcare around the world, consider the criteria the WHO uses to rank care quality. Be cautious of the comparisons made by the WHO when commenting about “quality” when they truly do not measure it directly.