Friday, May 29, 2009

United States spends more per capita than any other system and not by a small amount

Original Link:

By MarkH

A dishonest campaign has started against healthcare reform in this country and the first shot has come from Conservatives for Patients Rights (CPR), a group purporting to show that patients in universal health systems suffer from government interference in health care. To bolster their argument, they have a pile of anecdotes from people around the world who have suffered at the hands of evil government-run systems. The problem, of course, is that anecdotes are not data, it is impossible to determine the veracity or reasonableness of these claims, and there is no way, ethically or practically, to respond to claims against doctors in these systems.

And should we be surprised? Every other country in the industrialized world has universal healthcare. Some are government run, single payer systems, others are mixtures of private and public funding to guarantee universal coverage. I would be shocked if you couldn't find a few people to provide testimonials about how they're angry at their coverage. After all, Michael Moore made an entire movie about such testimonials against our system.

So what do we do? How do we find out the truth when the ideologues and financially interested parties have started a campaign to muddy the water with anecdotal attacks?

We look at the data of course. And surprise, surprise it doesn't support CPR's assertions that our system couldn't stand some improvement.

During the next couple of weeks, I think we should talk about what healthcare looks like here in the US and around the world. Rather than a few horror stories, let's take an in-depth look at what's happening in universal systems, and whether or not we should consider a change.

Let's start with an examination of some data from the literature on different experiences people have with these healthcare systems.

The usual complaints levied against the universal systems are that they will ration care, you have long waiting times for doctors, and quality of care then suffers. It seems to be a given that in the United States with our private system that we have better access, better quality, and fewer mistakes. But what do the data show?

Let's start with the Health Affairs article Toward Higher-Performance Health Systems: Adults' Health Care Experiences In Seven Countries, 2007[1], a survey on healthcare experiences in the US, versus the universal healthcare systems in the UK, the Netherlands, Germany, Australia, New Zealand and Canada. These systems are highly varied, and I hope to write about their benefits and drawbacks in the next few days. But briefly,

the US is a non-universal patchwork of public and private spending, drugs and procedures may be subsidized by insurance

the UK is completely single-payer with private care as an option, all drugs and procedures are paid for

Canada is single-payer with provinces deciding how health care is spent and strict limits on private care, prescription drugs are heavily subsidized,

Australia has a public baseline access to physicians with subsidization of private insurance and option of private care, prescription drugs are heavily subsidized,

New Zealand has universal public health care, primary care and prescription drugs are subsidized with some cost sharing, and private care is an option

the Netherlands has a system of obligatory private health insurance (like a nationwide Massachusetts system), premiums have a flat rate for all citizens, with subsidies for poorer people who can't afford insurance premiums. Individuals pay for about half, and employers pay for about half, with government making up the difference.

Germany has a system of mandatory insurance with purchase of access to one of several hundred "sickness funds" paid for by employers, there is a private option for those who afford it, and those who cannot or are unemployed are subsidized by government.

Each of these systems is very complex, most are a mixture of public and private hospitals, and public and private insurance. Universal health insurance, it should be clear does not mean we have to have a single-payer system like Canada, or like Britain as the anti-reform ads would suggest.

In their first figure, this table is a comparison of the per-capita costs of the different healthcare systems.

Note the United States spends more per capita than any other system and not by a small amount. We spend almost twice as much as the next nearest spender, Canada, and this without covering all of our citizens. We also spend more of our GDP than any other country, almost twice as much as any other country. Note, most other countries have a high percentage of patients enrolled with electronic medical records, a system that makes sharing of information between facilities (currently a major cause of redundancy in expenses) more efficient. Note also that universal doesn't require primary care providers be the gatekeepers. Other systems exist that allow self-referral to specialists.

The Commonwealth Fund, which sponsored this study, has a figure in one of their online chartbooks of health data that summarizes how we spend nicely.

The entire presentation is fascinating and worth a look if you have time. Almost universally we pay more for less. We pay more per capita for fewer hospital beds, we pay more per capita for fewer ICU beds, and pay more for ICU stays despite patients staying for fewer days, we have far fewer long term stay facilities, we spend more on fewer practicing physicians per capita, and for all that we perform worse in indices of mortality, and control of chronic disease.

But are people happy with these systems? Not surprisingly, no one is ever really happy with their healthcare:

Almost all systems have a high number of citizens who think it needs significant changes, although only the US system has a 34% rate of people desiring it to be completely rebuilt, almost twice that of any other country. For the most part, the belief that their medical systems will provide high-quality, expert care, is similar across these countries. This table addresses another critic complaint though. What about wait times? Some countries do have a clear problem with elective wait times for surgery. Canada and the UK are the worst in this regard, but several universal systems have wait times that appear to rival or surpass those in the US. Worse, US citizens complain more of access problems than any other country, with 37% of respondents forgoing care, not seeing the doctor or filling prescription because of issues of cost

Now, on the issue of access, despite claims to the contrary, in most of these systems access to a doctor is rapid, with appointments available in the same day:

In fact, aside from Canada, we were least likely to be able to get an appointment on the same day, and most places could provide access to a doctor in an ER faster than in the US. So is access really worse in universal systems? It would appear that in most universal systems, doctors in clinics and the ER are more available than in the US.

The remainder of the data compares perceived quality of care, and coordination of care between primary care and specialists, and for the most part, the systems are equivalent according to the subjective experience of those surveyed. In the US, there were more complaints about expense of prescription medications, and poor coordination of care - I suspect due to poor penetrance of the electronic medical record.

So, after seeing some data on more than the few horror stories from health systems around the world, are you convinced that universal systems will mean longer wait times? Poorer care? More expensive care? I believe the data suggests more people around the world in these systems experience less of these problems than those of us in the US. We spend more, almost twice as much as any other country. Despite that, our wait times for physicians are worse, we pay far more out of pocket for prescriptions and copays than any other system, we spend more on administration of health care than any other country, we have more people who avoid seeing the doctor for fear of costs, and we are more likely to say we want our system scrapped. In an update to this analysis [2] the Commonwealth fund found that in deaths which were amenable to health care interventions the US performed worse than the other 18 industrialized countries to which it was compared. If we performed as well as one of the top three countries, we would eliminate about 100,000 excess deaths a year. Which is the real horror story?

The plural of anecdote is anecdotes, not data, so don't believe the horror stories, look at the total experience in these systems to find a better approximation of the truth.

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