U.S. Healthcare Better than Europe

Atul Gawande may be emerging as the anti-Czar of American healthcare reform. I wonder if he drives his old automobile to work every day. Gawande makes the case, as I describe in my last post, that a model of healthcare reform that delivers better care at a lower cost is already well established in the U.S.

He describes this model in a piece he co-authors in the New York Times. He and his coauthors scoured the country for "hospital referral regions" that provided cheaper care on average, according to Medicare costs, but ranked higher than average in quality outcomes. What is the secret?

He doesn't lay it out nearly so well in this short article as in the New Yorker piece, but basically it is this: the medical communities in the 306 models of success that they identified got together (or the clinic administrators laid down the law) and they decided to focus on quality outcomes. Wow. Who'da thunk that could work? It certainly seems to.

This is hardly a secret, but it's hardly what we have been arguing about either. The President's defenders have argued that a lot of the elements in the Gawande model of reform are in the various Democratic plans. Maybe. But the debate so far has focused almost solely on the "public option," with one side greatly fearing it and the other side deeply desiring it. Both the fear and the desire may be all out of proportion. The result seems to be favoring the fearful, as public confidence in the Democrat's proposals has been steadily eroding, along with the President's approval ratings.

Gawande et. al. make a very bold claim for their model:

If the rest of America could achieve the performances of regions like these, our health care cost crisis would be over. Their quality scores are well above average. Yet they spend more than $1,500 (16 percent) less per Medicare patient than the national average and have a slower real annual growth rate (3 percent versus 3.5 percent nationwide).

That would be great if it were true. It may be true, though it is not substantiated in the article. But it is important to recognize that the U.S. system as a whole already delivers healthcare outcomes that are as good and sometimes much better than do state-heavy, European systems.

Samuel H. Preston and Jessica Y. Ho authored a study, published by the University of Pennsylvania's Population Studies Center, that compared five year survival rates for the most deadly diseases in the U.S. with rates in Europe and other developed countries. Here is the beginning of their summary:

We have demonstrated that mortality reductions from prostate cancer and breast cancer have been exceptionally rapid in the United States relative to a set of peer countries. We have argued that these unusually rapid declines are attributable to wider screening and more aggressive treatment of these diseases in the US. It appears that the US medical care system has worked effectively to reduce mortality from these important causes of death.

This conclusion is consistent with other evidence that we have reviewed on the performance of the US health care system: screening for other cancers also appears unusually extensive; 5-year survival rates from all of the major cancers are very favorable; survival rates following heart attack and stroke are also favorable (although one-year survival rates following stroke are not above average); the proportion of people with elevated blood pressure or cholesterol levels who are receiving medication is well above European standards.

The comparison of cancer survival rates in the U.S. and Europe are astounding. Here is a chart

5-year survival rate (%)		United States	Europe
Prostate Cancer		99.3	77.5
Skin melanoma		92.3	86.1
Breast		90.1	79.0
Corpus uteri		82.3	78.0
Non-Hodgkin lymphoma		62.0	54.6
Stomach		25.0	24.9
Lung		15.7	10.9
All malignancies	(men)	66.3	47.3
All malignancies	(women)	62.9	55.8

 

This is not a system "in crisis," at least with regard to healthcare outcomes. Persons in the U.S. are more likely to be tested and more likely to be effectively treated for a range of deadly cancers than similar persons in Europe.

I have little doubt that the U.S. system can be made more cost-effective by the kind of reforms that Gawande et. al. advocate. We may be able to improve outcomes across the board. But the "public option" and "single-payer" debates have nothing to do with it. One of the reasons that the Democrats have, for the second time, lost public confidence on this question is that they have steadfastly ignored what most Americans can tell for themselves: that the American system is delivering very good healthcare.

One of the reasons that American healthcare is so good is that it relies on self-organizing systems. The models Gawande et. al. produce are locally generated, by people who know the conditions they are dealing with. They are not mandated from the top. Maybe the top can give the system as a whole a push to follow the best models. But trying to replace the system with another, modeled on Europe, is not warranted by the facts.

Comments

[Ken]

I don't think anyone is arguing that we have good healthcare in this country. We certainly have the research, technology and perhaps brightest specialists... FOR THOSE THAT CAN AFFORD IT. The problem is, we have hundreds of thousands without insurance and hundreds of thousands more that are under-insured. For millions more, spiraling insurance costs have cut into our available income to the point where our ability to pay for basic necessities are affected. That causes people to go into debt that they don't have the ability to repay, go into forclosure on their homes, banks going out of business... and you know the rest of the story.

So it is not that we have broken healthcare, as much as we have a broken healthcare system. That is why the WHO ranks the US system 35th in the world and life expectancy as 27th in the world,behind virtually all advanced nations. This, despite our costs measured as %GDP as high as #2 in the world (behind only Marshall Islands).

The problem is exasperated even more with high unemployment, and ridiculously rising pharmaceutical, hospital and insurance rates, mostly in the name of higher profits, bloated executive salaries, and wall street expectations.

In my opinion, Insurance is the biggest culprit. High profits, executive compensation, and bloated marketing budgets, none of which contribute to taking care of our medical needs. In most of the top ranked healthcare systems, you have either single-payer systems or private insurance that are NON-Profit companies.

[A.I.]

You read more into the data than the authors of the U of Penn. study intend. They conclude there summary by saying: "The question that we have posed is much simpler: does a poor performance by the US
health care system account for the low international ranking of longevity in the US? Our answer is, “no”." They make no other claims.

The study did not address whether or not a public option might improve U.S. results or whether our system is in crisis. Thus it does not support a contention that the U.S. system is superior overall, is not in need of improvement or is not in crisis.

Nor can one conclude privately-funded health care is superior. It is possible the publicly-funded portions of our system are superior compared to those in other counties thus offsetting any shortcomings of private funding. Whatever the case, the fact remains that Americans spend far more for health care and continued growth in that spending as a percentage of GDP or personal incomes can not be sustained. Add to that the high rates of uninsured and under-insured despite what we spend and it would seem safe to conclude we do have a system in crisis.

[FascistSocialist]

Ken Blanchard, you would do well to actually back check where the statistics you cited come from. When they are comparing "Europe" and "the US" in that Lancet Oncology Study, they are including such places as Slovenia, The Czech Republic, and Poland in "Europe" and excluding wealthier countries like Portugal and France. Also the US oncology data they use for this study only covers a small fraction of the total US population.

Many individual European countries beat us on several cancer treatments where Europe averaged worse than the US as a whole during those two particular years the study covers (2000-2002).

Also, they left out half of the listed cancers where Europe (even with those basically 2nd and 3rd world countries) averaged higher than the US. Like:
hodgkins lymphoma and testicular cancer.

Not to mention there were some countries, like Iceland, that beat us across the board for every single cancer listed. I would also like to point out that participation in the submission of data for the US statistic was voluntary to the point where it is dubious the the worst performers in the US would be likely to volunteer to submit their data to the registry.

Plus, people who are not treated for cancer are not in the US statistics, since we don't cover about 16% of our population those who die of cancer in that group are not included in the US statistics. Also, it may be higher yet since a significant number of the very sick are purged from private insurance rolls and left untreated because of "pre-existing conditions".

So, completely ignoring the rest of the post I would say you should probably retract that section.

I would also venture to guess that hundreds of thousands have died in the US from complications with unnecessary procedures and that Europe does not have a similar problem.

[lexrex]

ken, much of what you say in your first paragraph is true. but one major reason why health care is so dang expensive, here, is because of the socialized systems in other countries that cap what docs, hospitals, and pharmaceutical companies can charge.

when a pharm company sells a pill in canada, for instance, it can't recoup all of the development and invention costs, because of the price caps and mandates that require generics. so, it's forced to balance their loss out by raising the prices in free-market countries, such as the united states. so, in a way, our country is subsidizing the lower cost of medicine in other countries.

[FascistSocialist]

"Many in Congress and the Obama administration seem to recognize this. The various reform bills making their way through the process have included provisions to protect successful medical communities by incorporating payment approaches that reward those that slow spending growth while improving patient outcomes. This is the right direction for reform." The Atul Gawande article you're citing from the NYT.

[KB]

A.I.: You are quite correct that the Penn. does not examine the relationship between public and private healthcare, on the one hand, and healthcare outcomes, on the other. I am certainly not making an argument in favor of correlation.

But it does knock the wheels off the claim, frequently stated all over the debate, that the American system is worse than Europe in terms of healthcare outcomes. It isn't. If the opposite were true, and survival rates were appreciably better in European-style, state provided healthcare systems, that fact would certainly be repeated over and over by the proponents of a "public option," wouldn't it? Knowing that the U.S. system produces better outcomes is surely a very good reason for wanting to make sure that those outcomes are maintained.

Ken & FS: I am responding in my next post. Thanks to all for the comments.

[KB]

FS: no problem about the repeated posts. That sort of thing happens a lot with this software.

Minor point: It's not, as I acknowledged, that the kind of reforms Gawande advocates are entirely neglected by proposed legislation. It's that they aren't at all what everyone has been arguing about. Lust for and fear of the "public option" has dominated the debate. I think that this fact is making any effective reform less likely.

[FascistSocialist]

I think death panels has dominated the debate and is being pushed by republican officials as much as crazy talking heads, even supposed republican moderates like Chuck Grassly of Iowa. It's a non-issue, when there are so many REAL issues and perhaps areas of actual contention, it's depressing - and I have to say that Miranda and you also to an extent are guilty of pulling the discussion in that non-productive direction. I'm glad to see you're no longer on that path.

[Daniel]

Has anyone in the US seen the Commonwealth Fund's report "Why Not the Best?"

Fact: The US has by far the highest infant mortality rate of any industrialized country on earth. Whether you look at WHO or CIA data there are over 30 countries beating us; including some non-industrialized countries.

Fact: The US has one of the lowest life expectancies of any industrial country.

Fact: The CommonWealth Fund’s study found that the US had the highest “Mortality Amenable to Health Care” of the 19 industrial nations examined. Out of 100,000 people per year, France had 65 people die from conditions preventable by adequate health care. The US had 110.

Fact: The US spends more than twice what any other country spends on health care; and our rate of increase is greater than any other major nation. And while spending an additional $6,000 per person per year more than any other country we get more dead babies.

[FascistSocialist]

Ken, I know you're probably not a statistician, but these percentages mean very little without knowing the per capita rate. For instance the US might have 99.9% 5 year projected survival rate for prostate cancer and European countries might have 75% 5 year projected survival rate. But, since Europeans are only diagnosing the people who actually are at risk of being affected adversely from their prostate tumor it is entirely possible that you end up with the following:

If you live in Europe you have a 2 in 100,000 chance of dying from prostate cancer.
If you live in the US you have a 4 in 100,000 chance of dying from prostate cancer.

But as we're diagnosing say... 400% more people, it doesn't matter that we have 100% more people dying per capita because we have a much higher % of people diagnosed with prostate cancer and this results in an absurdly biased statistic like 99.3 vs 77.5

[N.J.]

One problem with attempting to compare things like rates of cancer as some form of
evidence that the U.S. has a better health system than Europe does making the argument false is that cancers are relatively rare compared to other conditions that effect health. And of course the older the median age of mortality is for any given population, the higher the rates of cancer will be.

There are only three factors that can be used to determine how good a health care system is. The first is infant mortality. A child will have a better chance of surviving the first year in a nation that has a better health care system. The United States falls down on this statistic. The second determinant is the median age of death in a country. The United States SHOULD have a better record on this than it does, primarily because we are a diverse nation. Diversity leads to a better gene pool, which is more favorable to dominant genetic qualities, while lack of diversity results in the recessive genes being expressed more often. Yet the United States falls behind other nations in Europe, some of which have little ethnic mixing.

Finally the most important statistic is not merely how long individuals live, but how long they live in good health. The United States is last of all the developed nations in this key measure. Americans spend more years at the end of their lives in poor health compare to other nations which have some form of universal health coverage.

The argument that universal health insurance will some how destroy the private sector has been proven false many times. The private health sector has remained in existence in every developed nation that has provided some form of universal health insurance and in all cases the private health sectors of the economies of Europe, Japan, New Zealand and Australia are in fact thriving parts of their economies. Even in Great Britain there is a very economically sound private health insurance sector. In fact most British citizens enroll in the National Health System and also purchase some form of private insurance.

When it is stated that the British spend half as much money on health care as the United States, they are not merely counting the dollars spent in the National Health System. They are giving the total sum paid for both public and private health care.

The fact is that the existence of a public option makes even private care less expensive. The average English citizen who is on their NHS and who decides to have his NHS public primary care doctor give him a referral to a private specialist to treat any given health problem still spends considerably less on the total health bill than an American in the same position would.

Every country in Europe has a thriving private health system. Largely it is because their universal health care is based on private doctors, private hospitals and dare I say it, coverage is given through private insurers.

The difference is that the private health insurers in Europe run exactly the same way they used to run in the United States before 1980. That is they legally have to be not for profit corporations. This was once the case in the United States and while it was the case, health care was affordable in the United States.

The skyrocketing cost of health care began almost at the same time that the companies were allowed to become "for profit" corporations.

And having them become "for profit" has had nothing to do with the advances in medical care that has occurred since 1980. The health insurance industry does not provide much money for medical research. The U.S. government provides much more.