For years, Americans had an easy answer for anyone who questioned how much we spent on health care: Quality has a price, and we have the best health care system in the world.
Then those pesky comparative studies started coming out, and they showed that although U.S. health care can be great, it’s not great for everyone. For some, the poor quality and lack of access to care can be as bad as in Third World countries.
Even when the United States does well, there’s often no discernible benefit from our higher costs: The pills aren’t any better because we pay more for them; the medical procedures would work just as well without that big markup for administrative costs.
But how do we use this knowledge to improve American health care and make it more affordable for all?
Karen Davis, an internationally respected economist and president of The Commonwealth Fund, tackled this question in a lecture last week at Brown University.
The topic was supposed to have been “Why We’re Not Number One,” but Davis made it “Getting to Number One.” Drawing on research by experts at the New York-based foundation, which focuses on health care system improvement, as well as on studies done in Germany, the Netherlands and other places, she offered lessons for the U.S. to follow.
Davis began by outlining some of the U.S. system’s deficiencies: We spend too much, for starters – $6,102 per person in 2004, compared with $3,165 in Canada, $3,005 in Germany and $2,546 in the United Kingdom, according to the Organization for Economic Cooperation and Development; and too much of that spending goes to administration – 7.3 percent in 2003, compared with 2.6 percent in Canada, 3.3 percent in the U.K. and 5.6 percent in Germany.
If the differences seem small, Davis said, note that if the United States had the administrative costs of the best three countries, France (1.9 percent), Finland and Japan (both 2.1 percent), “we would save $85 billion a year, and that would be enough to cover the uninsured.”
Cost now limits access to health care for 40 percent of our population, compared with 9 percent in the United Kingdom, for example, and 17 percent in Canada.
Getting care at night and on weekends and holidays is far more difficult than in many other countries, so while we don’t have the long waiting times for hip replacements and cataract surgeries that other countries see, Americans often can’t get care quickly, either.
The United States also has higher mortality rates, Davis said, and we have big variations from state to state. And we have high medical error rates, lots of duplicate medical tests, and very limited use of electronic health records, which other countries use to save money and improve quality.
“We have a very expensive, fragmented, disconnected system, and it leads to a lot of waste,” she said.
To fix it, we have to start by offering affordable health insurance coverage to all, Davis said.
The Massachusetts health plan is a step in the right direction, she said. “I think we all recognize that eventually, we’re going to need a national solution,” she added, but in the meantime, the state efforts are worthwhile and can offer valuable lessons.
Second, Davis said, we must implement major quality and safety improvements.
Germany, for example, set up a national quality benchmarking system involving about 2,000 hospitals – with real-time reporting of quality indicators – and dramatically improved performance.
America has its own examples of how this can work, Davis noted. Since the health plans began reporting data on quality indicators, they have improved dramatically on those points, especially the former worst performers. Rhode Island is also a prime example, she said, with its nursing home patient and family satisfaction surveys.
Quality and cost reporting and transparency are also key, Davis said, and other countries can teach us plenty on that front.
Another lesson, she said, is that we must emphasize primary, preventive and patient-centered care. That means paying primary care doctors better, for example, and offering incentives to provide care after hours, by phone or by e-mail.
In America, she said, only about 40 percent of medical practices have arrangements for patients to see a doctor or nurse after hours, versus 87 percent in the United Kingdom and 95 percent in the Netherlands.
In Denmark, there’s a full-fledged system that kicks in at 4 p.m., she said, with doctors who work the after-hours shift and care for patients by phone, by e-mail and in person, relying on electronic medical records to pull up needed information and send a report to the patients’ regular doctors.
Health care IT is another field where there are plenty of lessons to be learned, Davis said.
Electronic health records, still a novelty here, were being used five years ago by 90 percent of doctors in Sweden, 88 percent in the Netherlands and 58 percent of U.K. doctors. Having a single organization that runs the IT system seems to help, she noted – in Denmark, for example, a nonprofit that operates at arm’s length from the government connects doctors, pharmacies, hospitals, etc.
Lastly, she said, it’s important to provide incentives for providers to improve quality and participate in improvement efforts. Rhode Island’s RIte Care is a great example of that, she noted, with incentives that have reduced emergency-room use and significantly improved prenatal care, infant mortality and use of preventive care.
The good news is, Rhode Island is “already a leading state” on many of these fronts, Davis said. But she acknowledged that there are bigger forces at play – from the powerful pharmaceutical industry to health insurers with a stake in not changing things.
One audience member asked whether the huge importance of health care as an employer and economic driver works against efforts to control costs. Christopher F. Koller, Rhode Island’s health insurance commissioner, built on that question, playing devil’s advocate:
“Is having 17 percent [of the population] uninsured just an unfortunate side effect to what is really a good strong part of our economy?”
“Well, it does mean fewer jobs if we avoid repetition of tasks, and have fewer people hospitalized,” Davis replied. “But I just don’t think it’s a problem. We have an aging population; there’s going to be a growth in use of services.”
Her colleague Maureen Bisognano, chief operating officer of the Institute for Healthcare Improvement in Boston, makes the case for reducing wasteful spending in a different way, Davis said. “She says it is disrespectful of your staff to waste their time, and it’s disrespectful of your patients to waste their time.”
