Rational Arguments

Wow.  I’m taking a beating over at HuffPo.  Who knew I was such a corporate shill?

Anyway, I was giving a class today on quality in health care systems, and I added a few new slides.  I thought they might be of interest to all of you, as well. As always, these are OECD Health Data for all available years since 1993.  The US is in bright red.

First up, the number of people who die every year of a myocardial infarction (heart attack) per 100,000 people:

Not so good, huh?  With all the talk about how we get the best drugs and technology – plus the way other countries have “wait times” or “rationing”, you’d expect them to have much more death.  How about deaths from cerebrovascular illness (strokes):

Well, at least we do better here.  Of course, France is still beating us.  Socialists.  We must be the best at respiratory illnesses like asthma, right?

Um, no.  We do really poorly, actually.  But cancer?  Everyone knows that’s our thing.  That’s where we really have the goods.  Hmm?

Now remember how poorly the US did on those other metrics of quality?  Think of these when someone retorts that in the US we focus on curing disease and preventing death.  Not so much.

Yesterday on the radio I talked about quality in the United States’ health care system.  I mentioned a handful of metrics that could be used, and that they showed our quality to be surprisingly poor.  And – inevitably – I got an email like this:

According to an article I read not to long ago (sorry, can’t remember the publication)We are so far down on that certain list because of the way the different countries report those numbers. Supposedly some of the countries don’t count infant deaths that occur within 24 to 48 hours of birth. While some count those but do not count deaths as a result of certain parent induced problems like Fetal Alcohol Syndrome. According to the article I’m referring to the U.S. counts all infant deaths regardless of the time frame or reason. If I remeber correctly most of these “ranking” lists were coming from the WHO and each country had its own reporting standards as to how they counted infant mortality rates.

This is a common retort to the use of infant mortality as a metric.  Somehow the source is always real, but unknown.  But here, look at the data:

We are the worst.  Do you really think that every other country is massaging their data, year after year, in order to make themselves look better?  If so, why don’t we do the same?  What would be the motive behind the United States choosing to report their data in such a way as to make itself look bad year after year after year?  Can you come up with a reason?

And even so – I don’t care.  Every metric is flawed.  Pick another.  How do you account for our terrible maternal mortality:

Or percentage of kids immunized:

Or life expectancy:

Or number of physicians:

Or – most importantly – preventable years of life lost:

We do surprisingly bad in all of them.

Which is the more logical conclusion: (1) We have a separate excuse to explain why the measurements are wrong in every metric you might use, or (2) our system just isn’t that good?

*All of these are OECD health data comparing the 10 richest rountries in the world.  The United States data is self-reported.  Data are not available for China and South Korea.

Back from my vacation/trip.  No surprise – nothing has changed.  Lots of bluster, lots of politics, little substance.

But one bit of data caught my eye while I was away.  It has to do with life expectancy.

Before I show it to you, let me say that I know life expectancy is not a perfect metric of quality in a health care system.  There are other factors that can effect the life expectancy of a population.  That said, you would expect that we would do better than this:

That’s a slide I made using OECD Data that use regularly in talks about health care quality.  You’re looking at the expected life expectancy of the total populations (at birth) of 8 of the richest 10 countries in the world.  The United States not only has the lowest life expectancy, it has had the lowest consistently for a long time.

But this weekend, I saw something even more striking:

Here, you are looking at health care spending per person (on the left) versus life expectancy (on the right).  Here are the take home points:

1. The United States spends WAY more per person on health care than any other country.
2. The United States has a pretty poor life expectancy, especially when you see how much we’re spending.
3. The United States is the only country (besides Mexico) without universal health coverage.
4. The United States has some of the lowest average number of doctor visits a year.

Can someone justify this for me?  What’s the money for?

A reader pointed me to an excellent piece in The New York Times Magazine on efforts to improve quality in the heath care system.  It’s quite good, and I recommend you read the whole thing.  But, like Ezra, I actually noted that the article picked up on an important point; improvements in quality are often not accompanied by improvements in revenue:

But in our current health care system, there is no virtuous cycle of innovation, success and expansion. When Intermountain standardized lung care for premature babies, it not only cut the number who went on a ventilator by more than 75 percent; it also reduced costs by hundreds of thousands of dollars a year. Perversely, Intermountain’s revenues were reduced by even more. Altogether, Intermountain lost $329,000. Thanks to the fee-for-service system, the hospital had been making money off substandard care. And by improving care — by reducing the number of babies on ventilators — it lost money.

See, when I say we’re spending $2.5 trillion in health care, much of that is going into other people’s pockets.  We can only reduce health care spending by reducing the amount of money going into other people’s pockets.  This will make many people unhappy.  This will make them scream and shout.  It will be unpopular and hard.

And that’s why no one is talking about it.  Even waste is viewed positively by many sectors in the health care market.

I’ve been arguing for a long time that preventive medicine, while often producing good outcomes, does not always save money.  It’s something we should put in the quality column, not the cost column.  This hasn’t stopped lots of people, including President Obama and Larry Summers, from saying it’s one of the areas we could reduce cost.  But CBO director Douglass Elmendorf agrees with me:

“Some preventive medicine is cost-saving as well as health improving,” Elmendorf said, when asked to respond to Summers’ point. “A much larger share is health improving but cost increasing. And there is some share that is just terrible because it makes health worse and costs money.”

“Not everything that sounds good for health is good for the budget,” he added. “[A] general increase in preventive medicine may or may not have the sorts of favorable budget effects that people expect. That surprises many people. But the very important [point] here is that for somebody who ultimately gets the disease, it is cost saving as well as health improving to catch it early. But to catch it early in that person you generally have to deliver the treatment or administer the test to a much larger set of people, most of who will not ultimately get that disease.”

Look, I’m not saying preventive medicine isn’t a good thing.  It is.  It’s important to recognize, though, that when you make people live longer (a good thing) they can cost more money overall (a bad thing).  But let’s face it, the good of extending life is often worth the increased lifetime costs of care.  We have to abandon the idea that the only things worth doing are both good in terms of quality and cost-savings.  Trade-offs are natural.  Sometimes things are worth doing and worth paying for.