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October 29, 2004

INTERNATIONAL: US primary care looks poor in comparison to other nations

Not two weeks ago Bush yet again trotted his dad's old line about the American health care system being the best in the world. A little earlier this fall Robert Centor at DB's Medical Rants said that primary care in the US "trumped that in the UK". I posted my objections to both Bush and to Dr Bob on TCHB before, but I didn't have a lot of proof in terms of hard data.

Well I do now.

Health Affairs has published the latest Commonwealth Fund report, (survey research was conducted by my ex-colleague Kinga Zapert and her group at Harris Interactive), on primary care in 5 English speaking countries. Here's the Press Release and here's the whole article. Essentially on every measure, apart from peventative screening, on an absolute basis American primary care performed as badly as anywhere else and usually worse than everyone else. And of course it costs a whole lot more, both absolutely and in terms of out of pocket costs.

For example only 37% of Americans had a more than 5-year relationship with their primary care doctor, and 20% had no primary care doctor. Everywhere else more than 50% have a five year-plus relationship.

Here's a look at timely access to care:

The majority of adults in New Zealand and Australia said that they received appointments the same day the last time they were sick and needed medical attention. In contrast, only one-third or less of Canadian or U.S. adults reported such rapid access. Canadian and U.S. adults also reported long waits, with 20-25 percent waiting at least six days to get an appointment when sick, a waiting time rare in Australia or New Zealand.

Telephone help lines provide a potential source for primary care access after hours. In the United Kingdom, NHS Direct operates a twenty-four-hour telephone nurse advice and information service. When respondents were asked about any use of such assistance in the past two years, help lines were used most frequently in Canada and the United Kingdom, followed by the United States.

And then again costs really impact use of care, especially for the poor:
U.S. adults were the most likely to say that they did not see a doctor when sick, did not get recommended tests or follow-up care, or went without prescription medications because of costs in the past year. New Zealand rates of not seeing a doctor rivaled U.S. rates and were significantly higher than rates in the other three countries. The United Kingdom and Canada stand out for having negligible cost-related access problems. Australia stands midway between the country extremes. Lower-income adults' access to care was particularly sensitive to costs, with problems again the most acute in the United States.
And American primary care looks pretty bad regarding test results and patient communication -- a result I suspect of poor care coordination here:
8-15 percent of patients said that they were given incorrect test results or had experienced delays in being notified about abnormal results. Test error rates were highest in Canada, New Zealand, and the United States.....The study reveals missed opportunities to identify patients' preferences or concerns, to communicate well, or to engage patients in care decisions. On each of these measures, U.S. adults were significantly less likely to score their doctors highly and the most likely among the five countries to report concerns.
The US did better than other nations on some preventative screening measures like pap smears and checking for high blood pressure, which the study attributes to the pressure brought on providers via the NCQA's HEDIS measures. But otherwise there's a really clear question. What are we getting for all the extra money that we're spending? In fact the authors come straight out with it in the discussion phase when they write:
Across multiple dimensions of care, the United States stands out for its relatively poor performance. With the exception of preventive measures, the U.S. primary care system ranked either last or significantly lower than the leaders on almost all dimensions of patient-centered care: access, coordination, and physician-patient experiences. These findings stand in stark contrast to U.S. spending rates that outstrip those of the rest of the world. The performance in other countries indicates that it is possible to do better. However, moving to a higher-performing health care system is likely to require system redesign and innovative policies.
It's of course no secret where the extra money goes in the US system, where we lead the league in excessive care of the virtually dead, or as THCB contributor Dave Moskowitz said yesterday "For 70% of healthcare dollars to be spent in the last 12 month's of a patient's life means that it is spent on surgery and ICU care that is futile but expensive". And of course the recent Dartmouth studies showed that the variation in ICU and end of life care and costs both between states and between leading hospitals in different parts of the US varies by a factor of 3! Not to mention Uwe Reinhardt's point that we pay higher prices for the same amount of medical services delivered here.

In other words, buyers here(and by that I mean the big employers and the Federal government) have got to start changing the way they regulate the system and how they pay for care. It makes no sense for us to continually defend the way we've been doing things when the indicators are that everyone else can essentially do better spending less money. And saying it can't be done, or Bush denying that there is anything wrong, reminds me of American auto execs in the 1970s poo-poohing the threat from Toyata. The alternative, of course is more of the same and the rest of the economy picking up the tab, at considerable social cost.

Meanwhile, the foreigners are trying to get further ahead. Here's a webcast from Kiasernetwork of the study's lead author Cathy Schoen ripping the US system, and a somewhat smug--and every right to be--UK health minister explaining how the government there is working to add improvements to the system (and no that doesn't mean introducing more cost-sharing, which seems to be our only idea here).

Finally, the study also used the three part Harris question that you've seen me reference before. The question asks people to put their views on the whole system into three buckets which are in favor of a) minor tinkering, b) fundamental reform, and c) complete rebuilding. Most people end up in the middle bucket, of course, but the number of Americans looking for complete rebuilding is way higher than anyone else's, and is now back up to 33%. In fact another Blendon study conducted more recently found that it was at 36%. Immediately before the 1992 election that number was at 42%. My forecast is that as cost shifting continues and as the uninsured rate rises, that number will climb here back to near the 40% mark, and a big debate will ensue.

October 29, 2004 in International | Permalink


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