By Walker Ray, MD, and Tim Norbeck
This article originally appeared on Forbes.com and is reprinted with permission of the authors.
Well, here we go again. More new studies that indict the U.S. health care system directly — and by inference, America’s physicians — have been published.
A new report in JAMA published in March comparing U.S. statistics with those of the highest-income countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland and Denmark) indicates that the American health care system fares quite poorly. Surprise!
The primary author is Irene Papanicolas, PhD, affiliated with the Department of Health Policy, London School of Economics and Political Science. She and co-authors, Liana R. Woski, MSc., and Ashish K. Jha, MD, MPH (affiliated with the Department of Health Policy and Management at Harvard), deserve credit for compiling the numbers in such a comprehensive report. Throughout, the point is made frequently that the U.S. spends far more per capita on health care when compared with other countries, but has less in health care outcomes to show for it. These conclusions are not so different from other studies previously published. However, there are valid reasons for these differences, and we feel compelled to address them.
For one thing, even our system’s captious critics admit that it is far easier to manage health outcomes in smaller and more homogeneous countries. The U.S., with a population of 323 million, is far larger than any of the other countries mentioned in the sample. In fact, the mean population for all of them is a mere 69 million. Recent research, including an insightful book by Dr. Buz Cooper, all suggest that poverty and other social determinants have a significant impact on our health and health care costs. Unfortunately, the U.S. poverty rate is higher than the other countries at 12.7 percent of the population.
In an accompanying JAMA article also published in March 2018, Ezekiel J. Emanuel, MD, observes that “administrative costs contribute significantly to the cost difference between the U.S. and others used in the comparison.” This is a point on which Papanicolas et al. resoundingly agree. Emanuel also mentions that a major driver of cost differences is high-margin, high-volume procedures. For example, he points to knee replacements where the U.S. performs nearly twice as many per capita as in the Netherlands.
Tim had a knee replacement himself in May and enjoys far greater mobility. He also has a tennis friend in Connecticut who in the past year had both knees replaced and is back to playing tennis three times a week. His age: 90! We suspect that it would be very difficult, if not impossible, for a 90-year-old to receive two knee replacements in any of the other countries and in a very timely fashion. However, much of America prides itself on physical fitness and quality of life at every age. The price of this is certainly reflected in our higher health care costs.
Papanicolas et al. also call attention to the fact that the U.S. performed the second highest number of MRI scans per capita (behind Japan) and the most CT scans. We don’t find that unusual, given the current medical liability environment that exists in the U.S. The medico-legal Sword of Damocles hangs precariously over every physician for every procedure.
If little Johnny falls off his bike and strikes his head in the U.S., a physician will order some type of scan. If not, if the child were to suffer serious complications from the injury and files a lawsuit because the physician failed to do a scan, the jury will likely side with the victim. Similarly, physicians require patients to have a CT scan for many injures to avoid potential complications that would be missed by x-rays or physical examinations. As stated in Scientific American: “No physician wants their patient to die because they didn’t find an injury.” We would add: especially in view of the present liability system! It is also sad that, along with a jury’s recognition that the insurer will pay, so “don’t worry about it,” little do they realize the physician’s (and their family’s) anguish during malpractice trials, and that their premiums will just keep going up. It is a threatening and pernicious liability system, and, of course, we lead the world in the number of CT scans performed. No other country has our onerous liability laws.
Of course, one of the big “knocks” on America’s health care system is our infant mortality rate, especially when compared to the other countries. Experts all agree that there is a lack of consistent and reliable data out there in which to make truly valid comparisons. But they are made anyway.
As Alice Chen, Emily Oster, and Heidi Williams mention in a recent and very comprehensive study article that appeared in American Economics Journal, cross-county comparisons of aggregate infant mortality data rates provide very limited insight. One of the reasons is that countries vary in their reporting of births. Another serious study, performed by Korbin Liu, Marilyn Moon, and Juki Chawla for the Centers for Medicare and Medicaid Services, entitled: International Infant Mortality Rankings: A Look Behind the Numbers, sheds more light on the subject. “These rates,” the authors mention, “are affected by the socioeconomic status of mothers and their children.”
Unfortunately, the U.S. poverty rate is higher than all of the countries, and considerably higher than half of them. Furthermore, the Liu-Moon-Chawla study points out that in infant mortality reporting, mechanisms vary greatly among the countries compared with the U.S. For example, in France, “a baby has to be alive at the time of registration, which could be 24 to 48 hours after delivery. If the infant does not survive at that point, it is recorded as a false stillbirth.” On the other hand, if a newly born infant in the U.S. takes one breath and dies, it is recorded in the infant mortality stats.
“Germany requires evidence of the function of both the heart and the lungs before it is reported. Russia excluded from their report of live births infants who were less than 1000 grams in weight or less than 28 weeks of gestation — if they die within seven days of birth.” The reporting differences are such that it is impossible and unfair to make valid comparisons on infant mortality. But people continue to make them.
But there is even more to be said on the subject. Experts agree that low birth weight and teen pregnancies vitally affect infant mortality rates. Teen birth rates in the U.S. are higher than most other countries. According to the Centers for Disease Control and Prevention, 80 percent of teenage pregnancies in the U.S. are unintended. “Pregnant teenagers tend to gain less weight than older mothers, due to the fact that they are still growing and fighting with the baby for nutrients during the pregnancy.” Papanicolas et al. observe that the U.S. is second only to Japan in low birth weight babies. In still another JAMA article (March 13, 2018), Stephen T. Parente, PhD, calls attention to how high the preterm birth rate in the U.S. is compared to other countries and that “infant mortality is nearly 30 times greater for very low birth weight births compared with normal birth weight births.”
We do not intend to make light of infant mortality, because it is important and needs to be continuously monitored. But clearly, it is not fair or accurate to compare problem apples with problem oranges. The effectiveness of our health care system should not be denigrated because of infant mortality statistics. Serious social problems like poverty, teen pregnancies and low birth weight infants must be resolved, and the reporting has to be uniform. When they are, our numbers will be every bit as good as those in the rest of the world.
Life expectancy has been another “knock” on the U.S. health care system. Unfortunately, our suicide rate is higher than the other countries mentioned in the Papanicolas et al. study, with the exceptions of only France, Switzerland and the world leader, Japan. We have the worst rate of car crash deaths and the highest rate of gun homicides. Furthermore, we lead the world in another very dubious “distinction” — that of obese or overweight adults. The Centers for Disease Control and Prevention reports that 36.5 percent of the U.S. population suffers from obesity, which sets the U.S. apart as the most obese nation when compared with the other listed countries.
With obesity comes diabetes, which greatly affects mortality and health care costs. The International Diabetes Foundation (IDF) reports that the U.S. has the highest rate of diabetes in the developing world, with an estimated 13 percent of Americans who struggle with the disease. In fact, the IDF reports that nearly four times as many Americans may die of diabetes as indicated on death certificates, which would bump the disease up from the seventh-leading cause of death to No. 3, according to estimates in a recent study.
Finally, when discussing or comparing U.S. health care costs with those in other countries, the cost of pharmaceuticals must be considered. Among the 11 countries listed, as mentioned by Papanicolas et al., the U.S. had the highest pharmaceutical spending per capita at $1,443, with a mean of half of that ($749) for all 11 countries. Regarding a “measure of innovation,” the U.S. and Switzerland had the highest number of “new chemical entities” at 111 and 26 respectively. All this said, it’s noteworthy that one of the virtues of our health care system is that its citizens have access to break-through brand-name drugs sooner than other nations.
We must continue to strive to improve our health statistics and the general health of our people. To that end, more attention must be spent in addressing the social determinants that currently compromise the health of too many and result in higher health care costs. These determinants, such as poverty, poor housing, job and income status, and socioeconomic characteristics (such as education) are relevant in every respect. It is one thing to merely look at the numbers and quite another to examine the very valid reasons for the differences. We must look at health care comparisons with transparency and truth. That requires a great deal of improvement in reporting mechanisms of all other countries, as well. Most importantly, we must also do what we can to reduce overall health costs without jeopardizing the high quality and access to care.
Walker Ray, MD, president of the Physicians Foundation and chair of the Research Committee, is a retired pediatrician in Georgia. Tim Norbeck is the chief executive officer of the Physicians Foundation and served as the nonprofit’s first president. He previously served as the executive director of the Connecticut State Medical Society, the Rhode Island State Medical Society, and president of the American Association of Medical Society Executives.