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May 1, 2008

Rx for U.S. health care: Learn from other nations' successes

“Our leaders like to say we have the best health care system in the world,” said national health policy expert and economist Karen Davis. But that view is not shared by the American public, she said.

“It’s hard to look at what has happened in the health care system over the recent past and not have a perception that we’re on the wrong track with growing numbers of uninsured and rising health care costs,” said Davis, president of The Commonwealth Fund, a national philanthropic organization engaged in independent research on health and social policy issues.

Davis spoke April 17 on “Health Care: Solutions Without Borders,” delivering the Anne C. Sonis Lecture, an annual event sponsored by the Department of Health Policy and Management at the Graduate School of Public Health and the Center for Research on Health Care at the School of Medicine.

“One of the things we’ve routinely asked in our Commonwealth Fund surveys since 1998 is what does the public think about the health system. Basically, we have one in six satisfied customers,” an embarrassing and intolerable ratio, Davis said. “In addition, one-third of Americans say the health care system should be rebuilt completely.”

In contrast, only 9 percent of people in The Netherlands feel their system should be rebuilt from scratch, she said.

“So it’s useful to look at what other countries are doing that leads to a high level of public satisfaction. There’s a lot to learn from the international experience with health care, not so much that we would adopt any other country’s health system, but I think it’s important for us to examine other countries — particularly for innovative practices that are working well that we might adapt and modify for use in the U.S.”

Among those innovations are replacing traditional physician practices with patient-centered medical “homes,” that is, 24-hour clinics for primary, non-emergency and preventive care; comprehensive integrated electronic medical records systems that reduce duplication and increase service coordination, and various innovative payment structures, Davis said.

While Pittsburgh is blessed with a relatively high-quality, high-performance medical center, such a center is the exception rather than the rule, she said. “Care is highly variable in the U.S., and there are many things that we can do to make people live healthy and productive lives that we simply fail to do, and many missed opportunities for improving the lives of Americans,” Davis maintained.

A Commonwealth Fund commission articulated goals for the U.S. health care system that include having the ability to live healthy, long and productive lives; having high-quality care that is accessible to everyone, regardless of income, race, ethnicity or health status; getting value for the resources invested in health care, and having a system that continues to improve and be innovative, Davis said.

The work of the fund’s commission built on a comprehensive national scorecard on U.S. health care system performance published in the journal Health Affairs in September 2000.

“We started to use benchmarks as quality indicators,” Davis said. “These are not the ideals of what one might want in access, quality, efficiency, equity, health outcomes, but what were for the most part achieved by the best countries. We asked how does the U.S. average compare with what has been achieved at least in some places for some populations.”

The commission looked at 37 indicators across 19 mostly European industrialized countries and compared the U.S. average level to the benchmarks.

“On average, the U.S. system scored a 66 out of 100,” she said. “In efficiency, for example, the U.S. scored 51 out of 100, looking at different indicators, such as duplication, administrative costs, variations in cost across geographic areas; variations in communications; numbers of avoidable hospitalizations, and avoidable hospital re-admissions. In the efficiency category we fare particularly poorly.”

Not that the country is doing much better on any of the indicators, she added, with a high score of 71 out of 100 on overall health care quality.

“We asked: What percent of the U.S. population is up to date with preventive care? We all were stunned to see only one-half of Americans are up to date on preventive care as recommended by their physicians,” Davis said.

Further, she said, the United States is falling behind in several health care indicators.

“For example, one specific indicator on health outcomes that we used on the national scorecard is called ‘mortality amenable to medical care.’ We were 15th out of 19 in 1997-98 data. This year, although the U.S. had improved — in fact, mortality went down by 4 percent — the average decline of the other countries was 16 percent, and we have now slipped to 19th out of 19 countries on mortality that could be prevented,” Davis said.

“What does that mean? If the U.S. were as good as the best countries, in this case France and Australia, we would save 101,000 lives a year,” she said.

There are numerous reasons for the comparative inadequacies in the health care system in the United States, Davis said.

“Some of it is related to our insurance system: The Institute of Medicine estimates that 18,000 Americans die every year as a direct consequence of being uninsured. Some people with chronic conditions don’t take medications because they can’t afford them. Almost 37 percent of American adults say they don’t fill prescriptions or they skip doses because they can’t afford the medications, which makes us stick out like a sore thumb compared to other countries. They don’t go to the doctor, they don’t call the doctor to get recommended to specialists as often as they should.”

According to the Institute of Medicine, the aggregate annualized cost of uninsured people’s lost capital and earnings from poor health and shorter life spans falls between $65 billion and $139 billion for each year without coverage. Clearly, universal coverage is needed, she said.

“One criticism of other countries’ health care systems, which is valid, is that it is hard to get specialized care, and there are longer waits in other countries for elective surgery such as for cataracts or hip replacements,” Davis said. “But what shocked us in the survey is that Americans have a much harder time to get to see their own doctors.”

Only 30 percent of survey responders said they could get an appointment with their PCP on the same day, compared to more than 50 percent in most other countries, and 20 percent of Americans said typically they had to wait six or more days, by far the highest percentage among the 19 countries, Davis said.

“When we asked physicians: Do you have arrangements for after-hours care?, I expected that 100 percent would say they do. Only 40 percent said they had any arrangements for appointments at nights or weekends. That’s unbelievable, and you can see it has a big effect on emergency room usage and costs for treatment that could be provided by the PCP.”

Additional reasons that other countries are doing better in health care are a reflection of their governments’ policies, such as setting national goals; having specific strategies for improved performance in selected areas, and having accepted guidelines for care of patients with certain conditions.

“We get worse results than other countries, but we excel at spending more than other countries — we spend twice per capita what other countries spend, and we are going up at a somewhat faster rate than other countries,” Davis said.

Americans pay more for nearly all health care services than their international counterparts; other countries pay on average 40 percent of what Americans pay for the same drug.

“A practice that is common in other countries is to have some kind of national body that really evaluates the effectiveness and the cost-effectiveness of alternative drugs, devices, procedures for treatment,” Davis said. “But, most importantly, other countries negotiate the prices of pharmaceuticals that are made available in their populations.”

What does the fund’s commission on health system performance think needs to be done? The commission issued a report last November called “An Ambitious Agenda for the Next President” that highlighted five strategies:

• Extend affordable health heath insurance to all. “We are the only major industrialized country that does not provide universal health insurance coverage. It’s just so basic that that is a flaw in our system, and it should be a priority to remedy,” Davis said.

• Align financial incentives to enhance value and achieve savings. Data show that financial incentives for providing the highest-quality care, as opposed to simply more care, work in improving overall health care performance, she said.

• Organize the health care system around the patient to ensure that care is accessible and coordinated. “That means having a system in place where someone is accountable for the total care of the patient, not just for doing one piece,” Davis said. “When you think about half of the U.S. population is not being up to date with preventive care, who is the provider, who is the physician that is responsible? What is the practice that is responsible for seeing that 100 percent of the patients are up to date? There needs to be accountability.”

• Meet and raise benchmarks for high-quality, efficient care. Part of this strategy is to narrow variations in patient care by standardizing treatments and to focus on specific preventable problems, such as hospital-borne infections, she said.

• Ensure accountable national leadership and public/private collaborations. “We can’t get the highest performance health system without national, accountable leadership and without the public and private sector, for example, the payers, all moving in the same direction trying to achieve the same national goals,” said Davis. “But to do that the commission said we need a focus on information technology, quality-improvement activities, comparative effectiveness, transparency in public reporting and workforce investment.”

The United States generally is thought of as the world’s leader in information technology. “Yet the U.S. lags well behind other countries on adoption of health information technology,” Davis said.

“Only one-quarter of [U.S.] PCPs said they have electronic medical records. When we asked about their functionality, such as: Can you order electronic medical records? Can you order prescriptions electronically? Can you get tests results? Do you have disease registries? the percentage even drops off a bit more. Canada is worse, but in a country like The Netherlands, 98 percent of PCPs have this type of support in their practices,” she said.

Davis pointed to Denmark’s health care system as a model in many respects.

“Denmark has the highest public satisfaction with their health system. They were the first country to try a blended system of payment for primary care: About two-thirds is fee-for-service, about one-third is payment for the medical ‘home’,” she said. “The primary care physician [in the medical ‘home’] is responsible for the total care of their enrollees, and they get a certain amount from the government for each patient per month.”

Danish PCPs, who make more than their U.S. counterparts, have office hours weekdays from 8 a.m. to 4 p.m. “At 4 p.m. they go home, and the off-hours service kicks in. Physically, these are clinics, but on site are physicians with headphones and computer terminals. Before you show up at the off-hours clinic, you’re supposed to call. When you do, a doctor answers the phone! No answering service, no push this button or that button.”

These after-hours docs readily agree to work because they make a significant amount on a per phone-visit rate, she said. “He or she pulls up your record on the registry. They can prescribe electronically and then they email your primary care doctor about the care you receive from the off-hours service, so there is a tie-in with the regular source of care.”

The Danish government paid IBM to develop the non-profit MedComm system, which nearly all Danish primary care doctors use. MedComm runs the system for $3 million a year for 5.4 million Danes. “That’s 60 cents a person to maintain a more-or-less complete medical record of every patient. Patients have direct access to the records; home care nurses have access. Patients can check who has looked at their records,” Davis said. “What we’ve learned from the survey of PCPs about the information technology’s perceived effect on their care is that those PCPs with high levels of IT functionality say the care is better, and they’re more satisfied with their experience of practicing medicine.”

Davis concluded with a few “take-away messages” for the United States.

“It’s clear that many of these patterns of access, quality and costs are a reflection of specific policies those countries have adopted. Universal care obviously matters. Beyond that, having a medical home, a place that’s accountable for your care in an integrated system that ties the information together, also is needed,” she said. “Medical homes clearly make a difference. Every indicator we looked at — patient safety coordination, patient experiences with care, physician management, waste, such as duplicating tests, accessibility of care, all of the things related to care and patient satisfaction — improved in the medical home environment.

“What can we do differently? Cover everybody, organize care, provide information technology, fundamentally change the way we pay and have some national leadership and coordination in our system to pull this off.”

—Peter Hart


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