Saturday, August 25, 2007

Why the U.S. Ranks Low on WHO's Health-Care Study

The New York Times recently declared "the disturbing truth ... that ... the United States is a laggard not a leader in providing good medical care." As usual, the Times editors get it wrong.

They find evidence in a 2000 World Health Organization (WHO) rating of 191 nations and a Commonwealth Fund study of wealthy nations published last May. In the WHO rankings, the United States finished 37th, behind nations like Morocco, Cyprus and Costa Rica. Finishing first and second were France and Italy. Michael Moore makes much of this in his movie "Sicko." The Commonwealth Fund looked at Australia, Canada, Germany, New Zealand, the United Kingdom and the United States -- and ranked the U.S. last or next to last on all but one criterion. So the verdict is in. The vaunted U.S. medical system is one of the worst. But there's less to these studies than meets the eye. They measure something other than quality of medical care. So saying that the U.S. finished behind those other countries is misleading.

First let's acknowledge that the U.S. medical system has serious problems. But the problems stem from departures from free-market principles. The system is riddled with tax manipulation, costly insurance mandates and bureaucratic interference. Most important, six out of seven health-care dollars are spent by third parties, which means that most consumers exercise no cost-consciousness. As Milton Friedman always pointed out, no one spends other people's money as carefully as he spends his own.

Even with all that, it strains credulity to hear that the U.S. ranks far from the top. Sick people come to the United States for treatment. When was the last time you heard of someone leaving this country to get medical care? The last famous case I can remember is Rock Hudson, who went to France in the 1980s to seek treatment for AIDS.

So what's wrong with the WHO and Commonwealth Fund studies? Let me count the ways. The WHO judged a country's quality of health on life expectancy. But that's a lousy measure of a health-care system. Many things that cause premature death have nothing do with medical care. We have far more fatal transportation accidents than other countries. That's not a health-care problem. Similarly, our homicide rate is 10 times higher than in the U.K., eight times higher than in France, and five times greater than in Canada. When you adjust for these "fatal injury" rates, U.S. life expectancy is actually higher than in nearly every other industrialized nation. Diet and lack of exercise also bring down average life expectancy.

Another reason the U.S. didn't score high in the WHO rankings is that we are less socialistic than other nations. What has that got to do with the quality of health care? For the authors of the study, it's crucial. The WHO judged countries not on the absolute quality of health care, but on how "fairly" health care of any quality is "distributed." The problem here is obvious. By that criterion, a country with high-quality care overall but "unequal distribution" would rank below a country with lower quality care but equal distribution.

It's when this so-called "fairness," a highly subjective standard, is factored in that the U.S. scores go south. The U.S. ranking is influenced heavily by the number of people -- 45 million -- without medical insurance. As I reported in previous columns, our government aggravates that problem by making insurance artificially expensive with, for example, mandates for coverage that many people would not choose and forbidding us to buy policies from companies in another state.

Even with these interventions, the 45 million figure is misleading. Thirty-seven percent of that group live in households making more than $50,000 a year, says the U.S. Census Bureau. Nineteen percent are in households making more than $75,000 a year; 20 percent are not citizens, and 33 percent are eligible for existing government programs but are not enrolled. For all its problems, the U.S. ranks at the top for quality of care and innovation, including development of life-saving drugs. It "falters" only when the criterion is proximity to socialized medicine.


Don't have a stroke in Britain

Patients who suffer strokes receive worse treatment in Britain than anywhere else in Western Europe. More die and more are left disabled, a leading expert says in this week's British Medical Journal, even though Britain spends as much as, if not more than, other countries on stroke care. The gap is wide, according to Hugh Markus, of St George's University of London medical school. One study showed that 15 to 30 per cent more stroke patients were left dead or disabled in Britain than in other countries.

Professor Markus identifies several possible reasons for the failure. European countries with better results tend to focus more on the care of patients immediately after a stroke, while in Britain the vast majority of money is spent on nursing and hospital overheads, and little on investigations or treatments. Stroke care is a "Cinderella subject" in Britain, falling between neurology and general and geriatric medicine, he says, whereas elsewhere it is an integral part of neurology. This lack of interest may have led to underinvestment and, therefore, poor outcomes.

New treatments that can help patients to recover from a stroke make the failings even more significant. In strokes caused by clots blocking the blood supply to the brain (ischaemic strokes) the use of clot-busting drugs is effective, but patients must first be scanned to determine what sort of stroke they have suffered. All hospitals have scanners, but struggle to scan stroke patients within 24 hours. For a patient to be treated with clot-busting drugs, the scan must be performed within three hours.

In many countries in Europe, and in North America and Australia, 20 to 30 per cent of patients get these drugs. In Britain the figure is less than 1 per cent. Britain also treats fewer patients in dedicated stroke units than other countries, though setting up such units costs nothing and there is abundant evidence that they improve outcomes.

The audit by the Royal College of Physicians found that fewer than two thirds of stroke patients were treated in stroke units, and only a little more than half spent more than half of their stay in such a unit. The benefits include early rehabilitation, access to physiotherapy and staff experienced in stroke care.

Jim Whyte, who had a stroke ten years ago at the age of 55, spent 27 weeks in hospital - only the last five in a specialist unit. Mr Whyte, from Enfield, North London, was treated at Chase Farm Hospital. "Once I got into the specialist unit I had physiotherapy twice a day, speech therapy and training on how to manage for myself." The best help he gets these days, he says, comes from a local stroke club, whose members help one another with advice. He said: "That's something the NHS didn't think of. When I left hospital I was given nothing in the way of information, about how to avoid a second stroke, that sort of thing. Things may have got better since, but we've still got a long way to go."

A significant challenge, Professor Markus says, is to change the perception of stroke among doctors and the public. Scanning units should be available 24 hours a day, and to achieve this regional specialist centres may be needed. Such changes have been achieved for heart care, so it is not impossible, he says, but it calls for commitment and a reorganisation of services, which have so far been lacking.

Joe Korner, director of communications at the Stroke Association, said that the present situation was unacceptable. "For many years the Stroke Association has been concerned about the UK's poor record in stroke care compared to other countries," he said. "That is why we have been campaigning hard to try to improve stroke services. "The Government, with a new stroke strategy in development, has shown a commitment to improving the future of stroke care across the UK. But it is vital that stroke gets the priority and investment it needs. "Without investment hundreds will die needlessly. Public awareness of stroke also needs to be increased so that people can recognise the warning signs."

Dawn Primarolo, the Health Minister, said: "In the last ten years the treatment of stroke in the NHS has progressed rapidly - more patients than ever before are being seen by stroke specialists, numbers of stroke deaths are falling and advancing medical understanding gives every prospect for a real revolution in stroke treatment over the next few years. "The National Stroke Strategy - setting out proposals for modernising stroke prevention, treatment and care - is currently out to consultation. "It was developed with the Stroke Association and stroke survivors and carers, and was debated by Parliament. It follows 20 million pounds invested in improved research into stroke and additional tools and support for hospitals on stroke prevention. "Although we have more improvement to make to the numbers of people given clot-busting thrombo-lytic drugs, there are hospitals, such as King's College, that are matching the best in the world."


The Australian Leftist solution to health-service shortages: More bureaucracy

Kevin Rudd has started to show his interventionist side. The toon below notes that the State governments would be glad to unload responsibility for their problematical hospital systems onto the Feds

VOWING to take personal responsibility for fixing Australia's public hospital system, Kevin Rudd has given away his administrative bent, backing it up with a small carrot and a big stick. In dollar terms, a pledge to spend an extra $2billion over four years is small change in the context of the total healthcare budget. The potential meat in Labor's plan is the establishment of a National Health and Hospitals Reform Commission to sort out the cross jurisdictional healthcare mess that allows each level of government to blame the other for its shortcomings. The proposed reform commission will negotiate a framework to clearly define the state and federal responsibilities in healthcare.

On one hand, the Opposition Leader's plan could amount to no more than an election-year promise that lacks substance and is designed to foil John Howard's opportunistic pledge to prop up a small Devonport hospital in Tasmania as part of a strategy to muscle up against Labor state governments. On the other hand, Labor's plan could represent the first concrete evidence of the highly interventionist style we could expect from Mr Rudd.

Mr Rudd has a history of heavy involvement shaking up health and education bureaucracies from his time as former Queensland premier Wayne Goss's top public servant. As well as cutting back public sector spending, Mr Rudd helped create a 10-year plan to refurbish Queensland's major hospital buildings. His process-driven reform pedigree is showing in the proposed reform commission, to be established in the first 100 days of a Labor win. Labor has pledged to provide financial incentive payments to state and federal governments who deliver better outcomes to patients. The big stick is the threat of a commonwealth takeover of Australia's 750 public hospitals if state and territory governments can't agree to a national reform plan by mid-2009.

Mr Rudd has proposed a referendum to secure a public mandate for any takeover, after which local communities would have a direct say in management of public hospitals with responsibility for the quality of patient care and funding resting with the commonwealth. In a Whitlamesque refashioning of commonwealth responsibilities, states would effectively be cut out of the loop on health. Mr Rudd says this would put an end to the blame game between Canberra and the states on health and hospital funding.

Mr Rudd has taken personal responsibility for the plan, declaring that as prime minister the buck would stop with him. While Queensland Premier Peter Beattie was quick to welcome a commonwealth takeover of what has been a continuing political train wreck for his Government, other state leaders were not so quick to embrace it. West Australian Premier Alan Carpenter rejected the plan, saying he did not believe the federal Government could do the job better than the states. South Australian Premier Mike Rann pledged to work with Mr Rudd to eliminate duplication and plug gaps in service delivery but stopped short of endorsing a commonwealth takeover of responsibility. So did Victorian Premier John Brumby, who said it was a good plan but a takeover would not be necessary. NSW Premier Morris Iemma said he welcomed a more results-based funding system.

While another bureaucracy is the last thing Australia's already cumbersome public health industry needs, properly focused, a reform commission might well be necessary to find what has proved to be an elusive solution to an obvious problem. As it is, the commonwealth is accused by the states of avoiding its responsibilities in aged care, leaving elderly people stranded in public hospital beds. The states are accused of shunting hospital costs from hospital budgets onto commonwealth-funded GPs. The public is wise enough to know that however healthcare is delivered, the full cost comes from the public purse.

The sensible thing is to make the healthcare system as streamlined and efficient as possible. This includes encouraging those who can afford it to take out private hospital insurance to take pressure off the public system. It includes making sure the public properly understands that the Medicare levy at its present level funds only a small fraction of the total healthcare bill and that, because of the enormous sums involved, no system will ever be capable of providing full treatment on demand for any ailment.

No one understands the political ramifications of taking the eye off the public hospital ball more than Mr Beattie, which probably explains why he was quick to support Mr Rudd's plan for a commonwealth takeover of responsibility. Queensland's health dilemma is made more acute by the fact it has a rapidly growing population, including many retirees to remote coastal locations where few if any health services are available. The reluctance of other state leaders to lose direct control will hopefully ensure they will co-operate with the reform commission process.

Traditionally, health is recognised as a strong suit for Labor. Mr Rudd appears to have embraced the challenge and deserves encouragement to get it right. It would be disappointing, however, if Labor's promise turned out to be little more than the creation of a new body designed primarily to strengthen Canberra's hand when it comes to indulging in the blame game with the states over health.


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