I have no problem with new and more effective pharmaceuticals (although I do have a problem with me-too drugs and fancy diuretics and laxatives that probably aren’t any better than over-the-counter products). Nor do I object to the advent of better health care technologies, if they really are better. After all, the increase in life expectancy wasn’t delivered by the tooth fairy. Health care systems, when they aren’t being destroyed by civil conflict or government corruption, have done an incredible job of increasing preventive care, promoting public health and trying to serve patients better. But the issue of how to pay for it all is a worry around the world.
This brings us to quality improvement efforts. Most people who work in health care, wherever they are, want to do the best job they can, and want to protect their patients. But that takes expertise, appropriate funding — and common sense. There are too many things that can go wrong in health care for anything to be taken for granted.
And although the United States system has long boasted that it is the best in the world, there is little evidence of that. A study issued in July, based on data from the World Health Organization and The Economist’s Intelligence Unit, reported that although per capita spending on health care in the United States is the highest in the world, we rank only 33rd in terms of outcomes. We use more technology and consume more pharmaceuticals than most societies, but it doesn’t seem to be helping much.
In case you were wondering, the top five in outcomes are Japan, Singapore, Switzerland, Italy and Australia. One can attribute some of the success in Japan and Singapore (although the latter has a really amazing health care system) to homogeneous racial and ethnic populations, but Switzerland’s society is somewhat diverse, and the populations of Italy and especially Australia are very much so. I suspect that if we drilled down into these data, we would find significant racial and ethnic disparities in health status and longevity.
And it’s difficult to maintain high quality — it is an all-consuming job. A report by Michael Reich and Kenji Shibuya, M.D., in the Nov. 5, 2015, New England Journal of Medicine conceded that Japan’s health care system — which includes universal coverage — is struggling with a rapidly aging population, a low birth rate and an economy that has been in the tank for years.
All health care systems could do better, whether in convincing all health care workers to wash their hands, reducing infections, limiting wait times or adopting electronic health records. Some are trying harder than others, and some don’t have a chance, given civil conflict, lack of resources and government indifference.
One of the most striking ways in which world health care systems are similar and are becoming more so is in the reconfiguration of the structure of providers. In the United States, of course, we are seeing massive consolidation of providers, insurers and even pharmaceutical firms.
Some systems always have been integrated, as in Britain. Others, like ours, are hybrids, as is also true of Australia, which has both public and private insurance, and most hospitals are private. At one point in the rather odd history of Australian health care, the government was selling private insurance to avoid a government monopoly.
There are many variations on the theme, but the three main questions are whether a system should be public or private (and the answer to that varies enormously) or a hybrid, how integrated the system should be, and how much competition should be allowed to flourish.
Competition in health care has been one of the main American exports to other countries, and there is nothing wrong with that. As a very wise man told me once, without competition, everyone is secure and has no reason to innovate or improve. I have seen that in health care operations overseas.
But anyone who ever made it as far as Economics 101 knows that the ultimate goal of competition is monopoly. Bill Gates knows that. Steve Jobs knew that. Establish a monopoly and you get all the money. So it’s a balancing act.
Another insight was recently provided by Austin Frakt, Ph.D., in a July 8 article on www.jama.com, when he pointed out that “competition” does not necessarily mean “private.” He used the British National Health Service as an example, saying that the introduction of competition among Britain’s public hospitals (any patient must be given a choice of at least five hospitals for treatment) has improved quality and empowered patients. Mortality rates have decreased, as has length of stay.
Competition need not be tied to unfettered markets. It can be a valuable and effective asset in a variety of health care settings.
Access to Care
All systems struggle with adequate access to care. In a disastrous situation like Syria, if it were not for humanitarian groups such as Doctors Without Borders and the International Committee of the Red Cross, no care would be available. When these organizations must withdraw from areas of civil conflict, people have no access whatsoever. In many other countries, these humanitarian services are the lifeline for thousands of people.
In some situations, it depends on how much money you have and what resources are available. In some of the more nationalized systems, waiting times are a given, except for emergencies. (This has been overplayed in terms of critics of the Canadian and British systems — people generally don’t die on waiting lists, but foes of single-payer systems will use any excuse to condemn them.) In a long-ago article in Health Affairs, Canadian physician David Naylor argued — in what I considered an unintentionally amusing concept — that having to wait for care gave the patient the chance to reconsider treatment and to put his or her affairs in order. Uh, OK. But then, U.S. hospitals are required to ask any incoming patient if he or she wants to donate an organ, which may be a little scary if you are just having a hernia repaired.
The challenges of access to decent care are many. In rural areas, it is a problem in most countries. The roads may be unusable in hard weather. Shortages of providers are commonplace. There may be threats from civil conflict, bandits or what have you. In urban areas, if it’s a cash-on-the-barrelhead system, if you can’t pay, you can’t get care. And in the many places where health care is being privatized, you need insurance or cash. Subsidies are often available to the very poor, but many people are left wondering whether they should buy food for dinner or inoculate their kids.
And despite the Affordable Care Act and the good work of our hospitals, community health centers and other providers, at least one out of 10 residents of the United States is still uninsured and, therefore, at risk of lack of access. For those who can afford it but choose not to buy insurance or pay for their care, I have no sympathy. But there are many others who really do not have the money.
I’m one of those bleeding hearts who believes that access to care is a human right. In many health care systems, that sentiment is not shared.
Workforce Adequacy and Distribution
Health care systems all over the globe are rife with workforce silos, turf wars, maldistribution and scope-of-practice issues. These may be more extreme in the United States, but they are not unique to our country. Tsung-Mei Cheng wrote a report for the Brookings Institution in May that found significant shortages of nurses and practitioners in certain specialties in Taiwan, which has an otherwise successful health care system. I recently spent some time with Professor He Jingwei, who works in Hong Kong and studies patient unrest in China. He has found that one of the main reasons for such dissatisfaction is that physicians are often required to see 60 patients a day, which means that few patients, if any, get appropriate care.