Category: Health Care

Update from the Centers for Disease Control (CDC).

In 2004 (the latest year that data are available for all countries), the United States ranked 29th in the world in infant mortality, tied with Poland and Slovakia.

That’s down from 12th in 1960, and 23rd in 1990.

A common response to these numbers has been that US rates are not really comparable to those in other countries, for an assortment of reasons, including a high rate of premature births in the mix. The CDC disagrees.

International comparisons of infant mortality can be affected by differences in reporting of fetal and infant deaths. However, it appears unlikely that differences in reporting are the primary explanation for the United States’ relatively low international ranking.

Here’s the report’s summary.

Despite the dramatic decline in infant mortality during the 20th century, the U.S. infant mortality rate appears to have plateaued in the first few years of the 21st century.

The U.S. infant mortality rate is higher than rates in most other developed countries. The relative position of the United States in comparison to countries with the lowest infant mortality rates, appears to be worsening. In 2004, the United States ranked 29th in the world in infant mortality, tied with Poland and Slovakia. Previously, the United States’ international ranking in infant mortality was 12th in 1960 and 23d in 1990.

There are large differences in infant mortality rates by race and ethnicity. Non-Hispanic black, American Indian or Alaska Native, and Puerto Rican women have the highest infant mortality rates; rates are lowest for Asian or Pacific Islander, Central and South American, and Cuban women.

Preterm birth has a considerable impact on the U.S. infant mortality rate. The plateau in the U.S. infant mortality rate from 2000 to 2005 is due to an increase in the percentage of infants born preterm (including very preterm and late preterm), together with a lack of decline in the infant mortality rate for very preterm infants. There has also been an increase in the relative impact of preterm-related causes of death. In 2005, 36.5% of infant deaths in the United States were due to preterm-related causes of death, a 5% increase since 2000. The impact of preterm-related causes of death was even higher for non-Hispanic black and Puerto Rican women.

NY Times: The Wrong Place to Be Chronically Ill

Chronically ill Americans suffer far worse care than their counterparts in seven other industrial nations, according to a new study by the Commonwealth Fund, a New York-based foundation that has pioneered in international comparisons. It is the latest telling evidence that the dysfunctional American health care system badly needs reform.

The results of the study, published by the respected journal Health Affairs, belie the notion held by many American politicians that health care in this country is the best in the world. That may be true at a handful of pre-eminent medical centers, but it is hardly true for the care provided to a huge portion of the population.

From the report:

Synopsis
A 2008 survey of chronically ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States found major differences in health care access, safety, and efficiency, with U.S. patients at particularly high risk of forgoing care because of costs and experiencing errors or inefficient, poorly organized care.

…

Key Findings

• More than half (54%) of U.S. patients did not get recommended care, fill prescriptions, or see a doctor when sick because of costs, versus 7 percent to 36 percent in the other countries.
• About one-third of U.S. patients—the highest proportion in the survey—experienced medical errors, including delays in learning about abnormal lab test results.
• Similarly, one-third of U.S. patients encountered poorly coordinated care, including medical records not available during an appointment or duplicated tests.
• The U.S. stands out for patient costs, with 41 percent reporting they spent more than $1,000 on out-of-pocket costs in the past year. U.K. and Dutch patients were most protected against such costs.
• Only one-quarter (26%) of U.S. and Canadian patients reported same-day access to doctors when sick, and one-fourth or more reported long waits. About half or more of Dutch (60%), New Zealand, (54%), and U.K. (48%) patients were able to get same-day appointments.
• A majority of respondents across the eight countries saw room for improvement. Chronically ill adults in the U.S. were the most negative; one-third said the health care system needs a complete overhaul.
• In the past two years, 59 percent of U.S. patients visited an emergency room (ER); only Canada had a higher rate (64%). In both countries, one of five patients said they went to the ER for a condition that could have been treated by a regular doctor if one had been available.

I’ve jammed a lot of pills down the throats of a lot of cats over the years, and have gotten reasonably proficient at it. Still, my reject rate is higher than I’d like, and I keep a precautionary tube of Neosporin handy.

Until now. When our local vet prescribed Prednisone, two pills a day, for our Orange Marmalade, they also lent us a nifty device for administering said pills.

It works like a charm, both for me and for Marmie, and it’s available through Amazon.com as the “Pet Piller Single For Small Pets“. At $2.99, even with another $4 for shipping, it’s a bargain, though you might want to check your local pet supply first.

Presumably it’d work fine for dogs as well.

Last month, PBS’s Frontline showed a fascinating documentary on the state of health care delivery in five developed countries around the world.

The program is available online. Watch it.

From the introduction,

In Sick Around the World, FRONTLINE teams up with veteran Washington Post foreign correspondent T.R. Reid to find out how five other capitalist democracies — the United Kingdom, Japan, Germany, Taiwan and Switzerland — deliver health care, and what the United States might learn from their successes and their failures.

Reid’s first stop is the U.K., where the government-run National Health Service (NHS) is funded through taxes. “Every single person who’s born in the U.K. will use the NHS,” says Whittington Hospital CEO David Sloman, “and none of them will be presented a bill at any point during that time.” Often dismissed in America as “socialized medicine,” the NHS is now trying some free-market tactics like “pay-for-performance,” where doctors are paid more if they get good results controlling chronic diseases like diabetes. And now patients can choose where they go for medical procedures, forcing hospitals to compete head to head.

While such initiatives have helped reduce waiting times for elective surgeries, Times of London health editor Nigel Hawkes thinks the NHS hasn’t made enough progress. “We’re now in a world in which people are much more demanding, and I think that the NHS is not very effective at delivering in that modern, market-orientated world.”

Reid reports next from Japan, which boasts the second largest economy and the best health statistics in the world. The Japanese go to the doctor three times as often as Americans, have more than twice as many MRI scans, use more drugs, and spend more days in the hospital. Yet Japan spends about half as much on health care per capita as the United States.

One secret to Japan’s success? By law, everyone must buy health insurance — either through an employer or a community plan — and, unlike in the U.S., insurers cannot turn down a patient for a pre-existing illness, nor are they allowed to make a profit.

Reid’s journey then takes him to Germany, the country that invented the concept of a national health care system. For its 80 million people, Germany offers universal health care, including medical, dental, mental health, homeopathy and spa treatment. Professor Karl Lauterbach, a member of the German parliament, describes it as “a system where the rich pay for the poor and where the ill are covered by the healthy.” As they do in Japan, medical providers must charge standard prices. This keeps costs down, but it also means physicians in Germany earn between half and two-thirds as much as their U.S. counterparts.

In the 1990s, Taiwan researched many health care systems before settling on one where the government collects the money and pays providers. But the delivery of health care is left to the market. Every person in Taiwan has a “smart card” containing all of his or her relevant health information, and bills are paid automatically. But the Taiwanese are spending too little to sustain their health care system, according to Princeton’s Tsung-mei Cheng, who advised the Taiwanese government. “As we speak, the government is borrowing from banks to pay what there isn’t enough to pay the providers,” she told FRONTLINE.

Reid’s last stop is Switzerland, a country which, like Taiwan, set out to reform a system that did not cover all its citizens. In 1994, a national referendum approved a law called LAMal (“the sickness”), which set up a universal health care system that, among other things, restricted insurance companies from making a profit on basic medical care. The Swiss example shows health care reform is possible, even in a highly capitalist country with powerful insurance and pharmaceutical companies.

Today, Swiss politicians from the right and left enthusiastically support universal health care. “Everybody has a right to health care,” says Pascal Couchepin, the current president of Switzerland. “It is a profound need for people to be sure that if they are struck by destiny … they can have a good health system.”

An International Update on the Comparative Performance of American Health Care from the Commonwealth Fund:

Overview
Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. This report—an update to two earlier editions—includes data from surveys of patients, as well as information from primary care physicians about their medical practices and views of their countries’ health systems. Compared with five other nations—Australia, Canada, Germany, New Zealand, the United Kingdom—the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives. The U.S. is the only country in the study without universal health insurance coverage, partly accounting for its poor performance on access, equity, and health outcomes. The inclusion of physician survey data also shows the U.S. lagging in adoption of information technology and use of nurses to improve care coordination for the chronically ill.

It would have been nice to have some other countries included (notably France), but it’s informative all the same.

Via Mark Thoma

(Cleaning out my closet of health-care pieces.)

Ezra Klein points us to a new study comparing Canadian to US health care outcomes.

Canada vs. America
It’s not that the data shows unbelievable advantages for Canada, to be sure. As the authors conclude, “although Canadian outcomes were more often superior to US outcomes than the reverse, neither the United States nor Canada can claim hegemony in terms of quality of medical care and the resultant patient-important outcomes.” The question raised is slightly different: How can we possibly countenance a system that costs twice as much as the Canadian system but delivers slightly worse care? Even assuming diminishing returns, our expenditures should result in care outcomes at least 20% or 30% better than Canada’s. Instead, they’re about 5% worse, but cost around 187%. Does it sound like we’re getting a good deal?

Reviewing Jonathan Cohn’s book, Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price, Phillip Longman suggests that we should be looking to the excellent VA hospital system, described in an earlier Longman piece, as opposed to following Cohn’s proposal of making everyone eligible for Medicare.

The key to the cure is understanding that there is more than enough money already sloshing around the health care system to ensure every American access to quality care. Unfortunately, the current practice of American medicine, whether financed by Medicare, insurance companies, or other sources, is stunningly inefficient, unsafe, unscientific, and getting worse. And that’s why it costs so bloody much.
…
Adopting the VA model, with its salaried doctors and its extensive use of electronic information technology and evidence-based medicine, would cure the American health care crisis. Throwing more money into the current, fragmented, profit-driven system without changing the actual practice of American medicine might ease the problems of the uninsured temporarily, but would also give us more inappropriate, sometimes dangerous, and ever-more-expensive care.

Dean Baker:

The New York Times had an interesting piece on the poor state of the dental care provided by the British public health care system in its Sunday paper. The article reports that people face long waits for even emergency dental care, and that many now turn to private dentists or go to foreign countries for treatment.

Readers naturally feel sorry for the plight of Britons with bad teeth and are thankful that here in the United States we have an efficient private health care system. The key fact missing in the story is that Britain spends less than 37 percent as much person for its health care as the United States. Whatever the relative merits of the British mechanism for providing health care and the U.S. system, it would be truly astonishing if the British system could best the U.S. in every category, spending just 37 cents to our dollar. (Britain does much better on life expectancy for its 37 cents.)

Paul Krugman, from behind the NT Times paywall, courtesy of Mark Thoma:

Many pundits see red at the words “single-payer system.” They think it means low-quality socialized medicine; they start telling horror stories — almost all of them false — about the problems of other countries’ health care. Yet there’s nothing foreign or exotic about the concept: Medicare is a single-payer system. It’s not perfect, it could certainly be improved, but it works.

So here we are. Our current health care system is unraveling. Older Americans are already covered by a national health insurance system; extending that system to cover everyone would save money, reduce financial anxiety and save thousands of American lives every year. Why don’t we just do it?

Sure, it’s cheaper and better health care. But it’s un-American. Via Kevin Drum:

Advocates of universal healthcare frequently claim that European-style national healthcare systems, aside from being fairer, are just more efficient than ours. They provide decent healthcare at a lower cost than the jumbled, pseudo-free market system we have in the United States.

But is it true? Do even relatively mediocre, underfunded national healthcare systems like the one in Britain perform as well as American healthcare? A new study published in the Journal of the American Medical Association reaches a pretty unambiguous conclusion.

The researchers studied health outcomes in both countries and controlled for age by comparing only people aged 55-64. They controlled for race by studying only non-Hispanic whites. They controlled for obesity. They controlled for income. They controlled for education. They controlled for everything they could think of. Here’s what they found:

“At every point in the social hierarchy there is more illness in the United States than in England and the differences are really dramatic,” said study co-author Dr. Michael Marmot, an epidemiologist at University College London in England.

….The upper crust in both countries was healthier than middle-class and low-income people in the same country. But richer Americans’ health status resembled the health of the low-income British.

Via Sam Smith, Shankar Vedantam reporting in the Washington Post:

Pharmaceutical giant Eli Lilly and Co. recently funded five studies that compared its antipsychotic drug Zyprexa with Risperdal, a competing drug made by Janssen. All five showed Zyprexa was superior in treating schizophrenia.

But when Janssen sponsored its own studies comparing the two drugs, Risperdal came out ahead in three out of four.

In fact, when psychiatrist John Davis analyzed every publicly available trial funded by the pharmaceutical industry pitting five new antipsychotic drugs against one another, nine in 10 showed that the best drug was the one made by the company funding the study.

“On the basis of these contrasting findings in head-to-head trials, it appears that whichever company sponsors the trial produces the better antipsychotic drug,” Davis and others wrote in the American Journal of Psychiatry.

Such studies make up the bulk of the evidence that American doctors rely on to prescribe $10 billion worth of antipsychotic medications each year. Davis pointed out the potential biases in design and interpretation that produced such contradictory results. Other experts note that industry studies invariably seek to boost the image of expensive drugs that are still under patent. Moreover, they say, the trials are relatively brief and test drugs on patients with simpler problems than doctors typically encounter in daily practice.

By contrast, when the federal government recently compared a broader range of drugs in typical schizophrenia patients in a lengthy trial, two medications that stood out were cheaper drugs not under patent. The medication that worked best for patients with severe, intractable schizophrenia was clozapine, whose sales lag well behind every other drug in its class. And an earlier leg of the study found that the largely unused drug perphenazine had about the same risks and benefits as far more expensive competitors that are widely assumed to be safer.
…
Uwe Reinhardt, a political economist at Princeton, said drug companies, device manufacturers and even physicians are reluctant to delve into questions of cost-effectiveness because such inquiries may find that the latest, most expensive treatment is not worth the cost.

“I have come to believe a lot of inefficiency is quite deliberate and supported by Congress,” he said. “One person’s inefficiency is another person’s income.”

Paul Krugman and Robin wells, writing in the New York Review of Books.

This inefficiency is a bad thing in itself. What makes it literally fatal to thousands of Americans each year is that the inefficiency of our health care system exacerbates a second problem: our health care system often makes irrational choices, and rising costs exacerbate those irrationalities. Specifically, American health care tends to divide the population into insiders and outsiders. Insiders, who have good insurance, receive everything modern medicine can provide, no matter how expensive. Outsiders, who have poor insurance or none at all, receive very little. To take just one example, one study found that among Americans diagnosed with colorectal cancer, those without insurance were 70 percent more likely than those with insurance to die over the next three years.

In response to new medical technology, the system spends even more on insiders. But it compensates for higher spending on insiders, in part, by consigning more people to outsider status—robbing Peter of basic care in order to pay for Paul’s state-of-the-art treatment. Thus we have the cruel paradox that medical progress is bad for many Americans’ health.

The idiosyncratically American practice of tying health care to employment is heading for a crisis.

Providing health insurance looked like a good way for employers to reward their employees when it was a small part of the pay package. Today, however, the annual cost of coverage for a family of four is estimated by the Kaiser Family Foundation at more than $10,000. One way to look at it is to say that that’s roughly what a worker earning minimum wage and working full time earns in a year. It’s more than half the annual earnings of the average Wal-Mart employee.

Health care costs at current levels override the incentives that have historically supported employer-based health insurance. Now that health costs loom so large, companies that provide generous benefits are in effect paying some of their workers much more than the going wage—or, more to the point, more than competitors pay similar workers. Inevitably, this creates pressure to reduce or eliminate health benefits. And companies that can’t cut benefits enough to stay competitive—such as GM—find their very existence at risk.

Once consequence of this trend is that Medicaid is under increasing pressure.

Medicaid has grown rapidly in recent years because i has been picking up the slack from the unraveling syste of employer-based insurance. Between 2000 and 2004 th number of Americans covered by Medicaid rose by remarkable eight million. Over the same period the ranks o the uninsured rose by six million. So without the growth o Medicaid, the uninsured population would have exploded and we’d be facing a severe crisis in medical care

But Medicaid, even as it becomes increasingly essential to tens of millions of Americans, is also becoming increasingly vulnerable to political attack. To some extent this reflects the political weakness of any means-tested program serving the poor and near poor. As the British welfare scholar Richard Titmuss said, “Programs for the poor are poor programs.” Unlike Medicare’s clients—the feared senior group—Medicaid recipients aren’t a potent political constituency: they are, on average, poor and poorly educated, with low voter participation. As a result, funding for Medicaid depends on politicians’ sense of decency, always a fragile foundation for policy.

The Bush administration’s response to the problem is to push consumer-directed health care. Bad idea.

What’s wrong with consumer-directed health care? One immediate disadvantage is that health savings accounts, whatever their ostensible goals, are yet another tax break for the wealthy, who have already been showered with tax breaks under Bush. The right to pay medical expenses with pre-tax income is worth a lot to high-income individuals who face a marginal income tax rate of 35 percent, but little or nothing to lower-income Americans who face a marginal tax rate of 10 percent or less, and lack the ability to place the maximum allowed amount in their savings accounts.

A deeper disadvantage is that such accounts tend to undermine employment-based health care, because they encourage adverse selection: health savings accounts are attractive to healthier individuals, who will be tempted to opt out of company plans, leaving less healthy individuals behind.

Yet another problem with consumer-directed care is that the evidence says that people don’t, in fact, make wise decisions when paying for medical care out of pocket. A classic study by the Rand Corporation found that when people pay medical expenses themselves rather than relying on insurance, they do cut back on their consumption of health care—but that they cut back on valuable as well as questionable medical procedures, showing no ability to set sensible priorities.

It’s worse than, that, though.

But perhaps the biggest objection to consumer-directe health reform is that its advocates have misdiagnosed th problem. They believe that Americans have too muc health insurance; the 2004 Economic Report of the President condemned the fact that insurance currently pays for “many events that have little uncertainty, such as routine dental care, annual medical exams, and vaccinations,” and for “relatively low-expense items, such as an office visit to the doctor for a sore throat.” The implication is that health costs are too high because people who don’t pay their own medical bills consume too much routine dental care and are too ready to visit the doctor about a sore throat. And that argument is all wrong. Excessive consumption of routine care, or small-expense items, can’t be a major source of health care inefficiency, because such items don’t account for a major share of medical costs.

Remember the 80–20 rule: the great bulk of medical expenses are accounted for by a small number of people requiring very expensive treatment. When you think of the problem of health care costs, you shouldn’t envision visits to the family physician to talk about a sore throat; you should think about coronary bypass operations, dialysis, and chemotherapy. Nobody is proposing a consumer-directed health care plan that would force individuals to pay a large share of extreme medical expenses, such as the costs of chemotherapy, out of pocket. And that means that consumer-directed health care can’t promote savings on the treatments that account for most of what we spend on health care.

The administration’s plans for consumer-directed health care, then, are a diversion from meaningful health care reform, and will actually worsen our health care problems. In fact, some reformers privately hope that George W. Bush manages to get his health care plans passed, because they believe that they will hasten the collapse of employment-based coverage and pave the way for real reform. (The suffering along the way would be huge.)

The obvious answer, of course, is universal single-payer health care. I won’t try to summarize the case here (read the whole thing), but the real problem is political, not medical or economic.

We believe that the compromise plans being proposed by the cautious reformers would run into the same political problems, and that it would be politically smarter as well as economically superior to go for broke: to propose a straightforward single-payer system, and try to sell voters on the huge advantages such a sys-tem would bring. But this would mean taking on the drug and insur-ance companies rather than trying to co-opt them, and even progressive policy wonks, let alone Democratic politicians, still seem too timid to do that.

So what will really happen to American health care? Many people in this field believe that in the end America will end up with national health insurance, and perhaps with a lot of direct government provision of health care, simply because nothing else works. But things may have to get much worse before reality can break through the combination of powerful interest groups and free-market ideology.