Monday, April 7, 2014

Does the United States have the best health-care in the world?

Does the United States have the best health-care in the world?

That was the question posed by a noted professor of medicine at a recent conference I attended.  Of the physicians and other health professionals that made up the audience, not one raised their hand.  Not one!  How could that be?

Was no one in the audience aware that the United States has among the highest survival rates for cancer treatment in the world?  That our outcomes for complicated surgery are the envy of the globe?  That trauma care is not equaled in any other country? 
Was the audience composed of a bunch of anti-American radicals intent on destroying the best system of medical care the world has ever seen?  After all, look at all the wealthy foreigners that flock to our hospitals to receive the latest innovations in treatment from the best and brightest doctors in the world!

One can say, with a fair degree of confidence that the United States is the best country in the world to be in if you are very sick (definitely where you want to be if you get shot, stabbed or if you’re involved in a high-impact motor-vehicle accident – yes, we’re the kings of trauma care!)  But the objective of a health-care system goes beyond caring for the ill:  it has the responsibility to help preserve health among the non-infirm.  And that’s where we don’t do so well.

This is not a function of the quality of the doctors in our country but of the organization of the preventive services we have available.  The key concept at play is that improving the medical care physicians provide will have a minimal impact on broader outcomes of health in our country.
This can be easily understood when we break down the determinants of one’s health listed here from highest to lowest importance:

Behavioral patterns (smoking, diet/exercise, use of seatbelts, etc.):     40%
Genetic predisposition:            30%
Social circumstances (income, socio-economic status):   15%
Medical care received:    10%
Environmental exposure:   5%

As you can see, medical care received is near the bottom of the list.  So access to great physicians, laboratory tests and newest medications is relatively unimportant in terms of an individual’s overall health compared to habits, genetic make-up and socio-economic status.

Yet, we continue to invest disproportionately in medical care; in fact we spend way more per capita on medical services than any other country in the world.  To make things worse, the traditional model of physician re-imbursement has always favored performing as many procedures (often of dubious value) on the individual patient as possible while not rewarding efforts towards improving health on a community level.

The professor giving the talk offered the following solution, very much tongue-in-cheek:  “If you’re really sick, come to the United States.  If you’re healthy and want to stay that way, go to Norway!”

A better solution would be to re-examine our health-care priorities in this country:  to change physician compensation so that it rewards preventive care instead of offering perverse incentives; to address social determinants of illness and eliminate disparities in delivery of care; and to engage patients as partners in health to promote healthy behaviors.  Until we do so, a large proportion of our health-care dollars will go up in smoke.

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