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.
