Lies and Statistics: What Really Makes a Health Care System Successful?

“Europe’s strong primary care systems are linked to better population health but also to higher health spending.”

With that auspicious title, Health Affairs recently regaled us with a bevy of articles, ostensibly showing us the error of our health care ways, the true path forward being clear if we are only smart enough to pay attention.  Topics ranged from “Health Care Cost Containment Strategies Used in Four Other High-Income Countries Hold Lessons For the United States” to my personal favorite, “Hospital Payment Based on Diagnosis-Related Groups Differs in Europe and Holds Lessons For The United States.”

But back to Europe’s “strong primary care.” The main thrust of the article can be summarized by their analysis “that strong primary care was associated with better population health; lower rates of unnecessary hospitalizations; and relatively lower socioeconomic inequality, as measured by an indicator linking education levels to self-rated health.” Really? What sort of metric is that?

From NationMaster.com, a few statistics from some of the countries specifically mentioned in the article:

Netherlands Spain Portugal Luxembourg Turkey Austria USA
Life exp (yr)
79
80
77
79
70
79
77
Smokers(%)
32
28
20
33
32
36
17
CAD death/100k
75
53
55
68
??
109
106
Obesity (%)
10
13
12
18
12
9
30
Inf Mort/1000
5.1
4.1
5.1
4.8
24.0
4.7
6.8
Hospital
beds/1000
11.1
4.1
3.6
8
2.4
8.3
3.3

In case you were wondering the heart disease death rate for Canada is 94, Germany 106, Australia 110, Norway 112, Iceland 115, and New Zealand 127.

Well, what about the six most populous countries in the world?

China India USA Indonesia Brazil Pakistan
Population (B)
1.3
1.1
0.33
0.24
0.188
0.165
Inf Mort/1000
24.6
60.7
6.8
34.3
24.2
76.2
Life exp (yrs)
72
64
78
67
72
64
CAD mort/100k
No Data
165
106
150
81
222
Nobel prizes
8
7
338
1
1
1

Are we to believe, based on this analysis, that fat people are smarter, smokers tend to live in smaller countries and those countries with lots of primary care doctors do a really poor job of providing basic health care advice like not smoking?

Likewise, is it true that countries (health care systems) with lots of “primary care” do better with less cost because of primary care doctors, the implication in the U.S.? Could it be that systems which encourage their populations to have routine care “do better,” a result much more likely a function of culture and payment model than “primary care.” Could it be that the physician of first contact is a gatekeeper, limiting access to higher levels of care?

I would speculate that incentivizing all providers to deliver first contact, broadly based care for large segments of the population is the key, the level of training of the provider notwithstanding.  Every cardiologist I know is an outstanding internist, a statement also true for the oncologists, pulmonologists and nephrologists with which I have the privilege to work.

Why not a simple tweak of the current, much aligned fee for service payment system, providing an incentive to function as a patients principal physician, moving us in that direction? For instance, why not increase the E and M payment by 20 percent, and reduce the procedural payments by a commensurate amount while making the hospitals a cost center rather than a profit center? Why not encourage providers in disadvantaged areas by paying them even more, a sort of reverse geographic price cost index?

Oh, I know. “It won’t work,” they’ll say. As if what we are doing now is working?

What are your thoughts?

One thought on “Lies and Statistics: What Really Makes a Health Care System Successful?

  1. I applaud your thoughtful comments, Dr. May. Much of what you stated is what many of us in the trenches of primary care are thinking as well. In that regard though, even though I am in agreement that sub specialists are also outstanding internists, most are so overwhelmed with work (especially cardiologists and pulmonologists) that they have no interest in providing primary care. Generally, they have no interest in filling out the myriad forms and other administrative burdens that end up falling to the lowest place on the hill, my lap and the lap of my colleagues who choose to provide comprehensive primary care (I deliberately am using that word, choose, I could and may still sub specialize for reasons stated herein). Changing the E&M system will not change our overall impending shortage of providers in nearly all clinical domains of internal medicine and its sub specialties. It may help those like yourself, of whom I know numerous, who also are sub specialists already serving as the sole point of contact for their patients. Those physicians are by in large salaried so their pay is not tied to their numbers and procedures. We already do pay primary care internists more to work in underserved areas, and that still is not attracting people into those areas. Why? The jobs are terrible in terrible places. That’s why no one wants them. Increasing access to telemedicine is one way to combat that shortage. Lets face it, most of us in internal medicine did not choose the field for the money. If that were the only consideration, I would be an ENT do who also did a plastics fellowship, or ophthalmology. I chose internal medicine for the same reason many of my colleagues did, the love of the intellectual feast that is the physiology of the Human body in health and in pathos, and for the love of helping others. What I think would do the most good is to get insurance companies to do what is right, not what makes profit. Wall Street should not dictate the terms of our art and science. Not for profit medicine has models that work. Stop direct marketing of pharmaceuticals to patients. Keep the lobbyists for the insurance industry and pharma out of the Capitol Building. Make medical education affordable. Reclaim the status as honorable people that physicians once held. Be accountable to your community, not a bean counter. Practice from a place of compassion, not out of fear that if you don’t see a patient every 10 minutes you will lose your job with that privately owned for profit employer. Volunteer a day or half day a week in the community free clinic. Bring back professional courtesy (anyone remember that?). Read the oath of Hippocrates you recited when you received your doctoral degree, it is in there. Engage our communities in prevention and educate them regarding their obligations and ownership concerning access to their healthcare resources, including physicians through philanthropy and grants. Yes, is what I’m saying here nothing short of rebellion and revolution? You bet. You said it well Dr. May, “Oh, I know. “It won’t work,” they’ll say. As if what we are doing now is working?” Einstein once said “If at first the idea is not absurd then there is no hope for it.”

    Respectfully Yours,
    Cynthia Archer, MD
    Internal Medicine

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