Archive for International Best Practices
by Fred Fortin
March 24, 2008 at 1:25 pm · Filed under Policy Makers, International Best Practices, International Health
Bill Hsiao, a respected Harvard China healthcare scholar, along with co-author Winnie Yip, also at Harvard, have in this most recent issue of Health Affairs describe the challenges China faces in healthcare reform very succinctly:
China is at a loss as to how to transform its new money into efficient and effective health care. To tackle the root cause of unaffordable health care—rapid cost inflation caused by an irrational and wasteful health care delivery system, the very same issue confronting the United States—China needs to decide how to reform its health care delivery and payment systems; otherwise, most of the new money is likely to be captured by providers as higher income and profits.
By injecting substantial government funding to provide basic health care universally, China has taken giant steps forward to address its problems of unaffordable access and medical impoverishment. But these initiatives are silent on how China intends to tackle a fundamental cause of its problems: rapid cost inflation and inefficiencies of the delivery system.
The decisions that China needs to make are complex, and there is no silver-bullet solution. In light of the potential scale and magnitude of their impacts, it would be advisable for China to take a step-by-step approach, guided by pilot experimentation and objective, evidence-based evaluation.
As I have argued before, the expansion of coverage without paying serious attention to the outcomes of that care, will be a very expensive and troubling experience for China.
by Nick Jacobs
November 28, 2007 at 2:19 pm · Filed under Policy Makers, International Best Practices, Research
According to Reuters today, Iceland overtook Norway as the world’s most desirable country in which to live in the world. Based upon an index blending figures relating to life expectancy, educational levels and real per capita income, the world’s countries were rated. Rich free-market countries dominate the top places, with Iceland, Norway, Australia, Canada and Ireland the first five, but the United States slipping to 12th place from eighth last year in the U.N. Human Development Index. The U.S. scores high on real per capita GDP, which at nearly $42,000 was second only to Luxembourg at a little over $60,000.
Here are a few statistics for your consideration . . .
We have 98,000 unnecessary deaths in our health system from medical errors each year, and we spend $10 a day more on average to imprison someone in the United States than we do for long term care.
Under the category “If I had known that I would live this long, I would have taken better care of myself” . . . If you are a 50 year old woman today, there is a 40% chance that you will live to be 100 years old. If you count all of the people in the history of the world who have ever reached 65 years of age, 65%of them are alive today. In 2012 five years from now, there will be more people in the United States as Social Security beneficiaries than there are working Americans to support them.
If you are a child today, there is a 30% chance that you will develop Type II diabetes. One third of all children today will be afflicted with Type II diabetes and the devastating impact of that disease.
Keep in mind that at least 30% of every health care dollar that is spent in the United States is spent on the last 30 days of life.
It’s also important to reflect on the fact that in 1993, 13.8% of the Gross Domestic Product was dedicated to health care, and by 2015, 20% of the United States GDP will be dedicated to health care. This year we spent $2.2 Trillion on health care and only 4% of that on preventative medicine.
We have 47 M uninsured and 43 M under insured citizens in the United States, and I’m not sure if that includes our illegal aliens.
Okay, how about passing this information on to our presidential candidates for their consideration because, my friends, it’s all about leadership, leadership at all levels.
by David Williams
October 10, 2007 at 9:56 pm · Filed under Policy Makers, International Best Practices
Writing in the September/October Health Affairs –which I finally found a moment to read–, Gerard Anderson (public health professor at Hopkins), Bianca Frogner (doctoral candidate at Hopkins), and Uwe Reinhardt (Princeton professor) examine the level of spending on health care in the US and elsewhere. (See Health Spending In OECD Countries In 2004: An Update.) As is often the case in health care when you take a look at the data, the conventional wisdom doesn’t hold up. Here are some interesting findings from the 2004 OECD data.
- US per capita spending is 2.5x the OECD median. (Ok, that one’s not a surprise.)
- US patients go to the doctor less often than the median: 3.9 MD consultations per capita in the US compared to the median of 6.1
- There are fewer doctors, nurses, and hospital beds per capita in the US than the median
- Inpatient bed days per capita are lower (0.7 US v. 1.0 median) due partly to a lower average length of stay (6.5 days US v. 8.2 days median)
- Number of advanced imaging units (MRI and CT) is similar to the median (though the authors don’t supply the data)
What’s causing this? The authors’ answer is the same as it was last time they looked at the data. “It’s the Prices, Stupid!” they say. In particular, they point the finger at “higher spending on physician services” though they don’t supply the data. They also indicate that the higher spending may be due to a high proportion of obesity in the US, though their case for this assertion isn’t particularly compelling.
There are a few things that would be interesting to know, beyond what the authors included:
- What is the impact of drug and medical device costs, both cost per unit and number of units?
- Does the authors’ culprit of “higher spending on physician services” hold up as a robust explanation or is it masking other factors?
- Do physicians have dramatically higher net incomes in the US or is some of the excess lost to administrative costs incurred by physicians looking to get paid? (Primary care physicians in the UK’s NHS seem to be well-compensated, for example.)
- What would be the impact of accounting for differences in financing medical education? If we added the cost of state-subsidized or fully paid medical school to some of the other countries’ tallies, how would that affect spending? Also, does self-financing of medical education in the US encourage physicians to seek out higher-paid specialties than they otherwise would in order to escape debt faster?
- Where do “rationing” and “waiting lists” fit in? Overall utilization is higher overseas, but that doesn’t tell us about specific services
by David Williams
June 22, 2007 at 6:30 pm · Filed under Policy Makers, International Best Practices, Medical Tourism
An article in today’s Business Week (The Doc’s In, but It’ll Be a While) examines the issue of waiting times for health care in the US.
One of the most repeated truisms about the U.S. health-care system is that, for all its other problems, American patients at least don’t have to endure the long waits for medical care that are considered endemic under single-payer systems… But… waiting times in the U.S. are often as bad or worse as those in other industrialized nations… In addition, 48 million people without insurance do not have ready access to the system.
The article’s author, Cathy Arnst, interviewed me for the story. She’d seen a commentary I’d written about a well-insured patient who had to wait for care, and I let her know about some data sources to back up the anecdotes.
Changing demographics are only worsening the problem. Patients are getting older and sicker and requiring more care. But a new generation of doctors, half or more of them women, is no longer interested in working long, grueling hours. Low insurance reimbursements and heavy paperwork loads also limit physicians’ willingness to see any patient any time. And tightening immigration rules have limited the number of foreign-born doctors entering the U.S. “There are restrictions on the supply side and growing demand, so longer waits are going to be inevitable,” says David Williams, a consultant with MedPharma Partners in Boston.
There are a couple of key takeaways for me:
- Americans may have more in common than we think with Europeans and Canadians who go overseas to avoid waiting times
- It reinforces my conviction that Americans shouldn’t look down their noses at health care provided elsewhere. We know we spend more in the US. The evidence on what we get for that extra spending is pretty thin
by Scott MacStravic
May 30, 2007 at 8:04 am · Filed under International Best Practices, Disease Management
Fred Fortin’s discussion of “Soft Power” suggests the potential for the US to lead by example in the healthcare arena, whereas it has lost influence to a significant degree in other areas, thanks to dropping behind on environmental issues and championing democracy. Given the amount of money the US spends in healthcare, and its leadership in technology applied thereto, the potential might seem great.
The problem is that our “lead” in healthcare seems to be mainly in our proven ability to spend far more per capita than any other nation on earth, while getting far less return on our investment in terms of the health of our population. The one area where we might offer leadership is in proactive health management (PHM), where we have a large industry devoted to reducing the incidence and prevalence of disease and injury, as well as managing existing chronic diseases in order to reduce their crises, complications, and worsening over time.
All other nations in the world share problems related to out-of-control increases in the incidence and prevalence of disease and injury, either infectious diseases in underdeveloped countries, or chronic diseases in developed. The reason we have not created leadership in this arena is that we have not proven to be cost-effective in doing anything about the problem.
Our government keeps coming up with the same conclusions, and publishing them for all the world to read, that disease management, as practiced here, has not proven to work. Moreover, the majority of PHM investments are still evaluated in terms of reducing the rate of increase in healthcare costs, where many other countries in the world, as well as many employers in this country, have long since added the far greater returns that are being achieved in improving workforce productivity and performance. Besides, preventing chronic diseases will clearly save a lot more money than managing them.
The rest of the world is often leading the US. Because insurers, employers and the government (plus taxpayers, of course) share the burden of paying for sickness care, most of the wellness, risk reduction and disease management efforts we have been involved in for the past few decades have been aimed at controlling sickness care costs. They have usually been piecemeal, rather than strategic, and looking for short-term rather than lasting payoff.
In Europe, plus countries like Australia, South Africa, etc. that are equally well “developed”, governments often bear the burden of sickness care costs. This does not mean that employers are unconcerned with employee health, however. For one thing, many employers bear part of the burden, or offer private health insurance for workers when use such fringe benefits to recruit and retain the talent they need. And for another, they have found that healthier/happier employers are significantly more valuable to their employers than are unhealthy/unhappy ones.
European firms, particularly those in the UK, have found that employee health and well-being efforts pay off in significantly reduced absence rates, as well as reduced productivity impairment when at work (“presenteeism”). Dramatic reductions in turnover have been achieved, along with on-the-job injuries and sick leave costs. And those that have looked have often found positive impacts on revenue as well.
Healthier/happier employees tend to deliver higher quality products and services, increasing customer satisfaction and loyalty. Their enthusiastic recommendations of their firms’ products and services, along with the word-of-mouth “advertising” by more satisfied customers have been credited with significant increases in new business and added revenue. While many other factors in the handling of employees contributes to these same results, any health improvement effort that does not is likely to miss a substantial amount of value already being delivered.
Until and unless the US qualifies to and actually takes a leadership role in the measurement and management of all the factors that affect employee productivity and performance, it will not be entitled to such a position in proactive health care, any more than it is in reactive sickness care. While our country enjoys one of the highest productivity levels in the world, that is more due to technological innovations and working employees harder than most other countries. When it achieves such pre-eminence via managing employee health and happiness better than anyone else, it may justify a leadership position in proactive health as well.
by Fred Fortin
May 4, 2007 at 2:03 am · Filed under Uncategorized, International Best Practices
The World Health Organization (WHO) launched its “Solutions for Safety” program yesterday to help reduce the toll of health care-related harm affecting millions of patients worldwide.
“Recognizing that health care errors affect one in every 10 patients around the world, the WHO’s World Alliance for Patient Safety and the Collaborating Centre have packaged nine effective solutions to reduce such errors,” said WHO Director-General Dr Margaret Chan. “Implementing these solutions is a way to improve patient safety.”
The WHO would like its Member States to re-design patient care processes and make them safer in the following areas:
- Look-alike, sound-alike medication names;
- Patient identification;
- Communication during patient hand-overs;
- Performance of correct procedure at correct body site;
- Control of concentrated electrolyte solutions;
- Assuring medication accuracy at transitions in care;
- Avoiding catheter and tubing misconnections;
- Single use of injection devices; and
- Improved hand hygiene to prevent health care-associated infection.
The organization has provided information materials on each of these areas and sees them as an inaugural set to get the effort off the ground. A separate pilot will study and measure the impact, implementation and long-term results of the Patient Safety program.
The WHO clearly recognizes the challenges this initiative poses given the complexity of health care and lack of international standardization. So it set some practical expectations.
“The Solutions from this initiative will not address the broad underlying causes of patient safety problems (e.g. inadequate resources), but rather will be directed at the specific level where good process design can prevent (potential) human errors from actually reaching the patient. “
While I think the official estimates of medical errors worldwide are grossly underestimated, this program hits all the right tones as it seeks to build an international consensus on how to move forward.
