Stop trying to copy health care systems from other countries

“It is immoral that the wealthiest nation on the planet does not provide affordable, high-quality health care to all of its citizens. Despite being the only global ‘superpower’ still standing, we trail much of the industrialized world in life expectancy, infant mortality, and countless other indicators of health. Until we fix our broken, prohibitively expensive delivery system, things will only get worse.”

I’m not sure if anyone has used those exact words, but the sentiments expressed therein have served as the impetus behind health policy reform in this country for years. And droves of “thought leaders” have stepped forward to make ours a healthier, more righteous nation — health insurance exchanges, EMR technologies, ACOs, quality strategies, rating systems, patient satisfaction surveys, pay-for-performance reimbursement models, and price transparency initiatives, together costing billions of dollars, have been the result. These same “disruptive innovators” and “creative destroyers” have also asserted that we must emulate other countries’ health care systems if we are to march toward a more equitable, salubrious national future and assume our rightful place atop the global health hierarchy.

The problem, of course, is that medical care, along with all of the other activities we collectively refer to as “health care,” has a rather negligible impact on aggregate health indicators such as life expectancy. In fact, we’ve known for quite some time that a nation’s health status is primarily a function of its socioeconomic idiosyncrasies and, to a lesser extent, the genetic composition of its citizenry. Similarly, how well or poorly a society treats its sickest, most vulnerable citizens is more a reflection of its collective values than it is a measure of its health care system’s efficacy or administrative efficiency.

Stated differently, “health” and “health care” are entirely unrelated concepts. Health is largely about life, about unique individuals, their daily struggles, their jobs, their mortgages, their lifestyles. It is neither attained nor lost in a doctor’s office, and it cannot be isolated from the culture that yields it or be easily reproduced in a different environment. Spending billions to introduce new layers of administrative refuse between physicians and patients, or to implement untested or foreign delivery models, is therefore useless. Those approaches are as ineffectual as attempting to improve education by incorporating Asian décor in our schools or investing more heavily in principals’ offices than classrooms.

So if improved health is the goal, and health is primarily a function of other phenomena, why focus almost exclusively on health care policy? Well, she’s currently the sexiest, most powerful woman in the room, and she’s got very deep pockets to boot. Sure, physicians know she lacks substance. But politicians are drawn to her because she controls millions of votes. And “thought leaders” flock to her because she’s financially promiscuous: “No health care experience? No medical training? No problem, stud. Here’s a billion bucks — go throw some shit against the wall and see what sticks. Show those doctors how it’s done.”

More importantly, however, health care delivery has increasingly become a convenient scapegoat in our society. We blame it for anything we find distasteful (e.g. death, inequality, drug addiction, racism). A health care system, though, is merely a mirror that reflects a society’s existing moral identity, not a womb within which that identity is conceived. Make no mistake — health care is important. But spending exorbitant amounts of money restructuring the administrative components of a system that does not cause, and cannot fix, the problems we wish to address is a waste of valuable resources. So what are some of the problems we should be addressing?

Wealth inequality

Take a look at the graph below which shows the median wealth and life expectancy at birth in ten countries:

Stop trying to copy health care systems from other countries

We already know that health status is closely linked to wealth — the wealthier you are, the healthier you tend to be — so the slope of these lines is no surprise. But viewing the data this way helps us understand why we have relatively poor life expectancy despite being the most affluent nation on Earth. Because of the staggering inequality in the United States, our median wealth ($44,911) is much closer to that of China ($8,023) or India ($1,040) than it is to the average median wealth of the other seven countries represented on the graph ($122,830).

Until we address the wealth inequality in this country, we will continue to die younger than the citizens of other nations, no matter how many patient satisfaction surveys we develop. If improved health is really the goal, focusing exclusively or disproportionately on doctors and hospitals isn’t an option.

Geocultural complexity ℠

So why not just pick another country’s health care system and “copy” it? Well, take a look at the graph below which shows the level of Geocultural Complexity ℠ in the same ten countries.

Stop trying to copy health care systems from other countries

Geocultural Complexity ℠ is a scale that attempts to quantify the degree to which a country’s geography, demographics, and culture pose a challenge to health care delivery. It incorporates numerous national characteristics such as land area, population size, age distribution, diet quality, inactivity levels, geographic distribution (rural vs. urban), linguistic diversity (LDI), and several other criteria.

The purpose of the graph, though, is not to prove that there is a strong correlation between this measure of complexity and life expectancy (though there may, in fact, be one — as complexity increases, life expectancy seems to decrease). Rather, the goal is simply to show that each country poses distinct challenges. And if you really think about it, that makes perfect sense.

Intuitively, we know that delivering health care to the small, highly concentrated populace of Singapore (population — 6 million; distribution — 0% rural; land area — 268 square miles) is less challenging than doing so in the U.S. (population — 319 million; distribution — 20% rural; land area — 3.717 million square miles). Similarly, it isn’t a stretch to assume that it’s easier to serve a homogenous population consuming a sound diet (e.g. Japan: LDI — 0.036; obesity rate — 5%) than a heterogeneous one consuming a poor diet (e.g. United States: LDI — 0.334; obesity rate — 33%).

The point is simply that every country is unique. And a health care system does not exist in a vacuum — it is born of, and inextricably linked to, a nation’s distinct political, cultural, geographic, and economic environments. “Copying” Switzerland’s financing model but not its restrictions on insurance company profit, emulating Japan’s delivery model but not its citizens’ diet habits, or adopting Singapore’s entire health care system but not itsstate capitalism will not make us any healthier. It’s just not that simple.

Moving forward

If we want to improve our nation’s health, we need to rethink our strategy. First, contrary to what our thought leaders tell us, we need to focus on making ours the best, most efficient “sick care” system in the world. Marketing tactics and political doublespeak aside, health care is, first and foremost, about caring for the ill, about providing them with low-cost, high-quality medical care when and where they need it.

Much of what we now label “patient-centered” is ineffective, overly expensive administrative clutter. And prevention is certainly important, but in many cases, it is best addressed outside the costly confines of a health care system. Paradoxically, the more we “study” health care delivery and attempt to “retool” it to solve problems it does not cause and cannot prevent, the more cost and waste we introduce. Let’s focus on cleaning up the clutter, removing administrative barriers, and allowing physicians to do what they were trained to do.

Next, rather than spending billions trying to make health care something it isn’t, we need to redirect those resources toward reducing inequality and improving education, two true determinants of health. Finally, and perhaps most importantly, we need to decide who we are as a nation. Let’s focus on building a health care system that is right for us, one that suits our culture, incorporates our values, respects our freedoms, and meets our needs, rather than simply adopting one designed to solve another country’s problems.

Luis Collar is a physician who blogs at Sapphire Equinox. He is the author of A Quiet Death.

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  • JR

    “she’s currently the sexiest, most powerful woman in the room…” “Sure, physicians know she lacks substance…”

    I hope I don’t need to explain why this statement is a problem?

    • Luis Collar, M.D.

      This was simply a metaphor intended to show that although many (e.g. politicians, administrators) find healthcare policy an “attractive” topic because of the money and votes associated with it, it lacks “substance” in that it does not cause, and cannot prevent, many of the health problems our nation faces. Much of the focus here is just a way to avoid addressing the issues (admittedly much harder ones to “fix”) that are really impacting our collective health.

      • JR

        I understood what the metaphor was.

        It is based on the oft-repeated “story” that a woman’s power is in her looks, not in her intelligence.

        http://www.ted.com/talks/chimamanda_adichie_the_danger_of_a_single_story

        This is a really powerful talk explaining how these “single stories” impact our society.

        • Luis Collar, M.D.

          The intent was quite the opposite. Specifically, that that is precisely what should not take place but often does (as in this case). Incidentally, the “power” I referenced was related to the money and votes attached to healthcare policy, and the “substance” was related to whether or not administrative healthcare policies can actually impact aggregate health outcomes. None of it was intended to deal with “intelligence” or the “story” you reference above.

          • JR

            When Adichie’s American college room mate asked to hear “her tribal music” there was no intent behind it. Rather, her college room mate had always been presented with a concept or idea of Africa as a unified place of poverty. This story has no room for a middle-class daughter of two professors raised in a city. This wasn’t the fault of her room mate, but that doesn’t mean it isn’t a problem.

          • Luis Collar, M.D.

            Your point is a valid one (though, again, it seems a bit of a stretch to apply it here). And I understand the issue and have seen the talk. I would only state that any man, woman, policy, or issue can, in fact, lack substance. While denying that reality may be politically correct, it is important to note that “finding” substance where there is none is just as dangerous as “ignoring” substance where it actually exists. Just take a look at reality TV ratings, the popularity of TV doctors or health “gurus,” and the public’s acceptance of any number of misguided, ineffective government policies. The unending need for “political correctness” can have a dulling effect on a society’s collective intellect and its ability to discuss issues openly and honestly. When that happens consistently over time, you end up with nothing but “safe” and “comforting” discourse that means little and solves nothing.

          • JR

            When someone evokes a stereotype, it appears to others that they are endorsing that stereotype as true.

            Take this story I used to tell:

            When I was a teenage girl, I heard a knock on the door. I opened the door to see a tall big black man, wearing a ski mask, holding a bloody deer leg!! He riped off the mask. “Hey, I brought this over for your dog!”. It was my neighbor who’ve I’ve known for years. I pointed him toward the back yard where my dog enjoyed the leg immensely.

            When I told that story, I had no ill intent toward anyone of any race. However, I’m evoking the “story” of black men being dangerous. Using a black man adds additional emotional impact to the story in the audience, because we accept that you have to be more careful around black men. They are dangerous.

            I don’t actually believe that. Yet by telling that story, in that way, I was conveying that I think that black men are dangerous to other people.

            Now, I’m aware of it. And because I’m aware of it I understand it and can change.

          • Luis Collar, M.D.

            If the story is true, and it happened that way, why not just tell it the way it actually happened? If there is any positive message that people can derive from it, and you change the story to be more “politically correct,” aren’t you, in fact, robbing people of the ability to learn from what, in your case, may have been the result of unintended bias?

            Again, I’ve explained that my intent was the opposite of the meaning you read into it. It was precisely that “one should not judge a book by its cover,” so to speak, but you seem to have come to a different conclusion. Had I stated it differently, we wouldn’t even be having this discussion, which I think is a good one. I think one’s words can always be misinterpreted, but dealing with that reality by saying nothing, or by self-censoring, defeats the purpose of dialogue.

          • JR

            Have you never had a patient that believed a stereotype about doctors?

            - You are only running this test to protect you from a lawsuit, not to benefit me.

            - Doctors are all rich and have lots of money, and you’re only wanting me to do this test/procedure to make money.

            - You are giving me the more expensive option in order to make money, not because it is a better option.

            No harm is done by stereotypes right?

          • Luis Collar, M.D.

            Sure, but I don’t see how being “politically correct” and avoiding the real issues does anything to fix that… And I never said stereotypes don’t, at times, cause harm (not sure where you got that from what I wrote). We seem to be going in circles here…probably just coming at this from different angles. Again, I’m glad you raised the issue, but “censoring” doesn’t help bring issues to light or resolve problems.

          • hawkeyemd1

            Being politically correct doesn’t fix anything. People that have those opinions of doctors won’t change their views no matter what we do. Just part of serving the public.

          • Luis Collar, M.D.

            Point well taken.

          • Eric W Thompson

            It is a stereotype that US Healthcare is poor. Just because it is backed up by numbers does not mean it isn’t a stereotype. As in your above example, blacks commit 50% of all murders though making up only 13% of the population. Thinking of them as dangerous is a stereotype and backed up by numbers. End all stereotypes and the discussion on US Healthcare also.

          • MDinTraining

            Blacks are also 50% of the victims of homicide. Why aren’t they then stereotyped as endangered? Numbers never tell the whole story, just the story the author wants to tell.

        • hawkeyemd1

          “It is based on the oft-repeated “story” that a woman’s power is in her looks, not in her intelligence.”

          Wow. I didn’t get that at all. Seems like the thought-police may be a little overzealous in this particular case. But then again I’m a guy so…lol.

  • Markus

    Are these graphs correct? Is the US really in a cluster of low wealth and short lives with China and India while western Europe and Australia are healthy and wealthy? No wonder that Dr Pho yearned to be French in one of his pieces a few weeks ago.

    • Jess

      The figures rely very heavily on real estate, which according to the report cited, forms 59 per cent of gross household assets among Australians. Real estate is very, very expensive in places like Australia and England; in Melbourne the median house price was $652,500 (AUS) as of first quarter 2014, in Sydney it’s around $700,000. Even Perth is around $550,000.

      I don’t think the average Australian thinks of herself as more than 5x richer than the average American is.

      • liz1rn1

        The numbers still apply though. The prices for real estate in those major cities are no different and probably cheaper than NYC, San Francisco, or Hawaii. I don’t know the exact number (maybe not 5x), but we’re falling behind other countries in terms of how the average person lives pretty quickly. All of that affect a person’s health much more than how many MRI machines a country has.

        • Luis Collar, M.D.

          Thank you for your comments. That was precisely my point.

        • Eric W Thompson

          Median prices are for the entire country. Ours is around $200K. Don’t compare cities to countries.

          • liz1rn1

            I was responding to a comment that cited high prices in individual cities so I pointed out individual cities in the US that are just as expensive. Do you think those don’t count? Is your argument that the average person in the US hasn’t lost ground to the rest of the world in wealth / income?

          • Eric W Thompson

            I think it is more that the rest of the world is catching up. Most of the places I lived outside the USA it still takes most of the average person’s income to live.

          • liz1rn1

            More like a big part of the world is pulling away, not catching up. We seem to already be behind most of western europe in wealth, and we’re losing ground in income there and elsewhere from what I’ve read recently.

      • Luis Collar, M.D.

        I used wealth (net worth) instead of income because the former is a more accurate representation of how individuals are doing financially over time. Income can be deceptive in that it is transient (can have a job making $50,000 today and then be unemployed tomorrow), and it says nothing about other important factors such as the relative cost of living in different places. Wealth, in contrast, says much more about what you have left to show for your labor after paying your bills over time.

        Also, wealth here is net of liabilities. That is, if you have an $800,000 home with a $760,000 outstanding mortgage on it, only the $40,000 in equity is counted toward your “wealth.” So to the extent that you are able to pay down your mortgage liability using current income, it is appropriate to include that amount as part of the wealth calculation. Of course, real estate valuations do influence the numbers, but that is consistent for every country represented. And the real estate prices in several US cities are every bit as high as the ones you reference (even after the huge dip in prices following the crash in 2008).

        Finally, I would only mention that even if you look at income and not at wealth, the US has lost ground there as well. The point is simply that by virtually any measure, we are individually not as wealthy as we once were relative to the rest of the world, even though we do still have the greatest collective wealth of any country on the planet. And that has much greater implications for a nation’s health than patient satisfaction survey results do..

    • JR

      We know that health goes beyond health care.

      Countries with the best outcomes spend more if we combine health care and social services. If you look at what the US spends on health care + social services combined, we actually don’t spend as much as we’d think. Our health care costs would go down if we implemented more social services.

      http://www.boston.com/lifestyle/health/health_stew/2013/12/why_the_us_spends_so_much_on_medical_care_–_revised.html

      Either way we’d still be spending money, we’d just end up with better health outcomes.

    • Luis Collar, M.D.

      They are correct. Of course, there are only 10 countries represented on the graphs. That means, for example, that there are other countries that fall between the US and China and are not represented here. But for the 10 countries shown, the data is accurate, and it is true that our median wealth is closer to that of China or India than to the other countries shown.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    You are underestimating the “reformers”, Dr. Collar. They understand these things all too well, and that is precisely why nobody is copying another system from a more fortunate country.
    What is costing us billions of dollars is the transformation of a health care system built to service a prosperous nation to a system custom built for a “superpower” with most of its citizens living in poverty. It’s not an easy task and it has never been done successfully… We are indeed pioneers…. More here: http://onhealthtech.blogspot.com/2014/06/health-care-for-poor.html

    • Luis Collar, M.D.

      Hi, Margalit… Probably should have been clearer… But I wasn’t implying that we have copied another system, rather that people often seem to want us to copy another system (e.g. the comments following most articles that deal with healthcare are often full of – “we should use Canada, or Switzerland, or Sweden, as a model”). The problem is that those systems were developed within a specific set of political, cultural, economic, and social values. There’s no reason to believe that just copying their healthcare system, or parts of it, would produce similar results given the other differences between those societies that lie outside the realm of their approach to healthcare.

      The other point I was trying to make was that ACOs, patient sat surveys and other administrative mandates / policies, while they are indeed homegrown and not imported from other countries, are not capable of truly improving our nation’s health. Just seems like we are wasting valuable resources developing administrative solutions to non-administrative problems, or problems whose solution lies outside the scope of a healthcare system entirely. Many of the problems we face originate outside our healthcare system and should be addressed head on where they begin.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        I think we’re saying the same thing in different ways :-)

        • Luis Collar, M.D.

          That’s starting to become a trend with us! Hope all is well.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Yeah… it’s all good… tilting at windmills as usual…

  • liz1rn1

    Great piece. Health is really about much more than what goes on in a hospital. I see this every day. But we focus on what goes on in the hospital and the doctor’s office much more than what goes on in “real life.” If we focused more on that, we might save more lives and even save money.

    • Luis Collar, M.D.

      Thanks for the kind words. Glad you enjoyed the piece.

    • hawkeyemd1

      Very true. But doctors are always an easier target. We’re low-lying fruit because we aren’t very well organized and don’t have the same lobbying capabilities as the other players.

      • liz1rn1

        I agree that they don’t have as powerful a lobby, but doctors aren’t exactly defenseless. At least no more so than the average American citizen or patient.

        • hawkeyemd1

          I wasn’t drawing a comparison between doctors and patients. I was only saying individual physicians are at a disadvantage as compared to large corporations.

          • liz1rn1

            I agree with that, but I still don’t understand why doctors don’t do more on that front. AMA and other organizations are supposed to work for you. At some point if your interests aren’t being represented properly then complaining won’t help without changing things. And if its that tough for you in a position of influence, what hope do patients have.

  • QQQ

    “Stop trying to copy health care systems from other countries”
    ———————————————————————————————
    A recent “Investor’s Business Daily” article provided very
    interesting statistics from a survey by the United Nations International Health Organization.

    Percentage of men and women who survived a cancer five years after diagnosis:

    U.S. 65%

    England 46%

    Canada 42%

    Percentage of patients diagnosed with diabetes who received treatment within six months:

    U.S. 93%

    England 15%

    Canada 43%

    Percentage of seniors needing hip replacement who received it within six

    months:

    U.S. 90%

    England 15%

    Canada 43%

    Percentage referred to a medical specialist who see one within one month:

    U.S. 77%

    England 40%

    Canada 43%

    Number of MRI scanners (a prime diagnostic tool) per million people:

    U.S. 71

    England 14

    Canada 18

    Percentage of seniors (65+), with low income, who say they are in “excellent health”:

    U.S. 12%

    England 2%

    Canada 6%

    And now for the last statistic:

    National Health Insurance?

    U.S. NO

    England YES

    Canada YES

    • DeceasedMD1

      interesting article QQQ. But the percentage of people in the US who have no access to medical care (whether related to cost, or the recent pre existing issues), makes their number zero.

  • Joe

    Are we really copying other countries? Don’t other nations have higher hospitalization rates and lengths of stay, for example? For another, aren’t most places in the world fee for service, which is exactly what we are trying to eliminate? I’ve never heard of the ACO concept being used in other countries. This is not rhetorical. I do not know the answer, but that is what I have seen/read in other places.

    • Dr. Drake Ramoray

      Other places have single payer, physicians can collectively bargain, med school is taxpayer funded, a completely different malpractice climate, relatively closed borders to immigration (Australia and New Zealand actually have an immigration score (do you have a skill and speak English etc)) (man in New Zealand is deported for being obese http://www.dailymail.co.uk/news/article-2380021/Albert-Buitenhuis-New-Zealand-kicks-obese-man-country-290lbs-heavy.html), much less use of NP’s or PA’s, physician pay is less (see above for taxpayer funded edudcation), and correct no ACO’s in other countries to name the differences that I can off the top of my head. Oh and there are twice as many people living in the state of New York than the country of Sweden (a country that relatively frequently gets used as an example model for those who prefer single payer).

      I have often linked the concept of single payer in the US to the need for physicians to be able to collectively bargain, and major immigration reform.

      • Joe

        Thank you. This is pretty much what I’ve heard elsewhere. So somebody clarify how we are copying other countries again?

        • Luis Collar, M.D.

          Replied to your first comment above. Hope that at least helps clarify the points I was trying to make. Thanks.

      • rbthe4th2

        Speaking of changing medical funding, have you seen this? http://www.physicianspractice.com/blog/designing-specialty-care-concierge-program?GUID=8D42C3C2-9E64-402A-997B-72124F0277EF&rememberme=1&ts=17062014
        I know you’ve talked about it but there was no other way I could send it to you. Good luck.

        Randy

        • Dr. Drake Ramoray

          Thanks for the link. This is not quite the same as I have in mind (hybrid concierge) as I think a thyroid only practice in particular is very amenable to a low cost direct pay practice more along the line of reasonably priced a la carte services. Each specialty is unique and I think new practice models are likely to continue to emerge among specialists as many of is lose interest in working for a hospital or be “part” of an ACO/PCMH. I think of oncology can did a way then anyone can.

          • rbthe4th2

            Hey Dr. D did you see this? Seems like you may want to hang around, you might get more valuable (albeit on the diabetes end): http://www.medscape.com/viewarticle/827244

          • Dr. Drake Ramoray

            Generally speaking endocrinologists don’t want to become more valuable on the diabetes end. I don’t sign up for stuff so I’m blocked from reading that. Thanks though the gesture is appreciated

        • hawkeyemd1

          Interesting article. Didn’t realize direct pay / concierge was becoming popular outside primary care. Thanks for sharing it here.

          • rbthe4th2

            I try to do what I can for those decent docs. Once you’ve been had by a doctor, it makes you sensitive to really cheering on the good ones. At least to a certain point. I couldn’t afford out of pocket but at least I dont begrudge someone a chance to be happy and try to do what they think is best for them, their family and patients.

          • hawkeyemd1

            Sorry about the bad experience you had in the past. Hope it was resolved and ended well. DPC is a good thing in my opinion, but I can see why it isn’t a solution for all or even most patients.

          • rbthe4th2

            I wish. It wasn’t. You know how it is: some egos go before patient health/care/welfare. Having been thru that makes me appreciate the good ones and try to give them my best, at the same time of drawing a line in the sand on what the MD did. I never want others to suffer through what I have and will simply because of an attitude problem.

          • hawkeyemd1

            I’ll let you in on an insider secret: lots of doctors are jerks. Don’t get me wrong, I respect a lot of my colleagues but lots (not 1%) are really cocky, self-absorbed, rude jerks that aren’t even all that smart. I don’t think we are worse than any other profession, but right now we really aren’t any better in a lot of cases. Lots of good ones, lots of bad ones.

          • rbthe4th2

            LOL I think the issue is that in medicine you are selecting for a population where “people” or “soft” skills aren’t a higher priority than maybe they should be? Yes the surgeon I had was all that. I’m just wondering what happened when the risk management got a small earful of what I put up with. I mean, I said the guy is good at one thing so why not keep him doing that? Reeducate him – and boy does he have a long way to go. What the bigger problem for me is the fact that my care got dropped and I’m suffering for it, without any joined care and its been put in the record even by one of his own that I’ve lost a lot by not having that.

            So how do you deal with these things?

          • hawkeyemd1

            From my perspective, the key is to just smile a lot and mind my own business. The cocky ones, I put them in their place if they pick a fight. Otherwise, I just avoid them. The ones that try to act very altruistic (at my expense) but really aren’t, I call out as being full of it. I’m a coworker, not their patient though so probably very different perspective.

          • rbthe4th2

            Thank you for that. I also call them out – but only with medical research at my back. That really seems to get their attention. I understand that docs can’t know everything. I expect my doctor has a life outside of his job, like I do. So I don’t mind doing some of my own research and then bringing that back to them for my care. I have just found a lot are intimidated by it, when I’ve even wrote multiple times, we’re a team. Yes, that ego scares me – they are the ones who cause bigger problems than any doc has to me by making a mistake. Its because the egos have made the bigger mistakes and then more on top of that by covering up. Besides, I want a doctor who knows how to fix messups, not someone who is going to make things worse by not doing it.

      • Luis Collar, M.D.

        “Oh and there are twice as many people living in the state of New York than the country of Sweden (a country that relatively frequently gets used as an example model for those who prefer single payer).”

        Great point. That is precisely why I tried to point out that understanding the context within which a nation’s healthcare system operates is critical to any public policy discussion. People are often too quick to assume that we can “copy” another country’s system and get the same, or even similar, results. Even though the ACA isn’t a replica of another system, people often call for that approach.

        Incidentally, I know that ACOs and other administrative policies currently en vogue here are homegrown and weren’t imported from other countries (that was part of a separate attempt to simply show that the billions spent on those administrative policies won’t make anyone “healthier”).

    • Luis Collar, M.D.

      Thanks, Joe. I probably wasn’t clear enough. I do not claim that ACOs are used in other countries. I was making two separate points.

      The first is that we are focused almost exclusively on developing administrative solutions (ACOs, patient satisfaction surveys, etc…) to problems that will not respond to that approach and are not even really related to healthcare (e.g. life expectancy, overall health). Spending so much money on ineffective administrative solutions to problems that really aren’t even related to healthcare delivery is not a good use of existing resources. Point is, surveys, EMRs, ACOs, etc, don’t really make our nation healthier.

      The second point was that many people like to point to other nations’ healthcare systems as ones that we should adopt here (not that the ACA or what we have done thus far is a replica of any of them). If you follow the healthcare debate closely, or read any of the comments following any articles that deal with healthcare, many repeatedly state that we should adopt Canada’s system, or copy Switzerland’s approach, etc… My point here was that since health is about much more than healthcare, and a healthcare system cannot be separated from the political, economic, and social constructs within which it exists, we can’t just copy another country’s system and expect similar results.

      • Joe

        Yes. That makes sense, and I appreciate your willingness to elaborate.

  • William Viner

    You can’t force good health on people no matter how you distribute the wealth. You also can’t discount good parts of a health care system just because the land and people are different. Why should we have to pay a middleman for health insurance? Why is health coverage often tied to a job? Why are there so many choices? All this does is cause more stress to those who partake of the system. I live/work in a country where I don’t have to even think about healthcare. I pay my taxes and I’m covered. If I want to be treated in a private hospital for a non-urgent surgery in a more timely fashion, then I’m free to pay for that luxury. I for one would be ecstatic if the US would copy a fairly well functioning system.

    • Luis Collar, M.D.

      I’m certainly not trying to “discount good parts of a health care system.” I’m merely pointing out that emulating all or parts of a system that was created to meet the specific needs of one country will not produce similar results in a different country, particularly as it applies to health (as stated in the piece, health and healthcare are largely unrelated).

      I also don’t believe that good health can, or should, be forced on anyone. I’ve written about that in the past:
      http://www.kevinmd.com/blog/2014/03/restrain-penchant-bans-mandates-health-care.html

      There are viable market solutions to healthcare, education, and even income inequality that are often ignored in favor of government-driven approaches that are at odds with many of our nation’s traditions.

  • DeceasedMD1

    Makes perfect sense that income inequality affects morbidity and mortality rates. But sadly the “unequal” are too sick or uneducated to take note or act. But where is Dr. Collar when you need him?

    • Luis Collar, M.D.

      Hi DMD… Sorry I couldn’t reply sooner. Hope all is well…

      Not sure I understand the question here. My point was simply that inequality affects a nation’s health much more than patient satisfaction surveys or other administrative “solutions”… So it doesn’t make sense to focus so much, and spend so much money, on developing administrative solutions to a non-administrative problem. We would be much better off addressing those problems head on.

      • DeceasedMD1

        Yes I see what you are saying. Your point is a very solid one and i thought it was spot on. There are so many economists writing books on this but so far no one has addressed how the inequality has affected poor pts. So I applaud your thinking and article.

        But this day and age it seems that CorpMed has no interest in what is logical or scientific. Feels like they do not care about solutions but just pacifying the public with surveys and admins which add no value. Their interest is in being a spin doctor. I sense that they are not interested in improving the system but just making money. That is the cynic in me. And then the people that are most affected really can’t fight back as they are the most vulnerable.

        But as much as they will continue to act in their own self interest, you have a very solid article here and i hope you could publish this elsewhere even an edit in NY Times would be most welcome. This needs to be outlined so it is more transparent to the public.

        • Luis Collar, M.D.

          Thank you, DMD. It’s funny that, if you really look at it, the billions of dollars spent on administrative “solutions” in healthcare have thus far provided a pretty poor ROI in terms of health. There have to be better approaches, approaches that actually lead to health gains, increase patient and physician autonomy, and bring patients and doctors closer together instead of driving them further apart.

          • DeceasedMD1

            That is our goal-not theirs. But it does create good jobs for admins.

  • Luis Collar, M.D.

    Not sure why this is an issue…the math is pretty clear here.

    I simply state that our median wealth is closer (not just “close” as you state) to China’s or India’s than to the average median wealth of the other nations on the graph. That is a fact (e.g. $45,000 is much closer to $8,000 than it is to $123,000), not an opinion.

  • hawkeyemd1

    “Much of what we now label “patient-centered” is ineffective, overly expensive administrative clutter.”

    Amen.

    ““Copying” Switzerland’s financing model but not its restrictions on insurance company profit, emulating Japan’s delivery model but not its citizens’ diet habits, or adopting Singapore’s entire health care system but not itsstate capitalism will not make us any healthier.”

    Amen.

    “If improved health is really the goal, focusing exclusively or disproportionately on doctors and hospitals isn’t an option.”

    …and AMEN. People just don’t get it that much of what ails them has nothing to do with health care. As usual, great job here. Your articles are consistently some of of my favorites.

    • Luis Collar, M.D.

      Thanks, HMD1. I appreciate the kind words.

  • Ava Marie Wensko George

    You know, when I began to read your article I was fully prepared to be disappointed. To the contrary – I am very impressed. I think the elephant in the middle of the room has been income inequality, the lack of education, and its impact on overall health and life expectancy. I am glad you so eloquently identified and explained the correlation between them. I work in healthcare and am a professor, so you hit a home run with me.

    • Luis Collar, M.D.

      Thank you very much for the kind words. Now, how can I get you to stop anticipating disappointment in the future? :) Just kidding…I always appreciate feedback, especially from those that disagree with me on policy, ideology, etc… I think we both want the same thing – better health for everyone. Good people can disagree on how to get there, but we won’t achieve progress unless everyone is truly committed to an open, honest exchange of ideas (and actually listening to those with whom they disagree). Your feedback is always welcome and appreciated. Thanks again.

      • Ava Marie Wensko George

        I just see so much of it :( We absolutely want the same thing…The health of our nation should not be predicated on politics or ideology. I think that even in the midst of disagreement, incredible ideas can develop. If we do not hold the discussion in an intelligent and respectful manner, we will continue to stagnate.

        • Luis Collar, M.D.

          I agree on all those points. The problem is that ideology (political or otherwise) inevitably does play a role – government vs. market solutions in healthcare, how best to address inequality, etc… – and so it needs to be discussed openly and honestly. Although discussions often devolve quickly as each side defends its “stance,” it is still a necessary part of the process. I tend to favor market solutions that empower individuals over bureaucratic mandates, but I am always willing to listen to all views.

  • Peter Schwimer

    “Let’s build a healthcare system that is right for us reflects our values etc. Problem is we already have one of those.

    • liz1rn1

      I don’t think everyone would agree with that statement. The ACA has many shortcomings that are very difficult to ignore.

  • Luis Collar, M.D.

    Great question. I wanted to limit the graphs to 10 countries for the sake of readability. I also wanted to limit the exercise to countries for which I could find reliable data, preferably from one source within each category (e.g. all life expectancy data from WHO, etc…) to avoid “picking” and “choosing” from different sources with different methodology, time frames, etc… This was challenging, particularly given the number of variables included in the geocultural complexity calculation, because I also wanted to use the same 10 countries for both graphs. To include Germany, I would have had to use a different source for median wealth than I did for the other countries studied (Germany was not included in the wealth section of the report / study linked to the post from which I obtained the wealth data). In other words, I had no “ulterior motive” for not including it.

    I would only add that, although the correlation between income and health has been studied extensively, the correlation between wealth and health has not been broadly explored. Although both terms are often used interchangeably, they are indeed different entities. My work in this area was only intended as a starting point (originally appeared only on my blog), but I think it is a worthwhile area of study as we consider future allocation of resources as part of our continued efforts to improve our nation’s health. Having said that, based on the data I’ve reviewed thus far, it is my opinion that the correlation would still hold with Germany (as it does across multiple European nations with varying degrees of home ownership).

  • liz1rn1

    “every other post”

    Really? In fairness, was only one reader raising the issue. I really don’t see what is so “controversial” about it. As a woman, the whole argument that the metaphor is inappropriate seems silly. Just my two cents.

    • hawkeyemd1

      Glad I’m not the only one that caught that.

  • Dorothygreen

    Dr Collar says: “Let’s focus on building a health care system that is right for us, one that suits our culture, incorporates our values, respects our freedoms, and meets our needs, rather than simply adopting one designed to solve another country’s problems”.

    “One that suits our culture etc”: from all I have read about American Medical Industrial Complex that has occurred since Medicare is that alongside all what is good about US health care there is a strong “culture of greed” which trumps a culture” of freedom and fairness.

    The only way to disrupt this “culture of greed” IS to do what ever other developed country has done. Using Switzerland as an example, not to carbon copy, in 1996 they outlawed private insurance for basic services and to negotiate prices and rates, at the Federal level for all players and then the insurance companies in the Cantons (like states),who do all the administration, negotiate collectively with hospitals and physicians. They too are strong capitalists, so insurance can sell supplemental, a al carte services for a profit. Seems to me this basic model fits the US very well for all the criteria you have given and is a moral plan – the Swiss population certainly had the solidarity to do this.

    US income inequality is markedly exacerbated by NOT having universal affordable health care for all. Like Switzerland the majority want such a system no one wants to see others suffer death, disability or bankruptcy due to lack of or insufficient health care.

    Why did the ACA require some 2000 pages? Politicians and their lawyers that’s why. If “we the people” outlawed private insurance for basic services, negotiated prices and insurance rates for basic care, stopped mandated employer health insurance in exchange for improved wages the US could have an affordable universal health care system for half of what it costs per capita now. There would be no need for the expansive legalese verbiage in the ACA.

    Also feeding the “greed machine” of health care costs, via the preponderance of preventable chronic diseases, is the SAD (standard American Diet) eating culture. Our eating must be disrupted as well. Big Ag and Big Food (beverage companies included) are given income tax payer subsidies while they own large chucks of US land and water to grow sugar, wheat, and maize for animals to offer cheap, accessible high caloric, low or non-nutritional “stuff” that is potentially addictive to humans (and the animals they have as pets) for substantial profit. Vegetables and fruits, the basis of any healthy diet are considered specialty foods. These are foods that should be subsidized. Those who want to eat the most nutritious must pay the most – for their food and for preventable chronic diseases of the masses.

    What rich countries have in common is – they are rich and can afford to have a universal health care system that encompasses its entire population without discrimination. It is indeed immoral and evidence of a dysfunctional government that the US behaves like it cannot afford universal affordable health care or reform its eating culture.

    • hawkeyemd1

      Greed is not good, and it leads to inequality (which is not good), so bring in the government. But bringing in the government limits freedom and autonomy, which is also not good. And leads to more inequality, then more government, and so on, and so on… Vicious cycle?

    • Peter Schwimer

      Well said. And in my mind right on target. Not many will agree I fear.

    • Luis Collar, M.D.

      I agree with you on several points, and they are all quite valid, but some of those same points simply reinforce the message I was trying to convey.

      First, much of what you discuss (e.g. big food, big ag, big tobacco, etc…) lies outside the scope of a healthcare delivery system, but it does have a huge impact on health. Addressing those issues, along with education, wealth inequality, etc…, would have a much greater impact on health than the expensive, ineffective patient satisfaction surveys and countless other costly administrative mandates we seem to have opted for instead.

      Second, our financing model is, in fact, similar to Switzerland’s (at least in part, with private payors still administering it), but we decided to use the “private insurance piece” and not the “restrict-insurance-company-profit piece” and several other of their “pieces.” And we will likely never have those “pieces” here because our national culture and political / economic / social values are quite different. We also don’t have their diet habits or social services or wealth distribution. So copying some or all of their healthcare system in isolation will not produce the same health results. And, health aside, it won’t even bring our healthcare costs down to their level, for similar reasons (e.g. different culture, different diet habits, different healthcare service consumption patterns, etc…)

  • liz1rn1

    Sorry, I misunderstood. I thought you were referring to the ACA as a system that is already right for us based on our values.

  • Luis Collar, M.D.

    I added, “particularly as it applies to health,” for a reason.

    I’m not sure what you are defining as “positive things.” But if the implication is that emulating another healthcare system will yield aggregate health results similar to those found in the country it was “borrowed” from, then I would be skeptical. A nation’s health status is not a function of its administrative healthcare policies.

    Above a certain, quite basic level of medical care, a nation’s sanitation, infrastructure, clean water supply, food quality / availability, socioeconomic policies, wealth distribution, social services, housing affordability, educational attainment, median income, unemployment rate, crime rate, culture, diet habits, inactivity levels, and many other elements that lie outside the realm of what we consider “healthcare” have a considerably larger impact on health. There is no reason to believe that adopting a system in isolation of those other elements would, or even could, yield similar results. .

  • Luis Collar, M.D.

    I do agree with your last statement. We should consistently learn what we can and evaluate / test / pilot different approaches, but we should only incorporate those that are truly effective / make sense given our particular circumstances, value systems etc… I also believe, though, that it is critical for politicians / administrators to look much deeper than they sometimes do when attempting to improve health. They need a stronger understanding of the differences between “health” and “healthcare.” Focusing on the latter disproportionately will not improve the former, and that also tends to be much more costly than simply addressing the true determinants of health directly.

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