Unsafe at any cost: mediocre U.S. health care: a new report suggests Americans need to start questioning some assumptions

Jeanne Schulte Scott

We are well known for our popular "truisms"--the "givens" that tend to govern our thinking and that hardly anyone ever challenges. Statements like:

* "Americans have the highest standard of living in the world."

* "Everyone else in the world wishes they could live in America."

* "Americans have the best health care in the world."

Well, it looks like the bubble has burst on the last one. A study conducted by the RAND Corporation published in the March 16 New England Journal of Medicine (Asch, Steven M., et al., "Who Is at Greatest Risk for Receiving Poor-Quality Health Care?") has raised questions about the quality of our health care.

The study reiterates the finding of an earlier RAND study by mostly the same group of researchers ("The Quality of Health Care Delivered to Adults in the United States," NEJM, June 26, 2003), which found that U.S. residents receive appropriate medical care only about 55 percent of the time. The 2006 study adds the bombshell that everyone is affected--regardless of race, income, education, or health insurance status.

Equal-Opportunity Bad News

Actually, the number was just under 55 percent. The researchers in the earlier study used 439 accepted standards to evaluate the quality of care that participants received for 3o common chronic and acute medical conditions and for disease prevention. The results disclosed that participants overall received appropriate medical care only 54.9 percent of the time.

When, in their more recent study, the researchers looked at demographics, they found that blacks and Latinos are actually getting slightly more appropriate care than whites, and females are receiving slightly better care than males.

High-income individuals do only marginally better than those with lower incomes. Participants with annual incomes of more than $50,000 received appropriate medical care 57 percent of the time, and those with annual incomes of less than $15,000 received appropriate medical care 53 percent of the time, according to the study. Experts say that an efficient healthcare delivery system should provide appropriate medical care 80 percent to 90 percent of the time. Obviously, this is a gap of gargantuan proportions.

Spending More, Getting Less

This report is especially bad news for the nation's political leaders. The Centers for Medicare and Medicaid Services says that the nation spent almost $2.1 trillion on health care in 2005. Does the RAND report suggest that the nation may be wasting upwards of 45 percent of its healthcare dollar on inappropriate, ineffective care?

The implications are staggering, particularly when the United States is compared with other nations over the quality of care being provided for the dollars expended. Already, the nation is spending about 16 percent of its gross domestic product on health care, and although our system of employment-based insurance leaves upwards of 46 million of our fellow Americans uninsured, we have always comforted ourselves with the thought that at least our quality of care is by far the best in the world. (a)

But what if it isn't? What if we are spending gazillions and getting, at best, mediocrity in return? Are Americans being bamboozled by their healthcare system?

More and more, the media is reporting America's dissatisfaction with the current system. The complexities of the new Medicare Part D drug benefit have left American seniors feeling confused and dissatisfied. Increasingly, employers are dumping their employee health insurance programs in favor of fixed high-deductible consumer-driven plans that leave patients with the burden of making quality decisions regarding their own health care along with the financial risks for the decisions. American healthcare consumers are being saddled with all the obligations of the healthcare system while being offered limited choice and little access to information about the actual quality of the care they are receiving.

Meanwhile, another truism is at play: "More health care is better than less health care." Americans seem to assume that if it is available, then we should get it, regardless of whether it is fully indicated or whether the care may be appropriate for our situation. We don't know if the care provided will work, but we ask for it anyway just because it might help.

Consumers are at sea when it comes to making truly informed healthcare decisions, and evaluating cost and effectiveness. The BAND study seems to indicate that physicians and other drivers of healthcare decision making are not much better off. If the current professional decision-makers are off 45 percent of the time, how can consumers hope to do any better?

Politics and the Elusive Common Thread

The findings add fuel to the confrontation between the two prevalent points of view in Congress. One predominantly Republican group of legislators is pushing for the country to switch from its current physician-managed, third-party-financed healthcare system to a consumer-driven system that is self-financed through tax incentives, in which patients are in charge of their own healthcare decision making. Meanwhile, a largely Democratic group is increasingly arguing for setting broader standards for healthcare quality and performance, which they argue will make the present system of employment-based insurance more efficient and thus more affordable.

Although these positions may seem opposed on their face, they share a key element: the need for information. Whether you are the consumer or the physician, the insurer, or the one who pays for the insurance, you need to understand the care decisions being made--you need to know the effectiveness and cost efficiency of option A versus option B.

Today that information is hidden, often from the providers themselves. What information is available is all too frequently obscured by incompatible systems of compilation and sharing. And the industry has added its share of obstacles. The American Medical Association, for instance, has long opposed publicly releasing information regarding physician practices, costs, quality, and the like.

Add the word transparency to your lexicon; you'll be hearing it a lot more in coming days. Absent an open information-sharing system--including pricing, effectiveness, and real quality information-the outlook for healthcare financing in the United States is not promising.

It's time we set aside our "truisms" and see what's really happening.

RAND STUDY: INDUSTRY REACTIONS

"Not only is no place safe-no one is safe from poor quality. No matter what group we looked at, whether they were black, white, rich or poor, uninsured, insured, educated, uneducated-all of them were receiving mediocre care:'

--Steven Asch, lead author of a RAND Health study indicating that Americans receive "appropriate" health care only about 55 percent of the time

"Just because you see disparities doesn't mean that everyone should be getting more care. Maybe they should be getting less care. There's a big question about overuse. It may not be what's being done but whether you are being treated by a high-quality physician."

--Amitabh Chandra of the Kennedy School of Government at Harvard University, responding to the RAND Health report

"This [RAND] study shows that it doesn't matter what subgroup you look at, we screw it up at a pretty constant rate throughout the nation."

--Brent James, vice president of medical research for Intermountain Healthcare

"Consumption of health care does not work like a trip to the grocery store. You do not always know what items you need, or even what items are available. And, more often than not, someone else, such as your physician, is by necessity selecting the items going into your shopping cart."

--U.S. Rep. John Dingell, (Mich.), ranking minority Democrat on the House Energy and Commerce Committee, reacting to the RA ND Health study and the question of "transparency" in healthcare information available to consumers

(a.) According to data compiled by the Organization for Economic Cooperation and Development, the United Kingdom spent only 7.7 percent of its GDP on health care. Germany spent 11.1 percent, France spent 10.1 percent, Italy spent 8.4 percent, Canada spent 9.9 percent, and Japan spent only 7.9 percent.

Jeanne Schulte Scott, JD, is a healthcare lobbyist in Washington, D.C. (jeanne.scott @health-politics.com).

COPYRIGHT 2006 Healthcare Financial Management Association
COPYRIGHT 2006 Gale Group