Sunday, August 22, 2010

Popular Ranking Unfairly Misrepresents the U.S. Health Care System

June 1, 2009 by Dawn  
Filed under Featured Writers

21-dr-fessler-article1By: Richard G. Fessler, MD, PhD

The media and political community have made a big deal out of the fact that the U.S. ranks 37 out of 191 countries on the World Health Organization’s Health Care Ranking System.  Is this tool a credible way to compare quality health care delivered in the U.S. vs the rest of the world? 

Let’s be perfectly clear about this, the United States Health Care is second to none!  Ask the tens of thousands of patients who travel internationally to the US every year for their health care.  As an example of the quality of health care delivered in the US, Americans have a higher survival rate than any other country on earth for 13 of 16 of the most common cancers.  Perhaps that is why Belinda Stronach, former liberal member of the Canadian Parliament and Cabinet member (one of the health care systems touted as “superior” to the US) abandoned the Canadian Health Care system to undergo her cancer treatment in California.1 

But to understand how WHO derives this misleading statistic, which has been ballyhooed widely by both the media and politicians alike, you need to understand how it is created.  WHO’s health care rankings are constructed from five factors each weighted according to a formula derived by WHO.  These are: 

1. Health Level:    25 percent

2. Health Distribution:    25 percent    

3. Responsiveness:    12.5 percent

4. Responsiveness Distribution:  12.5 percent

5. Financial Fairness:    25 percent  

“Health level” is a measure of a countries “disability adjusted life expectancy”.  This factor makes sense, since it is a direct measure of the health of a country’s residents.  However, even “life expectancy” can be affected by many factors not related to health care per se, such as poverty, homicide rate, dietary habits, accident rate, tobacco use, etc.  In fact, if you remove the homicide rate and accidental death rate from MVA’s from this statistic, citizens of the US have a longer life expectancy than any other country on earth.2   

“Responsiveness” measures a variety of factors such as speed of service, choice of doctors, and amenities (e.g. quality of linens).  Some of these make sense to include (speed of service) but some have no direct relationship to health care (quality of linens).  These two factors at least make some sense in a ranking of health care, but each is problematic as well. 

The other three factors are even worse.   “Financial fairness” measures the percentage of household income spent on health care.  It can be expected that the “percentage” of income spent on health care decreases with increasing income, just as is true for food purchases and housing.  Thus, this factor does not measure the quality or delivery of health care, but the value judgment that everyone should pay the same “percentage” of their income on health care even regardless of their income or use of the system.  This factor is biased to make countries that rely on free market incentives look inferior.    It rewards countries that spend the same percentage of household income on health care, and punishes those that spend either a higher or lower percentage, regardless of the impact on health.  In the extreme then, a country in which all health care is paid for by the government (with money derived from a progressive tax system), but delivers horrible health care, will score perfectly in this ranking, whereas a country where the amount paid for health care is based on use of the system, but delivers excellent health care will rank poorly.  To use this factor to justify more government involvement in health care, therefore, is using circular reasoning since this factor is designed to favor government intervention.   

“Health Distribution and Responsiveness Distribution” measure inequality in the other factors.  In other words, neither factor actually measures the quality of health care delivery, because “inequality of delivery” is independent of “quality of care”.  It is possible, for example, to have great inequality in a health care system where the majority of the population gets “excellent” health care, but a minority only gets “good” health care.  This system would rank more poorly on these measures than another country that had “equal”, but poor, health care throughout the system.

In summary, therefore, the WHO ranking system has minimal objectivity in its “ranking” of world health.  It more accurately can be described as a ranking system inherently biased to reward the uniformity of “government” delivered (i.e. “socialized”) health care, independent of the care actually delivered. In that regard the relatively low ranking of the US in the WHO system can be viewed as a “positive” testament to at least some residual “free market” influence  (also read “personal freedom”) in the American Health Care system.  The American health care consumer needs to understand what the WHO ranking does and does not say about American health.  Don’t be fooled by “big government” politicians and the liberal media who are attempting to use this statistic to push for socialized medicine in the United States.  It says essentially nothing about the delivery of health care or the quality of that delivery in the US.  It does say that, so far, the American health care consumer has at least some personal freedom to seek the best health care available, and is not yet relegated to the “one size fits all” philosophy of government sponsored health care systems. 

  1. Susan Delacourt, “Stronach travels to U.S. for cancer treatment.” The Star, September  14, 2007.
  2. Sally C. Pipes, “The Top Ten Myths of American Health Care”. Pacific Research Institute, pp 132-133, 2008.

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9 Responses to “Popular Ranking Unfairly Misrepresents the U.S. Health Care System”
  1. Xorox says:

    The United States neither has the best health care system nor the best outcomes. The statistics are irrefutable. Yes, we have bright spots and a few stellar institutions, but when you look at the overall health care provided to our citizens, we are failing miserably.

    US expenditure health care (2008) $2.4 trillion, and estimated to be $4.3 trillion by 2017. 46 million uninsured and another 25 million underinsured. 18% of US citizens can’t pay for medicines or health care their family needed in last 12 months (April, 2009).

    In the US, one out of two bankruptcies, medical debt is the major factor (one bankruptcy every 20 seconds is attributable to medical/hospital debts). Insurance premiums in the US have risen 117% in the last 10 years. Health expenditures per capita: US $6,714; Canada $3,678; UK $2,260. Results: overall poor medical care and poorer medical outcomes in the US when compared to any other industrialized nation. For example, in Canada, the proportion of GDP devoted to health care is 10.0%. In the USA, the proportion is 15.3% and growing rapidly. Yet, Canadians outlive Americans by over 2 years. Americans are paying more and dying sooner under the current US system when compared to other industrialized nations.

    This is unacceptable and we need to change out health care system.

  2. Mr_KGB says:

    This is an amazingly misleading blog entry. First, I will agree, the USA does have the best Dr.’s and medical technology the world has to offer, but it is only available to the select few. You make a lot of statements that certain categories do not have to do with quality of health care. Are you stating that quality of health care should only be measured by best case scenario, when someone can get the best health care available?

    Lets go item by item. First, life expectancy. Yes, that should probably be an asterisked statistic since there are other factors, but it does relate to preventative care and also is directly influenced by the quality of health care.

    Responsiveness. You state that “amenities” should not be a factor, and reference linens. Lets broaden that a bit, there are many other factors in amenities than the linens, and I don’t think they are looking at thread count when reviewing the amenities. Are you telling me a country where a majority of the patients are stacked wall to wall with people with various stages of all sorts of illnesses in comparison to a country where patients have their own rooms, is not relevant? A clean, healthy environment is an absolute must for quality health care. Quite possibly the greatest advance in health care was the simplest, the Dr. washing his/her hands prior to performing any procedures. It greatly reduced the rate of infant and mother motality during childbirth and the rate of infection from surgical procedures.

    Financial fairness is also a key statistic. A family of four who makes 20K a year will not be able to ensure there family, thus meaning they have poor quality health care because they have no preventative health care, and are less likely to go in when something is occurring. If the statistic benefits a “socialistic” medical system, maybe there’s a reason? Other protection services, which I think most rational people would consider health care a protection service, operate under a socialistic model; the police, the military, etc. If they used this same measurement for those services, would you apply the same logic? In a true free market, those would essentially be mercenary services, as our health care system has become.

    Health distribution and responsiveness distribution. I’m amazed anyone can legitimately claim this is not a factor in quality health care. Try telling that to that family of four who can’t afford health care, and therefore can’t afford to take there children to the Dr.’s unless it’s a serious situation, and really, still can’t afford it. They are not getting those preventative treatments that may reduce overall costs in the long run, avoiding a costly emergency because they were able to be on top of there health situation. Not too mention, when that family does go in, they are not getting the same “quality” health care that someone who can afford it does. They are getting the absolute minimum health care necessary to not violate their oath. Why else would a patient have to continually fight insurance companies who deny claims and the hospitals who will refuse treatments unless the insurance company will cover it, and that’s all assuming they are not one of the millions of Americans who can’t afford insurance?

    This blog post is a gross misrepresentation, distorting facts to demonstrate a case you are clearly biased on. It is irresponsible for someone who lists themselves as an MD to make such claims.

  3. nycheesehead says:

    I read your blog, and my reaction was, “So?” You can massage and manipulate statistics all you want in order to change the US health rankings versus the rest of the industrial/First World countries, but the issues remains the same: none of these other countries exclude 16% of its citizens from what I consider to be a civil right: reasonable access to basic health care. It is deplorable that the “richest, most powerful nation on earth” has been unable to provided basic universal health care to its population. Why have all the other countries been able to do it? Are they smarter than we are? Are they wealthier than we are? Perhaps the answer is that their people with power are less greedy than we are.

    The conservative “sturm und drang” is relentless and short-sighted: it was the same mantra for Social Security, Medicare, and the Civil Rights Act. Again, you are on the wrong side of both history and of how the world deals with health care.

    What is your answer to this nation’s healthcare issues? Let the “market” deal with it? Oh, wait; that’s right…the “market” did such a bang-up job with sub-prime mortgages and credit default swaps, etc., that they almost created a world-wide depression, didn’t they.

  4. WmLambert says:

    The WHO report is an agenda-driven study designed to produced a desired outcome. A more common-sense approach would apply real metrics: how much access to MRI’s and CT Scans? Are there waiting lists for critical services? What is the waiting list for patients to be seen, and after being seen, how quickly is necessary work scheduled? When patients are seen, are tests adequately ordered and how quickly are they processed? What are the triage limitations? Is an elderly patient denied costly medical procedures designed “merely” for comfort and quality of life? – Also, are numbers weighted because The U.S. accepts treatment for difficult medical positions, like extremely premature infants, when other nations do not have the ability for such treatment? Infant mortality is higher when preemies are treated rather than refused treatment and then not listed as medical stratistics.

    Elective surgeries are part of a tourist strategy for some countries, like cosmetic surgery tied to vacation packages. It may be you get what you pay for. Are the high rates of infection that denies patients the return flights entered into any calculation? Is there equivalence in going to the U.S. for heart surgery or other advanced medical procedures, compared to going to tourist traps for elective surgery?

    Is it ever noted that medical care is different that insurance coverage – and that no one is turned away from emergency rooms because of inability to pay? ..Or that unaffordable medical coverage is routinely written off by hospitals and physicians?

    There should be some mention of how illegal aliens come to the U.S. in order to enter hospitals knowing they will be cared for, when they would be excluded from their own nation’s services.

  5. Grandmother Spyder says:

    Ok lets stop the political jargon and put some real people stories up here. I will gladly share mine and that of a friend of my mother.
    My mother’s friend is two years older than me. They worked together until my mother’s recent retirement.
    During the past two years my mother’s friend and I have experienced the exact same physical condition and received the exact same diagnosis.

    I live in the US. I have a wonderful insurance. I only have $3 co-pays to my doctors. My medications only cost me $3. I have my choice of doctors, hospitals, specialists, and pharmacies. Very few medications are restricted. Virtually no treatment is restricted. Sound’s like I am set. Right?
    My mother’s friend lives in France. She has her choice of doctors, hospitals, specialists, and pharmacies. Very few medications are restricted. No procedure is totally restricted. Sounds like she is set too. RIght? (Well except for the fact that France has one of those nasty Socialized Systems that have people dropping dead on waiting lists and all…….)
    Here is our trip through each of our respective healthcare systems.
    I woke up one day and realized that I was lying in a pool of blood. I cleaned myself up and called my doctor. I was having an extrememly heavy menstrual flow and was concerned. They scheduled me an appointment two days later. The doctor examined me and ordered some radiological tests (ultrasound & CT). I was scheduled for them one week later. Meanwhile I am passing clots of blood the size of my fist and cannot stand up without blood running down my legs. Not very appealing. The doctor also gives me a referral to a specialist (OB/GYN). The OB/GGYN appointment is scheduled one week out from the radiography appointment (total of two weeks from the original doctor’s appointment). Yes, I am still bleeding. I see the specialist and she tells me that I have a hardening of the uterine walls and have two cysts on my ovaries. She informs me that we need to remove the uterus. I asked her about the cysts on the ovaries and if they were going to be removed also. She told me no and I asked why not. She told me there was no need and that when the uterus was gone the cysts would likely go away on their own. I argued that I wanted them removed anyway just to be safe because my grandmother died from a reproductive system cancer. She refused and told me that if I wanted them removed I would have to find a different doctor. By this time two weeks and two days out from the day I woke up in the puddle of blood I was desperate. I agreed to do it her way. The surgery was scheduled over a week away. So now I am coming up on 4 weeks from the day I woke up in the puddle of blood and have yet to get anything actually done about the problem. I was reduced to wearing depends in order to contain the large flow of blood. Finally the surgery was done. I stayed 24 hours in the hospital and was sent home to my three kids and my loving husband. I got an infection and had to go back and spen three days in the hospital. One year fourteen days and 8 hours from the day I woke up in the puddle of blood I became so weak that I had to leave my college classes and go home. I never went back.Over the next two weeks I suffered severe depression and ridiculous manic highs. it was like having Bipolar Disorder on steroids. I went from speaking to my husband in civil tones to wielding a knife and threatening his manhood in a matter of 3 minutes. Needless to say when that happened the doctor was called. My husband will tell you that, although I have a temper, these behaviors were extreme even for me. Two days later I have an appointment. he orders tests again. Can you see the cycle repeating itself here? Yes it did. The change came when I reached the office of the specialist. I cursed her out when she told me that both my ovaries had large cysts on them and that there was a possibility they were cancerous. Eventually because of my temper tantrum (hormonally induced….well mostly) I wound up going to a gynecological oncologist (yet another specialist with a two week waiting list). So now I am four weeks and two days out from the day I threatened to turn my husband from a rooster to hen and I have still not gotten anything done for the hormonal rages. Now let me tell you about the cancer treatment industry. They are a real great group of people. they make you feel like you are the most important thing around. I flet like the Queen of Sheba in their offices. The surgery was scheduled for two days after I went to them. I was treated like royalty. Well, I was before the surgery. You see the cysts were not cancerous and I was no longer a financial gravy train to them. Treating cancer is big business. It is big money making business for the doctors and eventually you die from it anyway (particularly the really strong types like breast and reproductive cancers). When I was cancer free, I was useless to them and I was treated like trash. I needed my medical records in order to get to continue in college becasue I failed every class during the semester that I had the surgery. I had to show the sudden onset and prove how the situation was out of my control. they made it very difficult for me to do that by dragging their feet about sending me my medical records.
    So the summary of my experience is that I had to have two surgeries and lost over 120 days of school total between the two surgeries.
    Lets look at my mother’s friend and her experience:
    She was at work when she passed the first huge clot. She telephoned her doctor on her cell from the ladies room at her job. She spoke directly to her doctor and explained the situation. He had an ambulance dispatched for her and called the human resources office at her job and told them where in the building she was and that there was an ambulance on the way. The company medical person went to her and stayed with her until the ambulance arrived. She was taken to the hospital nearest to her house because she preferred that one. They did the same two tests that I had and admitted her to a room. her doctor came by to see her and spent 30 minutes explaining to her what was happening. He told her that the cysts might go away but most likely they would not and that it would be better to remove the ovaries at the same time. She agreed and the surgery was scheduled fot the next day. After the surgery she spent two weeks in the hospital, one week in a inpatient rehab house, and then she went home. She was given an referral to a medical retreat in the south of France and she left that day for a three month stay without hubby or kids. The government provided assistance to the husband with the care taking of the children while his wife was at the medical retreat. Her total time missed from work….. Well if you count only the working days and not the weekends that she did not work on anyway then her total days out of work was 51. The 120+ I lost were days out of school not including weekends either.
    Is there anyone out there that would care to tell me all about the evils of Socialized Medicine now?

  6. ozlissa says:

    Ok, americans really need to do their research before they speak and start spouting half truths about why people from around the world go to america to receive treatment. There are quite a few reasons and none of them because america has the “best” health care system. Here are few reasons people go to the usa for treatment.
    1. Third world countries dont have the care even available and america is the easiest country to get into immigration wise for medical treatment.
    2. Alot of medicines and treatments are available in the usa and not in other countries because other countries regulations are stricter and alot of the disallowed medicines and treatments have been deemed unsafe by other countries health regulators. These patients are at the “last resort” phase of their seeking for solutions to their illnesses. All you need to do is watch current affairs programs here in australia and you see all the people going to the usa to try drugs and treatments as their last hope.
    Hmm last resort.. if the u.s.a was so great at taking care of people then why do others only seek out treatment in the usa when there is no other alternative left….. that says it all doesnt it.
    3. Every other ‘1st world’ country takes care of its vets. The usa treatment of your returned service men is disgusting and dishonorable. You should all be ashamed of yourselves.

  7. Geri says:

    It is very difficult for me to believe that Grandmother Spyder was so ill treated by her Medical Team. I am a retired Nurse who spent over 25 years in the Medical profession and never
    experienced such incompetence.

    I assume her “Doctor” was/is her Primary Care Physician [PCP]. My PCP would not have ordered any radiological tests but would have made an emergency appointment with an [OB/GYN]. The Gynecologist and not the PCP would then decide what tests should be ordered. Since she had a “Wonderful” Insurance Company, could choose her own Physician/Specialist and assuming she already had a Gynecologist after having three children, I fail to understand why she did not go directly to a/her Specialist first.

    Ovarian Cysts are common and are not surgically removed unless a Pap Smear is positive. They are rarely cancerous; consequently, I can understand why the Surgeon was reluctant to remove the cysts. I had one myself and it disappeared after 6 weeks.

    My husband worked for a French Company in the late 80s and frequently traveled to Paris on business. Since all of our children were grown, I often accompanied him and had the pleasure of meeting some of his French fellow employees and their families. They all were quite satisfied with the Social Security System [nicknamed Nanny] which was an all encompassing Cradle to Grave system for everyone that included Retirement at 60 at 80% of the best year’s wage; free Healthcare; free Medication; free Convalescence after Surgery [even Birth] and many other Perks for life. They did complain a little about having to see their “Referral” doctor [equivalent to a PCP] before they could see a Specialist and they did not very much like the “wait time” that sometimes had to be endured. There was just one little thing that they did not really like about Nanny. They had to pay 20% of their wages/salaries and their employer had to pay 50% to 60%. Self employed paid a like amount. A Senior Engineer’s salary was half of what it was in the US but they did not need to worry about paying for Healthcare [ever] or worry about income after retirement. That was then but it is not so rosy now because there are not enough people working to pay for Nanny.

    As they say: “Socialism is a great idea until you run out of other people’s money”.

  8. rkt says:

    I could not agree more that “great ideas” become tarnished when “you run out of other people’s money.” Take unbridled “capitalism,” for example. After bailing out the financial industry, I have decidedly “run out of…money.”

    During the ten years following deregulation of the financial industry, a dozen or so giant financial institutions consolidated their control of the market by acquiring most significant competitors. Those institutions thus became “too large to fail” because they gained a stranglehold on the industry. If they failed the world economy may well have collapsed. So you and I — and our progeny — had to bail them out.

    Capitalism requires a certain level of competition. If the companies at the top of the food chain simply purchase all but a handful of meaningful competitors, capitalism effectively becomes “Cartel-ism,” and free market dynamics cease to exist.

    Just like the banks, the large health insurance companies have purchased most of their competitors over the past ten years, effectively creating a health care cartel. Their profits increased 500 percent from 2000 to 2007, a hallmark indicator of a concentrated market. Thus, the health insurance industry now holds us hostage just like the “too large to fail” banks.

    United Health Care, the largest of the insurers, actually purchased the largest two independent agencies that assess medical claims to determine what costs should be reimbursed. In other words, the insurers now control companies that formerly served as watchdogs of the industry.

    Geri is correct that taxes will likely increase if the US adopts a single-payer system. (Presently, only a public option is being considered.) However, health care costs have increased dramatically over recent years, and it takes little imagination to realize the large insurers will continue to wield enormous “closed-market” power without increased competition. Unfortunately, the large insurers are so powerful they can easily prevent entry by private competitors. Thus government may be the only competitive option.

    A corporation’s sole mission is to maximize profits for the shareholders — at any cost. Further, the greater a corporation’s profit, the more its CEO is compensated. In 2007 the CEO of United Health Care was paid $125 million dollars — while your premiums increased dramatically. If your employer provides your health insurance, ask how rapidly health insurance costs are escalating, and how that influences employment decisions.

    Our choice may be to incur increased taxes in order to pay for the level of care Grandmother Spyder describes her French friend received, or to be bled to death by greedy, profit-maximizing health care corporations. And keep in mind their Wall Street counterparts are already paying themselves huge bonuses — while refusing to lend us OUR bailout money.

  9. BCPipes says:

    I have decent health insurance and access to good hospitals and a great primary care physician. This isn’t about me.

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