Wednesday, January 6, 2010

Effect of System Complexity - It's Complicated: This U.S. Health System

It’s complicated, difficult, inconvenient, and often politically incorrect, trying to explain the U.S. health system.

If you give the system two cheers for its accomplishments and performance, as I do, it is even more complicated. Consider the 2000 plus pages of the House and Senate reform bills, and you’ll realize just how complicated.

In my book, Obama, Doctors, and Health Reform, I compare the system to a whirling Rubik’s Cub with millions of interrelated moving parts, institutions, and people , each with agendas to pursue, axes to grind, and oxen to gore.

Global Health Statistics

Take the matter of comparative global statistics. Ten years ago, the World Health Organization issued a report focusing on cost and access. The U.S. ranked 37th in the world. The report has since been discredited for its flaws and for failure to mention the U.S. ranks first in innovation and responsiveness, but it remains a rallying point for champions of single-payer.

The Argument

The argument goes: If only we had a uniform government-run system, our statistics would surely improve. This argument ignores these factors, which are largely beyond the reach of the health system or government.

The Contribution of Medical Care to National Health

Medical care accounts only for about 15 percent of the health status of any given population (Leonard Sagan, The Health of Nations: True Causes of Sickness and Well-Being, 1987). Life style accounts for 20 percent to 30 percent, and income differences, and lack of social cohesion for the other 55 percent(D. Satcher, and R, Pamies, Multicultural Medicine and Health Differences, 2006).

Violence and Accidents

If one were to eliminate violence and accidents from the statistics, the U.S. would rank near the top in longevity. John Holcomb, M.D., the U.S. Army’s top trauma surgeon is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s a useful statistic to keep in mind when comparing national health systems. Iif one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country. Civilian trauma and deaths are largely beyond the health system’s reach.


The U.S. is the number one destination for the world’s immigrants. The U.S. receives some 85 percent of the world’s immigrants. Because of such things as poverty, cultural differences, poor prenatal care, and discrimination, the non-white population, a disproportionate number of whom are immigrants, have lower life expectancies as follows; whites 81.0 years, black 63.6 years, Hispanic 74.0 years, Asian 75.2 years. (Abstract of the United States, 200-2004). From 1993 to 2003, the U.S. population exploded by 12.3 percent, due in large part to newly arrived immigrants with and their subsequent fecundity. This unexpected growth contributed to the physician shortage, lack of access to care, and dismal statistics.

Costs and Outcomes – Hospitals, High Tech, and High Doctor Pay

Or take the matter of costs and outcomes.

Much is made of a 1999 Institute of Medicine study indicated some 100,000 Americans died needlessly in U.S. hospitals because of unsafe care. The methodology of this report has been since questioned, but the stigma remains. It is seldom mentioned that federal policy of paying hospitals a fixed amount for a fixed time in the hospital by DRGs may contribute to this toll. Because patients tended to rushed out the hospital lest they exceed DRG payments, patients may be discharged “quicker and sicker,” and some 20 percent may have to be rehospitalized.

Much is also made of the fact that health costs exceed those of other nations by 50 percent. Much of the blame is laid at the feet of greedy hospitals and specialists who are paid on a fee-for-service basis by the volume of care delivered not the quality of care or its outcomes. It is rarely mentioned that the U.S. has some of the best results in the world for cancer and heart attack survival. Not enough attention is paid to the fact that the U.S, produces a different health care product – prompt access to life-saving and life-style restoring technologies – than other countries.

We led the world in use of imaging technologies, cardiac procedures, hip and knee replacements, and preventive drugs, such as statins. The American public has come to expect this access as the standard of care, and patients, backed by malpractice attorneys are quick to sue if their expectations are not met.

Finally, there are culture and economic factors that complicate matters but receive insufficient attention.

One, medical education and postgraduate training are long and expensive, often culminated in debts of $150,000 or more for doctors entering practice. Small wonder , then, that doctors try to make up for lost time and expense.

Two, American hospitals receive their lion’s share of profits,m perhaps 80 percent, from high tech procedures. That’s why hospitals so vigorously market their specialists, their robotic surgical machines, and their latest high-tech gizmos.

Three, Americans admire high tech and the concreteness of procedures more than low tech care with high touch advice. That is why a recent American Medical Group Association Compensation and Financial Survey found the five more highly paid and lowest paid specialists were:

Five highest

Orthopedic surgeons -- $580,711 to $641,728
Cardiac and thoracic surgeons -- $507,143
Radiologists -- $438,115 to $478,000
Radiation therapy -- $413,518
Gynecological oncology -- $406,000
Cardiology -- $398,034

Five Lowest

Family Medicine -- $197,655
Pediatrics -- $202,832
Internal Medicine -- $205,441
Psychiatry -- $208,462
Geriatrics -- $211,425
Hospitalists -- 211,835

It may be a government system with health reforms could turn the system upside down. I doubt it. It’s much too complicated.

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