The first in a series of the “10 biggest myths about the U.S. health system”
According to Gallup surveys, four of five Americans believe the quality of care they receive is good or excellent, and the majority think it is the best available in the world. Surveys by Roper, Harris Interactive, Kaiser Family Foundation, Harvard’s Chan School of Public Health, and others show similar findings. And the public’s view hasn’t changed in two decades despite an avalanche of report cards about its performance, a testy national debate about health reform and persistent media attention to its shortcomings and errors. But is the public’s confidence in the quality of the care we provide based on an informed view or something else? It’s an important distinction.
Two considerations are useful for context:
Measuring quality of care objectively in the U.S. system is a relatively new focus. And we’re learning we’re not as good as they think we are. Historically, the public’s view about “quality of care” has been anchored in two strong beliefs: 1-the U.S. system has the latest technologies and drugs, the world’s best trained clinicians and most modern facilities, so it must be the best and 2-the care “I receive” from my physicians and caregivers is excellent because they’re all well-trained and smart. These beliefs are virtually unchanged since 2001 per Gallup. But since the turn of the Millennium, we’ve learned we’re probably not quite as good as they think we are. Three reports sparked the birth of the modern quality improvement era in our system almost 20 years ago:
In 1999, the Institute of Medicine published To Err is Human: Building a Safer Health System concluding “as many as 98,000 people die in any given year from medical errors that occur in hospitals.” Patient safety and medication error were its central foci prompting every hospital to examine its medication management processes and related clinical operations.
Shortly after, in 2001, it published a sequel, Crossing the Quality Chasm: A New Health System for the 21st Century expanded quality beyond safety to include care effectiveness, patient centeredness, efficiency, equitable access and timeliness. And it put an uncomfortable spotlight on unnecessary care and its pervasiveness in our system.
In 2003, a team of RAND researchers found gaps in quality pervasive: “Participants received 54.9% of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9%), the proportion of recommended acute care provided (53.5%), and the proportion of recommended care provided for chronic conditions (56.1%). Among different medical functions, adherence to the processes involved in care ranged from 52.2% for screening to 58.5% for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7% of recommended care for senile cataract to 10.5% of recommended care for alcohol dependence…The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted.”
And in tandem with these results, data from the Dartmouth Atlas showed widespread variation in Medicare spending and practice patterns across the country leading its iconic leader, Jack Wennberg, to offer that as much of one third of Medicare’s spending is wasted on unnecessary care and the zip code where a person lives a keen predictor of the quality of care the public gets.
Wow. Say it aint so. Can it be that quality is not uniform across the U.S. system? Can it be that some doctors get better results than others and some hospitals are safer for patients than others? Is it true that some approaches to care get better outcomes than others?
Inside the industry, these studies and hundreds since have revealed widespread variation in the quality of care we provide our patients. But the public remains largely unaware, and fewer than one in ten is predisposed to study our methods and results closely.
Quality of care in the U.S. cannot be readily compared to quality of care in other systems of the world. Data about the healthcare systems in 35 developed countries from the Organization for Economic Cooperation and Development allow comparisons of life expectancy, morbidity, access to providers and admission rates to hospitals among other metrics. For the most part, they’re accurate (though some are self-reported and dated). Supplemental analyses by academics like Robert Blendon and others also provide country comparisons. In these analyses, the U.S. system is always the most expensive, near the best in age-adjusted life expectancy, morbidity and mortality, on par with most for hospital admissions and access to specialized services, and lower than most for preventive health, public health and primary care services.
But these comparisons are misleading. Beyond the complexity of our pluralistic payment system, there are major differences between the U.S. system and other developed systems in the world:
In the U.S., our “human services” programs like the TANF (Temporary Assistance for Needy Families), Supplemental Nutrition Assistance Program aka “food stamps” and others operate almost independently from our delivery system. De facto, the U.S. operates a “health system” that’s focused on hospitals, doctors, clinics, drugs and devices, and a set of “welfare” programs (TANF, Medicaid, Food Stamps, SSI, EITC and Housing Assistance) for 70 million lower income citizens and legal immigrants. We spend more on the health programs proportionately than other countries and less on the human services programs. That’s why private foundations, like Kresge, Robert Wood Johnson and many others supplement funding in the safety net. In other countries, safety net services for more directly integrated in their care delivery strategies; in the U.S., they’re not. So larger investments in safety net programs in other countries and their integration into their delivery systems are major differences between the U.S. system and others.
The U.S. has unprecedented health challenges: the highest rates of suicide, gun violence and substance abuse in the world. The facts are startling: every day in the U.S., 123 commit suicide, 43 die from gun violence, and 175 will die from a drug overdose. It’s the health system that absorbs the responsibility for and expense associated with these deaths. No other country comes close.
And in most developed systems, their federal/provincial government plays a larger role in paying for healthcare and thereby determining what’s appropriate and inappropriate care. Most use a strong primary care front door to their system, so preventive health and referrals for specialty care are appropriately maintained. Most have a mechanism whereby decisions about major interventions of guidelines for diagnosing and treatment are evidence-based and followed closely. Most negotiate with drug, device and technology suppliers directly and get significant discounts vs. what’s paid in the U.S. And most have a global budget for their health and human services investments, forcing regulators and providers to establish priorities and address tough decisions about end of life care, the usefulness of costly technologies and more.
Public opinion surveys in countries like France, Switzerland, the UK and others show higher levels of satisfaction with their systems that ratings of our system by Americans, so the U.S. system is NOT the world’s most popular as viewed by its constituents. It is our system’s complexity, uneven access and administrative red tape that push our ratings down while the majority believe our quality is “the best in the world”.
Here’s my take:
The quality improvement movement in the U.S. system has had profound impact. Clinicians and academicians have improved clinical processes for diagnosing and treating specific patient populations, addressing variability for virtually every diagnosis specific to signs, symptoms, risk factors, patient values and social determinants of their health. It has made household names of Deming, Juran, Crosby in healthcare C suites, recognition as Codman, Eisenberg, and Baldridge desirable and the roles of the National Quality Forum, National Association for Quality Assurance and others all the more relevant to our system’s future. The results of these efforts are clear and positive.
Health services researchers have correlated adherence to evidence-based clinical practices with better outcomes and lower costs. Accreditors and regulators have crafted rules and regulations based on process measures for which hospitals, physicians, and post-acute providers can he held accountable. Government agencies have become more aggressive in scrutinizing quality. And the sweeping change in incentives for providers from volume to value is premised on the assumption that achieving evidence-based thresholds of quality a basis for participating in savings. All these are derivatives of the quality improvement movement in the U.S. system about to begin its third decade.
The bottom line is this: there is no standard definition of quality in the U.S. health system but every sector is paying more attention. Hospitals have been the focus for most government-initiated efforts since they’re 32% of total spending, then physicians. Drug company scrutiny about the efficacy and effectiveness of their compounds and the underlying clinical research is getting more attention and how insurers manage their coverage and denial decisions is under the spotlight. How regulators define and the public responds to “quality of care” appropriated through emergent disruptor-led systems sponsored by Amazon, CVS, Apple, and others is the next chapter.
We are improving, especially in high volume patient populations and care coordination but there’s much more to be done. Our society’s challenges around guns, drug abuse and income disparity render comparisons to other countries’ quality of care moot.
The U.S. public believes our quality of care is the world’s best. They think it’s unaffordable and complicated, but the world’s best based on what they’ve experienced for themselves. It’s a belief that’s strongly held, but not entirely based on an informed view of facts.
They’ve not been duped, but many might change their minds if they understood the gap between the quality they think we deliver and the facts. We’re making progress but we have a long way to go.