Here we go again, another report slamming the US health system, once again from the Commonwealth Fund. (Comm. Fund Report) Basic premise, same as always, we spend more and get worse quality. The comparison countries, Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. Notice that all these countries have a population that is similar in size and diversity to the US–not. 72 measures in five domains–care processes, equity, access, administrative efficiency, and health outcomes. Think these might have been selected to help lead to the right answer? Think they might be weighted to ensure that? Why does anything other than the overall health and health outcomes for the population matter at all? If you think that you would be right.
A primary flaw of the system is that many of measures used have an inherent judgment about what is a good or bad ranking in their formulation. Might be nice to have an actual link to better health and better health outcomes, but then that would screw up the whole point of the study. Care processes, for example, generally have been shown to have no strong link to health outcomes and neither have the other domains, including access. And of course there is no weighting for population characteristics or illness burden. All the other care systems would look a lot worse if they had to treat our population. And those characteristics and illness burden are not the fault of the health system; the population is what it is and many of our citizens are fundamentally irresponsible when it comes to health behaviors. That may be a public health issue, but it is not a health system performance issue.
The US finished dead last overall and on most of the individual domains, a conclusion foreordained by the way the study was conducted. Top scorers were the UK, Australia and the Netherlands. Kind of hilarious to see the UK found to be a top system in this study, since there have been waves of stories for years about mistreatment and inefficiencies in the system and there is rising dissatisfaction. And of course we all would like to be in a system where a court can decide what care we or our children can get. Any system like that is de facto pathetic. Oh, and did I mention that the UK finished next to last in health outcomes, certainly the most important domain. Might want to further note that we spend more because we have higher health prices, not more utilization. Those higher prices are someone’s income, usually doctors. Want to cut doctors’ incomes in half? We can save a lot of money, and I am sure we won’t lose any of our good physicians.
Here is the good you need to know. Our system does very well on measures relating to the doctor-patient relationship, which obviously is very important. Our system does exceptionally well in providing a wide range of potential treatments for patients and in achieving very good outcomes on very complex cases. While this (idiotic) study ranks the US last in health outcomes, that is only because it includes population characteristic-influenced measures like infant mortality and life expectancy. Real treatment outcomes are the best. And while you see a lot of very sick people from other countries coming to the US for care, you don’t see a lot of Americans going overseas. They can find what they need here. What we clearly need most to focus on is increasing personal health responsibility. Hard to do that when our system rewards bad behavior with free health care.
The Commonwealth Fund is particularly prone to letting ideology dominate its “research”. To help correct this problem, it, and anyone else claiming to do independent research, should describe the political affiliations and political contributions of the researchers, writers, editors and governing board, and should describe their policy beliefs. That would allow an assessment of the credibility of the work. And perhaps they should fully explain potential alternative designs, measures or statistical analyses that might lead to different conclusions. This kind of result-driven research doesn’t help improve health or health care for anyone. And this particular study is embarrassing for its complete failure to note potential issues with how it was done.