Care for Chronic Conditions in the U.S. Stinks

Although the issue of healthcare was largely absent from the recent elections, I continue to be amazed at the naïveté of many Americans who truly believe that healthcare in the U.S. is vastly superior to most other countries (not that they've ever used the healthcare systems in any other countries to make a comparison). I think I may have mentioned this, but in 1987, I actually lived as an exchange student in Finland -- the home to Santa Claus (where they actually eat reindeer, which is not half bad when prepared properly, unless you happen to be a vegetarian), and the birthplace of the sauna (which is a Finnish word, BTW). Finland is also home to cell-phone giant Nokia, and the country which has the highest incidence of type 1 diabetes bar none.

These "average Americans" (perhaps best depicted by "Joe the Plumber") I mention tend to base their uninformed opinions on unsubstantiated rumors related to healthcare rationing and long waits for live-or-die surgeries. In reality, their perceptions are usually overblown or just plain wrong. Even conservative publications like BusinessWeek as well as more liberal publications like The New York Times are reporting a rise in "medical tourism" because the cost differential between the U.S. and most everywhere else on earth is simply too big, and its actually cheaper to send people to Asia, South America or Europe to have major surgery done there than it is to do those operations in the U.S. -- and that includes the cost of air transportation and everything else. Although residents in other countries sometimes complain about their National Health Services, the irony is that few (if any) would consider trading their systems for the supposedly "superior" U.S. system -- the one which left 47 million Americans completely uninsured last year.

Less we need any further example, according to a new STUDY by the Commonwealth Fund, a New York-based foundation that has pioneered in international comparisons, chronically-ill Americans (e.g. those who suffer from at least 1 of 7 key chronic conditions: including hypertension, heart disease [including heart attack], diabetes, arthritis, lung problems [including asthma and emphysema], depression and cancer) suffer far worse care than their counterparts in seven other industrialized nations (the other countries examined include Canada, Australia, New Zealand, the United Kingdom, the Netherlands, France and Germany).

The U.S. also stands out in this study for having the most expensive system ($7,000 per capita vs. <$3,500 per capita in the other countries as of 2006), for its enormous gaps in coverage (e.g. many Americans are uninsured, even if they are employed full-time), and for its high cost-sharing -- even for patients with insurance. As one might expect, the uninsured suffered most, but even 43% of those who had insurance all year skipped some care due to the costs. The trend of high cost sharing in the U.S. continues unabated. In fact, the median deductible for traditional PPO plans (the most common type of insurance offered by employers) doubled in 2008 to $1,000 according to a new study from Human Resources consulting firm Mercer (see the WSJ Health Blog for more detail here). Not surprisingly, this week, The New York Times featured an editorial on our abysmal rankings for chronic disease care in the U.S. The author concludes "The care Americans with chronic conditions received — or more often did NOT receive — ought to be a cause for shame."

Taking a closer look at the Commonwealth Fund chronic care study, we see that more than half of the American patients went without care because of high out-of-pocket costs. This means they did not visit a doctor when sick, skipped a recommended test or treatment or failed to fill a prescription. But Americans with chronic ailments are also most likely to report wasting time because their care was so poorly organized (think of all of the referrals and redundant paperwork/forms typically required to obtain care or process claims as an example). About a third reported that medical records and test results were not available when needed or that many tests were duplicated unnecessarily. One-third experienced a medical error, such as being given the wrong medication or test results as a result. Overall, some 40% found it very difficult to get after-hours care without going to a hospital Emergency Room. The Times editorialist concludes "By contrast, Dutch patients reported far more favorable experiences with their health care system, largely because the Netherlands provides universal coverage (through individual mandates and private health insurance), a strong primary care system and widespread use of electronic medical records. It should be possible to achieve the same level of performance here."

That remains to be seen.

The FDA, the CDC, Medicare and Medicaid all fall under one federal department: the Department of Health and Human Services. This week, news broke that Tom Daschle, the former Senate Majority Leader, will soon be Obama's HHS secretary. Daschle will likely face easy confirmation by his former Senate colleagues, but the bigger job will be to implement a universal healthcare system for the U.S., a $2.3 trillion industry that accounts for about 16% of the U.S. economy (whose share is growing). By turning to the former Democratic leader to serve as his Department of Health and Human Services secretary, President-Elect Obama hopes that Daschle will be well-placed to work with Congress and pull together various interest groups to try to build consensus behind a sweeping overhaul. But its worth noting that every other Democratic President from Harry Truman to Bill Clinton has tried -- and failed -- to accomplish this herculean task. Daschle could also pose some thorny conflicts-of-interest problems for Obama's promise to change the way Washington does business. For example, the Obama Administration could require him to recuse himself from any matter related to either the Mayo Clinic or some of the clients he advised at Alston & Bird — a potentially broad swath of the health secretary's portfolio. But Daschle will be responsible for managing a $707.7 billion department with nearly 65,000 employees spread across 11 operating divisions. As HHS secretary, he will be under enormous pressure to revitalize the Food and Drug Administration (FDA), bring financial stability to the Medicare and Medicaid programs, and move away from what the consensus seems to be is the ideologically driven scientific agenda of the Bush administration.

Mr. Obama and Daschle will also be limited by a lack of money, as runaway deficit spending under Republican leadership ballooned over the last 8 years. I can't do that particular topic much justice, but a visit to DeficitsDoMatter.org has more than enough facts to validate this assumption.

During the long primary, Hillary Clinton kept nagging Mr. Obama about his healthcare plan's lack of an individual insurance mandate. The health insurance industry, not surprisingly, wants the federal government to require all Americans to have and maintain insurance, but Obama wants the rule, at least initially, to apply only to children. Think for a moment why a universal mandate is necessary. The many moving parts of healthcare reform simply don't work together unless the young and healthy are also paying into the system (and can therefore help defray the cost of caring for the older and sicker). Without all groups paying into the system, the economics of serious healthcare reform really don't work. But if the 1993 Clinton Healthcare experience taught us anything, it is far easier to work with incremental change rather than broad change -- initially.

Dashle even wrote a book entitled "Critical: What We Can Do About the Health Care Crisis", published in Feb.) to give us an idea of where he'd like to take things. The Wall Street Journal Health Blog wrote:

His basic idea: Create a board modeled on the Federal Reserve to "offer a public framework within which a private health-care system can operate more effectively and efficiently — insulated from political pressure yet accountable to elected officials and the American people."

Also, Henry Waxman just unseated John Dingell as chairman of the powerful House Committee on Energy and Commerce. That's a big deal for the health-care world, because the committee will be one of the key power centers for any big health-care reform bills. And it's a central player in Congress' relations with the drug and device industries. Perhaps 2009 will FINALLY bring some meaningful changes, even if they are only incremental.

Since 1993, U.S. Congress has done nothing to address this elephant in the room. But in the meantime, people with diabetes and other chronic diseases, which are demonized as being huge burdens on the cost of U.S. healthcare, might have a role to play. If they can make these people healthier, that would almost certainly help stem the rise in costs, but that also means taking better care of us to reduce the long-term costs that are associated with the current short-term business model for handling people with chronic conditions. Perhaps it would be wise to take another look at the Netherlands as a model on how to approach our reforms (last year, I suggested looking at the Netherlands model ... that country ranked highly in the Commonwealth Fund chronic care study, but its also important to look at the reasons why that country scored better than we did.