Replies to post #40084 on Simply Politics & News (GOV)

[n4807g]

Unfortunately I have ongoing conversations with an Oncologist at MGH monthly who has 1st hand experience with healthcare in England. She was born and raised in England. Her mother just passed away (pancreatic cancer). She was beyond distraught because in this country her mother's condition would have been found earlier. In England she had to have a stroke to be taken to the hospital where they incidentally discovered the disease. Her opinion of healthcare in europe is generally ok on average, and that it is just average. Her opinion of healthcare in the US is excellent in certain areas, above average in many cities, and average everywhere else. She has told me that given a choice, she'd take this healthcare system. I also have a cousin who is from Argentina, raised in Massachusetts, resides in England. His 20 something daughter was born with a cleft palate in a London hospital. All six surgeries to correct the problem were done in Boston at his full expense.

[n4807g]

a $1000 bucks???? Unless you work for the government or are on medicaid most deductibles are at least $1000 and much higher. Write your federal rep. ask for "free" healthcare...it's magic!

[StephanieVanbryce]

United States lags other nations on care quality
By Caroline Broder, Senior Editor 04/04/06

Despite spending more per capita on care, the United States ranks last on several key healthcare measures, two surveys of patients in six nations released Tuesday found.

The U.S. healthcare system ranked last on patient safety, efficiency, equality and its ability to focus on a patient’s needs, according to two new surveys from the Commonwealth Fund. The report measured patients’ healthcare experiences in Australia, Germany, Canada, New Zealand and the United Kingdom. One report looked at overall performance based on patient experiences in two surveys. The other examined patients’ experiences with primary care by income.

Among the findings, the U.S. performed the worst when it came to receiving a laboratory test error, getting the wrong test or waiting a long time to receive abnormal test results. The United States also ranked last on patients who reported that they left a doctor’s appointment without having their questions answered.

In addition, patients reported that they were more likely to seek treatment in an emergency room for a condition that could have been treated by a regular doctor. A Commonwealth Fund survey released late last year fount that the United States led the same six countries in its rate of medical mistakes.

U.S. patients with lower incomes were more likely to experience poor primary care access, coordination and relationships with their physicians than their counterparts in other countries. Economic differences in healthcare based on income were rare in all other countries surveyed. Patients in the United Kingdom reported the most equitable care experiences by income.

There were a few bright spots for the U.S. healthcare system in the survey. The United States ranked first on providing preventive care, such as pap tests, mammograms and diet and exercise counseling, to patients. However, U.S patients were less likely than their counterparts in other nations to fill a prescription and were more likely to forgo recommended tests, treatments and follow-ups due to cost concerns.

“We have serious issues in quality of care in all of the countries surveyed,” said Don Berwick, MD, president and CEO of the Institute for Healthcare Improvement.

Contrary to the widely held belief that the United States has the best healthcare system in the world, it actually spends more and provides worse care to patients than those in other countries, Berwick said, noting that advances in the use of medical technology do not translate into better coordination of care.

IT one of several building blocks for improvement

The use of information technology is a “constructive building block” to improving the U.S. healthcare system, said Karen Davis, president of the Commonwealth Fund. However, with only 25 percent of physicians using an electronic medical record, more needs to be done, she said. Emphasis should also be placed on coordinating care, improving primary care and redesigning the healthcare system to improve patient safety, she said.

http://www.healthcareitnews.com/story.cms?id=4724

[StephanieVanbryce]

Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens

This report is based on two surveys of patients: the first was conducted in 2004 among a nationally representative sample of adults in Australia, Canada, New Zealand, the United Kingdom, and the United States; the second was conducted in 2005 among a sample of adults with health problems in the same five nations and Germany. It ranks patients' ratings of various dimensions of their health care, according to the Institute of Medicine's framework for quality.

Executive Summary
U.S. health care leaders often say that American health care is the best in the world. However, recent studies of medical outcomes and mortality and morbidity statistics suggest that, despite spending more per capita on health care and devoting to it a greater percentage of its national income than any other country, the United States is not getting commensurate value for its money. The Commonwealth Fund's cross-national surveys of patients' views and experiences of their health care systems offer opportunities to assess U.S. performance relative to other countries through the patients' perspective—a dimension often missing from international comparisons.

In 2004, we reported on U.S. performance using Commonwealth Fund international survey data from 2001 and 2002. This report updates these findings using data from two recent surveys. The first survey was conducted in 2004 among a nationally representative sample of adults in five nations: Australia, Canada, New Zealand, the United Kingdom, and the United States. The second survey was conducted in 2005 among a sample of adults with health problems in the same five nations and Germany. This report ranks the countries in terms of patients' reports on care experiences and ratings on various dimensions of care. While focusing on a limited slice of the health care quality picture—patient perceptions of care received—as well as a limited number of countries, the surveys nonetheless offer valuable insights.

We organized patients' responses according to the Institute of Medicine's (IOM) framework for quality, outlined in the six bulleted points below. We then ranked each country's score on individual items from highest to lowest. For each IOM quality domain, we calculated a summary ranking by averaging the individual ranked scores within each country and ranking these averages from highest to lowest score.

Overall, the findings indicate that the U.S. health care system often performs relatively poorly from the patient perspective. The U.S. system ranked first on effectiveness but ranked last on other dimensions of quality (Figure ES-1). It performed particularly poorly in terms of providing care equitably, safely, efficiently, or in a patient-centered manner. On measures of timeliness, the U.S. system did not score as well as some of the other countries and rarely received top scores. For all countries, responses indicate room for improvement. Yet, the other five countries spend considerably less on health care per person and as a percent of gross domestic product than the United States. These findings indicate that, from the perspective of the patients it serves, the U.S. health care system could do much better in achieving high-quality performance for the nation's substantial investment in health.

Key Findings

Patient safety: Among sicker adults, Americans had the highest rate of receiving wrong medications or doses in the prior two years. Among sicker adults who had a lab test in the past two years, adults in the U.S. were more likely than their counterparts in the other countries to have been given incorrect results or experienced delays in notification about abnormal results, with rates double those reported in Germany or the U.K. Rates of lab errors were also relatively high in Canada.
Effectiveness: The indicators of effectiveness in the 2004 and 2005 surveys were grouped into four categories: prevention, chronic care, primary care, and hospital care and coordination. Compared with the other five countries, U.S. patients fared particularly well on receipt of preventive care and care for the chronically ill, although all countries had considerable room for improvement. Canada scored well on primary care, and Germany ranked first on hospital care and coordination. Across the indicators of effectiveness, the U.S. ranked first and New Zealand ranked last.

Patient-centeredness: In 2004 and 2005, survey questions asked patients to rate the quality of their physician care in four areas: communication, choice and continuity, patient engagement, and responsiveness to patient preference. On measures of communication and patient engagement, New Zealand ranked highest. Germany was first on measures of choice and continuity, and Australia performed well on responsiveness to patient preference. Across the measures of patient-centeredness, Germany generally was highest, followed by New Zealand. The U.S. ranked last on nearly all aspects of patient-centeredness.

Timeliness: Germany and the U.S. stand out among the six countries in terms of patients with health problems reporting the least difficulty waiting to see a specialist or have elective or non-emergency surgery. Yet Americans, along with Canadians, were more likely to say they waited six days or more for an appointment with a doctor or had trouble getting care on nights and weekends. Across all five measures of timeliness, Germany and New Zealand ranked first and second, respectively. The U.K. ranked fifth, and Canada ranked last.

Efficiency: The 2005 survey included four questions on coordination of care that serve as indicators of health care system efficiency. Compared with their counterparts in other countries, sicker adults in the U.S. more often reported that they visited the emergency room for a condition that could have been treated by a regular doctor had one been available and that their medical records or test results failed to reach their doctor's office in time for appointments. About one of four U.S. sicker adults reported these concerns. U.S. sicker adults, along with their German counterparts, also were more likely to be sent for duplicate tests by different clinicians. On measures of efficiency, the U.S. ranked last among the six countries, with Germany and New Zealand ranking first and second, respectively.

Equity: Nine measures from the two surveys gauged the extent to which patients' income affected their ability to access care. The U.S. scored last on seven of the nine measures of low-income patients not receiving needed care and had the greatest disparities in terms of access to care between those with below-average and above-average incomes. With low rankings on all measures, the U.S. ranked last among the six countries in terms of equity in the health care system. The U.K. ranked first, with no or negligible differences in terms of patients' access to care by income. The U.S. is the only country surveyed with large numbers of uninsured, and this contributed to its low rating for equity in the health care system. But even among above-average income respondents, the U.S. lagged considerably behind their counterparts in other countries.

Summary and Implications
These rankings summarize evidence on measures of quality as perceived or experienced by patients. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients' assessments might be affected by their experiences and expectations, which could differ by country and culture. Yet, reports from the World Health Organization (WHO) that compare health care system performance using measures such as life expectancy, infant mortality, or preventable years of life lost as well as health expenditures also suggest that the U.S. achieves the least for its population among these six countries. A working group—supported by The Commonwealth Fund and with experts from each of the five countries surveyed in 2004, the Organization for Economic Cooperation and Development (OECD), and WHO—developed a set of indicators that provide measures of clinical effectiveness. It found that none of the five countries included in the study—Australia, Canada, New Zealand, the U.K., and the U.S.—were systematically best or worst on measures of clinical effectiveness, confirming the mixed story reported by patients.

On four of the six domains of quality of care included in the Institute of Medicine framework, the U.S. performs relatively poorly from the patients' perspective. On timeliness, the U.S. performs about average. Effectiveness was the only measure on which the U.S. system performed slightly better than the five other countries, due largely to greater use of preventive care services and better care for the chronically ill. Notably, both of these dimensions of quality have been the focus of quality and reporting measurement in the U.S. for more than a decade.

Findings from the 2004 and 2005 surveys confirm many of the findings from surveys in 2001 and 2002. In the earlier surveys, the U.S. ranked last on measures of patient safety, patient-centeredness, efficiency, and equity. However, compared with the earlier surveys, the U.S. has improved on measures of effectiveness, from being tied for last place with Australia to ranking first among the six countries. The earlier surveys included only limited effectiveness measures while the more recent surveys contained a broader array of measures.

The findings suggest that, if the health care system is to perform according to patients' expectations, the U.S. will need to remove financial barriers to care and improve the delivery of care. Disparities in terms of access to services signal the need to expand insurance to cover the uninsured and to ensure that the system works well for all Americans. Based on these patient reports, the U.S. should improve the delivery, coordination, and equity of the health care system.

http://www.cmwf.org/publications/publications_show.htm?doc_id=364436&#doc364436

[StephanieVanbryce]

None of these forms of competition increase health care value for patients.
Health Plans: Plans will continue to have an important role, but that role will change. Competition among plans is desired (as opposed to a single-plan system) and independence between plans and providers is essential. In contrast to the traditional and failed role of health plans that involved powerful networks, restrictive choice, and management of physicians, in a value-based model patients will be given wide latitude to select the providers that offer the greatest value. Plans will serve the role of measuring providers based on results, experience, and costs. Plans will deliver value in sharing this information with patients and helping to support and counsel patients in selecting providers. Plans will widen their geographic scope, providing patients with access to providers that offer the greatest value regardless of location—a move that is in the interests of both patients and plans. Also, plans will simplify billing, reimbursement, and claims processing, making them more efficient and transparent.


Key Learnings

1. The U.S. health care system is a paradox in that it has competition yet fails to deliver improving value. Competition has been shown to be an incredibly powerful force in driving increased quality and decreased costs. This has been the case across industries and countries. However, despite the fact that the U.S. has more competition than virtually any other health care system in the world, the costs are high and rising without delivering higher quality.

The problems with the U.S. health care system are generally well known: costs that are rising much more quickly than inflation; restriction of access and services; standards of care that lag behind accepted benchmarks; frequent treatment errors; wide variations in practice patterns; slow adoption of best practices; and slow diffusion of innovation. What is not as well known is how this paradox is possible, why previous efforts to reform the system have not worked, and what to do about it.

2. The root cause of these problems is that the competition taking place has been the wrong kind. The major actors in health care—providers, health plans, and employers—have all behaved as if health care were a commodity, which is far from true, and have focused on lowering costs and improving their competitive position with the gains of one participant coming at the direct expense of others (zero-sum competition). This competition has focused on shifting the costs to other players, amassing size, especially in local markets, to increase bargaining power, capturing patients, restricting choices and services, and when all else fails, taking legal action.

This type of competition has resulted in large, undifferentiated health plans and provider networks that emphasize scale and breadth. Attempts at reform have been largely ineffective as they failed to address the root causes of the problems and have dealt instead with micromanaging and inspecting providers and forcing process compliance as opposed to achieving outcomes and results. The issue of zero-sum competition has been lack of value for patients and lack of innovation.

3. The key to addressing these problems is moving to value-based, positive-sum competition. Unlike zero-sum competition where there is a winner and a corresponding loser, positive-sum competition can involve multiple winners by creation of greater value for all parties.

Effective value-based competition will be centered on addressing health conditions over the entire life cycle of care (not the specific components of care such as surgery, office visits, home care, and so on), and competition will shift from local in nature to regional and even national as consumers seek the best health care value regardless of location. (Some consumers will continue to choose local care because of greater convenience even if the quality is not as good.) Value-based competition will be supported with detailed information that measures results and allows patients to make choices based on value. Value-based competition will serve to drive innovation.

4. Moving to value-based competition has important strategic implications for providers as well as health plans and employers.

Providers: In an environment where competition takes place based on value, instead of offering similar broad service lines, providers will develop strategies, structures, and processes to provide unique and differentiated services in a limited number of areas of strength.

Innovative providers will redefine their business around integrated practice areas where all organizational resources are coordinated and aligned to focus on one or more specific diseases or conditions, such as cancer or heart disease. The organizational structure and staffing, work processes, and facilities will evolve to provide the highest value, highest quality, and most efficient care; this may involve separating diagnosis and treatment into distinct units because the skills and processes required for each are quite different. Services and locations will be better aligned, providing greater control and efficiency. Organizations will gather data on results and on process to demonstrate the superior value that they are delivering, and as a tool to continuously improve their processes. Innovative providers will market their areas of excellence and will grow geographically as opposed to growing solely by offering new products. There will be significant rewards for early movers.

These value-focused practices hold the potential to create a virtuous cycle in health care delivery with many winners. Areas of excellence will lead to accumulating greater experience, which will result in increasing efficiency and gathering better information on results and processes.

Specific focus on conditions will result in forming a more fully dedicated team, developing facilities that allow for better optimization of specialized care, greater leverage in purchasing based on focus and volume, greater capacity for sub-specialization, and eventually, an improving, self-enforcing reputation.


Employers: Employers can and should act as the agents of change, based on their clout and economic interests in driving the system toward value-based competition. To do so, employers must change their buying behavior to focus on value. They should push plans to provide employees with broad access to providers and to provide information measuring results and value on a disease/condition basis.

5. Public policy can serve as an important catalyst to accelerate change; however, policy changes are not necessary to initiate migration to value-based competition. The policy debate is complex, political, and often focuses on the wrong subjects. The debate is often around access as opposed to the configuration and value of the health care delivery system. By focusing on greater value, the issues of who should be covered (access) and what should be covered will be easier to resolve. While policy changes to require informational disclosure and to align incentives can help speed up the process of moving to value-based competition, policy changes are not essential for these changes to happen. Key policy areas to be addressed are:

Access: Ultimately, access to care must be addressed through mandatory health insurance with subsidies for low-income citizens not covered by Medicaid or Medicare. This is important for equity, and the best value is achieved when everyone is part of the system.

Coverage: To resolve ongoing debates regarding exactly what is and is not covered, one national list of minimum necessary coverage is required. The list provided by the Federal Employees Health Benefits Program is a good solution; this list determines what is covered for federal employees and members of Congress, with a process for addressing new areas to be covered.

Configuration and value of health care delivery: To facilitate competition, redundant and anticompetitive state licensing should be eliminated and strict antitrust review of M&A activity must take place; mandatory public reporting must be required documenting experience and outcome information based on defined standards (just as the SEC requires reporting of certain information); and Medicare pricing must be addressed.

http://hbswk.hbs.edu/item.jhtml?id=4486&t=audio_conferences