The Quality of Americans’ Health Care

GUEST: Karen Davis, Ph.D.
AIR DATE: 11/15/2003
VTR: 09/26/2003

I’m Richard Heffner, your host on The Open Mind. And when my guest today first joined me at this table some years ago I was, and very much remain, particularly pleased to have such a sign of the Commonwealth Fund’s intellectual, as well as material, support for this program.

For Dr. Karen Davis, President of the Commonwealth Fund is herself a nationally recognized economist, with a distinguished career in public policy and research. The first woman to head a US public health service agency, she served as Deputy Assistant Secretary for Health Policy in the Department of Health and Human Services from 1977 to 1980.

Well, now Dr. Davis and her executive colleagues at the Commonwealth Fund have written a report that can’t help but prove enormously disturbing to all of us concerned with American’s health care. They call it, “Mirror, Mirror On The Wall: The Quality of American Health Care Through the Patients’ Lens”.

Taking five English speaking nations … Australia, Canada, New Zealand, the United Kingdom and the United States, they rank each country on a series of patient self-reported quality measures; including patient safety, patient centeredness, timeliness, efficiency, effectiveness and equity.

And in this comparative study let me first ask Dr. Davis how the United States fares?

DAVIS: Well, all Americans think we have the best health care system in the world, and we certainly have the most expensive health care system in the world …

HEFFNER: [Laugh]

DAVIS: … but this study really raises serious concerns about whether we really have the best quality of care. And shows that there’s a lot of room for improvement in the US health care system and that we can learn from looking at other countries’ experiences.

HEFFNER: Why given these English speaking nations are we, in so many of the categories that you use … are we at the bottom?

DAVIS: Well, one of our problems is that, ironically, the fact that we spend so much. And we have a lot of specialists, a lot of high technology care. Americans are more likely to go to a number of different doctors; they’re more likely to be on a number of different medications. And because of that, they’re more at risk for suffering medical errors. So we found in our surveys that people in the US were twice as likely to report that they had experienced a serious medical error or a medication error over the past two years. Compared, for example, with the UK where that access to the high technology, very specialized care, maybe isn’t as good as it is here.

So one thing Americans have to look out for is to make sure that they don’t fall prey to a mistake; that the wrong patient doesn’t get the wrong procedure, where they don’t get the wrong drug.

HEFFNER: Since we’ve talked last, do you think much progress has been made along these lines?

DAVIS: Well, there are improvements in quality of care over time. Certainly there is a gradual improvement in preventive services; more women are getting mammograms. People are starting to learn that it’s important in … after age 50 to get regular colonoscopies or exams for colon cancer. So there’s some gradual improvement. So that’s, that’s the good side of it.

The bad side of it is we’re far short of reaching the kind of quality standards, for example, that other American industries reach. And we find a lot of waste and duplication in the US health care system. Sometimes people are getting the same tests when they go to a different doctor, or their medical records aren’t there when they show up.

So there’s a lot we could do to improve both the efficiency and the quality of our care.

HEFFNER: But it’s interesting that you say “other American industries fare better in terms of many of these …” well, in terms of efficiency, let’s say. How so?

DAVIS: Well, I think other industries have learned to listen to their customer. They know their customers want safety. Their customers want reliability. And I think we’ve had a health care system that’s driven more for the convenience of, of those who provide the care. And we really need to listen to patients, to listen to customers, to find out what their experience with care is, what their frustration is. There is some good news here.

HEFFNER: Please.

DAVIS: Americans aren’t impatient. Compared to other major English speaking countries, we wait very little time to have a surgery or to get hospitalized. Whereas in other countries, particularly, the UK, but increasingly in Canada, there are long waits to say, get a hip replacement; even to get a simple operation like a cataract surgery, you might wait a year in another country.

On the other hand, if you look at how easy it is to get into see your own doctor, the US is not doing so well. So in the US and in Canada about two thirds of people say it’s not easy to get in even when you’re sick.

And, and there it’s very interesting to look at the experience of Australia and New Zealand, where virtually everybody can get in the same day that they feel like they need to see the doctor, and not, unrelated, I think is the fact that in Australia and New Zealand, they are more likely to rate their doctor higher. To be more satisfied with care, to feel like their doctor is really listening to them, answering their questions and taking the time that, that patients everywhere really want from their physicians.

HEFFNER: But you know, Dr. Davis, one of the things that struck me as I read this survey, read the report, was a question: “Are we, Americans, just so kvetchy, are we such complainers, do we demand so much from our physicians that the timeliness question may have to be put in a different perspective?

DAVIS: Well I think we are a very demanding public and very demanding patients. We do expect access to all of the best care and we want it right now. But I think what we need to be aware of is that things are going wrong in our system. That people are experiencing medical errors, and that we need to actually be more active, and more engaged as patients. To learn more about what’s appropriate treatment for the conditions we have.

We found, for example, that many physicians in the US don’t even review patients’ medications with them; don’t’ go through the list to make sure that you are taking the right combination for multiple problems that you may have. So patients need to learn about what’s appropriate care for the conditions that they have, and to really be partners with their physicians in making sure they get good care.

HEFFNER: Now, do you think part of that becoming good partners is facilitated by the prescription drug advertisements, or by the non-prescription drug advertisements that have become so prevalent in recent years? Do you think that leads us to be better partners or worse?

DAVIS: Well, there are two sides to it. There are some studies that show that advertising has led people with a condition that was never diagnosed to have it properly diagnosed. So they found out about something and hadn’t realized there was a way of dealing with that problem, so they go in to see doctors.

But I think we need to really advance the science. We need to understand what are therapeutically equivalent drugs; we need to look at the cost of those drugs. And not just rely on advertising. So, other countries, again, have taken the lead on this. For example, in England they have a National Institute on Clinical Excellence that really looks at different drugs and different procedures and sees if one is better than the other. We don’t have anything comparable to that in the US.

HEFFNER: Would you want to see that?

DAVIS: I think we need to move in the direction of having more evidence-based care, science based care so that we’re not just swayed by advertisements, or the latest fad. We really need to know what works, what works for different kinds of patients, what’s equivalent, doesn’t matter whether you take “this” or take “that”. And really need to make better decisions both by patients and by doctors.

HEFFNER: This would be a government organization, then.

DAVIS: It makes sense, I think, for the Federal government to take a leadership role in this. Obviously it needs to involve the physicians, the specialty societies who really know, for example, what’s the best way to care for a diabetic patient. What’s the best way to care for a patient with rheumatoid arthritis. You would want standards, quality standards that made sense. But you also want them based on what the literature shows and what the scientific evidence is in support of this. So I would see it as a, as a collaborative undertaking.

But I think given that the cost of health care is going up, we need a better strategy, other than just saying, “Well, the patient ought to pay more”. And right now with employers facing rising premiums, with the cost of public programs going up, there’s more of a tendency to say, “well, let’s increase the deductible, let’s make patients pay more if they go to a more expensive hospital.” And I think what we really need to be looking at is, is this care necessary, are we going too often, are we having MRIs when they really aren’t indicated? And to really get serious about saying “what are the clinical indications that warrant certain types of imaging, exams, certain types of specialized procedures and, and to really work on improving the supply side of care.

HEFFNER: Several years ago when you were here there was a thought that this might be accomplished more readily by the use of computerization. Do you feel that’s true?

DAVIS: Yes, and I think we are beginning to get there with increased use of electronic medical records and information technology. But the health industry, again, has been slow to take this up. And again other countries sometimes are ahead of us in that regard. Physicians in the UK and in New Zealand are much more likely to have a medical record electronically in their offices than is true in the US.

And we know this is important for a number of reasons. One, it can help prevent mistakes. So there can be computer checks on whether those two drugs go together, or whether you’re getting the right dose. In fact in hospitals some of the studies show that mistakes can be reduced, cut in half, by having these types of systems.

But it can also be more efficient; it can cut down on administrative costs and make it much easier for patients to get to the right services, right medications that they need.

HEFFNER: But that requires supervision, too, doesn’t it? Regulation and supervision.

DAVIS: Right. And it mean, I think, taking that extra step and making information publicly available. How well are we doing at managing diabetes. How well are we doing at managing pediatric asthma so that physicians and hospitals can, can look at the evidence and say, other places are getting better results, what are they doing differently? How can we put systems in place in our office that we make sure that we are staying on top of a child’s asthma, we’re staying on top of a patient’s diabetes.

HEFFNER: Does this mean a kind of competitiveness?

DAVIS: Well I think we can make competition … work for the better of patients if we have information on quality and instead of competitiveness to try to increase the costs to patients, if we can really turn that around and tap the ingenuity in our system at every level to really reach high standards of care.
The other step, though, is, I think we have to reward higher quality of care. Right now we pay hospitals the same … for example under the Medicare program … no matter what results they get. And I think we need to start thinking about bonuses for physicians and hospitals that do a better job.

This is starting in the UK. They have a new, what is called GP contract. So the way they pay their General Physicians will … now have bonuses for higher quality care. That happens in a few places in the US …out in California some of the managed care plans give bonuses to physicians that provide high quality care. So we need to learn more about those systems and whether they’re really working to improve quality of care.

HEFFNER: In a sense you couldn’t have that without managed care.

DAVIS: Well, take the Medicare program. They’re starting a demonstration now, giving bonuses to hospitals that reach high quality targets. So you get an extra 2% on your Medicare payment per patient, for patients with a given diagnosis if you reach high quality targets. On the other hand, after three years, if you’re still down at the bottom, you might lose one or two percentage points of your payment. So these are modest incentives.

But it’s a beginning to really … one, measure quality, so we know how well hospitals, physicians, nursing homes and others are doing. And then providing the money to these institutions that reward them, because it takes, really, a team approach to care. It may take sophisticated information technology that’s expensive for hospitals and physicians to acquire. But if we can give bonuses, if we can give a little extra payment for places that do that and get good results, I think we’ll have competition really, over who can be the best provider of care in this country.

HEFFNER: You said “places” and before you said “people”. You mean we can do it with both, with individual physicians.

DAVIS: I think we need to get at every level. I do think we need to look at performance at the individual physician level, also at the medical group level, because they may hire some nurses to call up their patients with congestive heart failure and say, “Are you on your medications, are you taking them appropriately. Has your weight fluctuated lately?”. So, if we pay at the group level, then they can hire some additional personnel that work for all of the physicians in that group.

But when I say “places” I also mean hospitals and I mean nursing homes. So whether it’s an institutional setting, it’s in a doctor’s office or it’s in a system of care that maybe has doctors and hospitals all working together in the same health system, I think we can find ways of appropriately rewarding those who are on the front lines of care for delivering high quality care.

HEFFNER: You know, but it was clear several years ago when you were here that this optimism of yours is a very, very, very important point. Has it been … I don’t know quite how to phrase this question. The last three years do you feel that that optimism has been justified by the progress that has been made in these multiple areas?

DAVIS: Well, I think it’s a mixed story. I think there are some exciting advances in getting information out on quality of nursing home care. I think there are some exciting advances on better managing chronic diseases.

On the other hand what we haven’t made any headway on in the last three years is reducing the number of uninsured people. The US is the only industrialized nation that does not cover everyone for basic health insurance. And yet we spend more than any other country, and the situation has gotten worse. We now have 41 million people who are uninsured.

And what our international studies show is the most striking disparities occur between people with above average incomes in the US, those with below average incomes, or for people who are uninsured. They report that they don’t get their prescription drugs; they simply don’t fill them even if a prescription is written for them. They don’t go to the specialists when the doctor tells them they need to do that. They don’t go get the colonoscopy or the mammogram or the specialized procedures or tests, that might detect their cancer in an early stage.

So the US does rank poorly in terms of equity of care. Are we serving everyone? And we find that a lot of our problems with not getting the best care to everyone comes because people can’t afford to get that care. They are not insured or they don’t have adequate insurance.

HEFFNER: I was intrigued in your study with the results coming from Canada. Now I’ve been, in my lifetime, the recipient of information that the best medical system in the world, in terms of equity certainly, was in Canada. And I’m beginning to see that this may be less so and less so and less so in a variety of these areas. Is that true?

DAVIS: Well, no country is perfect. I think when we all look internally we see problems that need to be improved. Canada went through some major economic readjustments in the mid-1990s. They had large federal deficits; they had major economic problems; and the federal government cut back on funding. And actually the percent of the gross domestic product or the total economic resources going to health care, went down in Canada in the 1990s. A number of hospitals were closed, so provinces went to more of a regional system of care. All of a sudden the emergency rooms were over flowing, a lot of patients were going home before they were really quite, quite recovered. And families felt the strain of trying to take care of people who were discharged quickly from hospitals.

So they’ve had a lot of concerns and we see in our surveys that the Canadian public are saying “hey, we value health care and the kind of spending cuts that have taken place are leading us not to get the kind of care we want” and the Canadian government, I must say, in the last three years has reversed that, started pumping more money into the Canadian health care system, but certainly there’s a lot of discontent, with shortages, with waiting times, even waiting times to get in to see a physician.

HEFFNER: Do you think there is the political will, coming back to this country, to take us from the bottom of the list in so many of these categories?

DAVIS: Well I think we are sometimes blind to the problem here. We think that every body surely must be getting care when they need it. But I think Americans are basically a compassionate people and if they understand that 18,000 people die every year as a direct result of not having health insurance as a recent Institute of Medicine study showed us; that they really would be alarmed and would be willing to devote some resources to it. I think we’re learning more about what it would cost to cover people without health insurance and I think we’re talking about three or five percent of, of total health care spending and recognizing that we could join all other industrialized countries in providing coverage for every American.

HEFFNER: Dr. Davis what does it cost not to do so?

DAVIS: Well, again …

HEFFNER: Has that measurement been made?

DAVIS: Yes. We’re learning a lot more of the cost of not covering the uninsured. The Institute of Medicine estimates that we lose 65 to 130 billion dollars each year, which is more than it would take to cover the uninsured because of lost productivity. When people are sick they can’t work, they often retire early for health reasons and then the devastating human, but also economic toll of having preventable deaths simply because we’re not catching cancer at an early stage, we’re not appropriately managing chronic conditions. So the cost of not having health insurance for all shows up in a number of ways.

People use emergency rooms, rather than lower cost primary care physicians. We have high administrative costs. People are not only uninsured, they’re getting insurance and losing insurance all the time. And every time they change insurance there is additional administrative costs for that; they may also have to change where they go for care and they have to change their medical records. When we look across countries, that what the US spends on administrative costs from this very complicated, fragmented system that we have, we pay a price in much higher administrative costs. We spend about $111 billion dollars a year just on administrative costs for insurance alone.

HEFFNER: Do you think it’s possible to dramatize those figures?

DAVIS: Well, I think we need to bring it down to the individual patient level and what it would mean to people in different circumstances if we were to provide coverage. I think when we’ve had attempts in the past to move toward a universal coverage, people have been afraid, “well, I would lose what I now have.” So I think it’s important to assure people they can keep what they have now, but to build on what works, to expand employer coverage.

For example to help the unemployed keep their coverage in force when they leave their job or lose their job and to, to open up Medicare, for example, to people who are age 60 if they don’t have health insurance from any other way. Or we’ve had a very successful children’s health insurance program, but we don’t cover the parents. So … so, I think there are some modest expansions, ways that we could move, step by step that are quite feasible that move and build on current programs.

HEFFNER: Do you think it’s correct, my feeling that you’re sitting on a powder keg in terms of your particular interests, that this area, medical care is one of the most pressing areas of our national concern.

DAVIS: Well I think health care is coming back as a major concern. And that’s for a couple of reasons. One, health care costs are going up so we know that health insurance premiums are going up about 14% a year; pharmaceutical costs have been a major concern for seniors; but for others who don’t have adequate health insurance coverage for that. And people are worried, either they’re uninsured or they are worried they’re going to lose their insurance because their employer might drop the coverage or they’re at risk of losing, losing a job.

And it’s a time when there’s new technology, when we recognize that access to life saving drugs, life saving surgery procedures can really make a world of difference for ourselves and our family members. So, yes I would say health care is back on the national agenda, and I think we can learn by looking at other countries, all of them cover everyone; all of whom spend less than we do; to really learn from that about how we improve the performance of our health system.

HEFFNER: We have less than a minute left. I want to know why you picked only English speaking countries for your comparative study?

DAVIS: Well, some of it, for us, is historically we’ve been involved with trying to improve care in these countries …

HEFFNER: I see …

DAVIS: … since 1925. But I also think that when we look for other models, we tend to look across the border to Canada or to countries where we think people maybe have some of the same, similar issues and concerns that we have here in the US. Australia, in many ways, is closer to being a mixed public/private system like our own and has a lot of important lessons for us.

HEFFNER: Karen Davis, thank you so much for joining me today for a discussion … health care, as you say, is coming up in our attention. Thanks again.

And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.