Wednesday, January 30, 2008

The Academy Remains True to Form

Well, I knew that Michael Moore's docu-ganda film, “Sicko” was undoubtedly going to be nominated for an Academy Award. And it was; what a surprise! On the up side, it probably will not win. On the down side, another docu-ganda film, “No End in Sight.” (Cinnamon Stillwell addressed the politics of the Academy Awards last year: “Hollywood's Big Ho Hum.”)

So, since it did, I thought I would recycle something I wrote shortly after its release earlier last year. Here ya go!

I now keep hearing this statistic tossed at me all the time, that the US is ranked 37th in healthcare, right there next to Slovenia, and I keep asking, well, what does it mean? Today, I perused the internet, and found it--it comes out of some World Health Organization report. And I STILL have no idea what it means!

Like any overly broad ranking, it means very little. Rankings are an OVER-SIMPLICATION of statistics. (And let me just interject here: “Lies, Damned Lies and Statistics.”)

It reminds me of the US News and World Report college and university rankings--assigning numbers based on a select set of criteria, which, when added up, essentially amounts to zero, zip, zilch, nothing. And those criteria are chosen, and weighted, based on what the evaluator is looking for. With this WHO ranking, maybe we have really FANTABULOUS medical care, but if someone want us to look bad, they might heavily weigh the analysis so that we would.

For example, we have a lot of land mass that is fairly sparsely populated, and there are people there who travel far for medical care. If you come with a criterion that states: “The percentage of geographic area in which residents must travel 1+ hour(s) to receive medical care,” we'll bomb. (In the interest of full disclosure, this is NOT a statistic I found buried inthe WHO report.)

I notice the countries ranked higher (France, Finland, etc.) tend to have a higher numbers for:
  • General government expenditure on health as % of total expenditure on health. (France at 76 vs 43 for the US).
  • Social security expenditure on health as % of general government expenditure on health (97 vs. 33)
While we have higher numbers for Private prepaid plans as % of private expenditure on health (61 for the US vs. 53 for France.) Do the people who calculate the ranking DEDUCT points for that, or what? And REWARD countries for socialist style medicine? (I'm betting YES!)

How do they interpret in their ranking the fact that as a per capita total expenditure on health (at average exchange rate US$), France spends $2981 while we spend $5711? I'll wager that counts against us! But solving THAT problem is NOT going to be done by going to a single-payer system, to government run healthcare! That number is so high because of a variety of reasons: insane litigation, the fact that the individual consumers generally don't pay (for insurance or for the product/service) and therefore healthcare has little consumer-driven pricing structure; our willingness/eagerness to perform ground-breaking procedures, etc.

Another issue with this is that it compares apples and oranges, and apples and asparagus, and apples and armadillos... There are VERY few countries with which the US can compare in terms of population, land mass, GDP/GNP, etc. It is INSANE to compare us to France: We have a MUCH larger landmass, a MUCH larger population, a far LESS dense population (293 vs. 80 per sq.mi., not too mention that over 90% of France's population is in metropolitan areas.) We have a different system of government and taxes, and while we are much closer culturally with France than we are with, oh, say, Djibouti, we do nonetheless have a very different cultural—and therefore DIFFERENT EXPECTATIONS OF OUR HEALTHCARE SYSTEM.

According to WHO, some of the things that this ranking apparently tried to address included (description are from WHO):
  • Fairness of financial contribution: The measurement is based on the fraction of a household's capacity to spend (income minus food expenditure) that goes on health care (including tax payments, social insurance, private insurance and out of pocket payments). Colombia was the top-rated country in this category, followed by Luxembourg, Belgium, Djibouti, Denmark, Ireland, Germany, Norway, Japan and Finland.

    Countries judged to have the least fair financing of health systems include Sierra Leone, Myanmar, Brazil, China, Viet Nam, Nepal, Russian Federation, Peru and Cambodia.

    Brazil, a middle-income nation, ranks low in this table because its people make high out-of-pocket payments for health care. This means a substantial number of households pay a large fraction of their income (after paying for food) on health care. In North America, Canada rates as the country with the fairest mechanism for health system finance – ranked at 17-19, while the United States is at 54- 55. Cuba is the highest among Latin American and Caribbean nations at 23-25.
Obviously, the less socialized the medicine, the less likely to come out on top with this statistic. Actually, the U.S. ranking at 54-55 puts us in the mildly socialized level. But of course, this does not take in to account how much of the taxes that people pay go into propping up the socialized medical structure, (not the tax rate of the country.)
  • Overall Level of Health: To assess overall population health and thus to judge how well the objective of good health is being achieved, WHO has chosen to use the measure of disability- adjusted life expectancy (DALE). This has the advantage of being directly comparable to life expectancy and is readily compared across populations. The report provides estimates for all countries of disability- adjusted life expectancy. DALE is estimated to equal or exceed 70 years in 24 countries, and 60 years in over half the Member States of WHO. At the other extreme are 32 countries where disability- adjusted life expectancy is estimated to be less than 40 years.
The United States didn't do too badly in this category, despite the fact that we are apparently such fat slobs, addicated to french fries and burgers, sitting on our fat asses, watching television. We ranked 24th under this system, with an average of 70.0 years of healthy life for babies born in 1999; female babies could expect 72.6 years of healthy life, versus just 67.5 years for male babies. Sure, we rank lower than Australia, (73.2 years); France, (73.1); Sweden, (73.0); Spain, (72.8); Italy, (72.7); Greece, (72.5); Switzerland, (72.5); Monaco, (72.4); and Andorra, (72.3). But then we have a much larger population, a much higher percentage of which is rural. We have a much more heterogeneous poplulation. Large numbers of diverse people living scattered across the geography makes public health more difficult to shove down their throats.
  • Distribution of Health in the Populations: It is not sufficient to protect or improve the average health of the population, if - at the same time - inequality worsens or remains high because the gain accrues disproportionately to those already enjoying better health. The health system also has the responsibility to try to reduce inequalities by prioritizing actions to improve the health of the worse-off, wherever these inequalities are caused by conditions amenable to intervention. The objective of good health is really twofold: the best attainable average level – goodness – and the smallest feasible differences among individuals and groups – fairness. A gain in either one of these, with no change in the other, constitutes an improvement.
I have no idea where the U.S. ranked in this category. If you can find any information about this, please let me know. The link to the report is below.
  • Responsiveness: Responsiveness includes two major components. These are (a) respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider).

    The nations with the most responsive health systems are the United States, Switzerland, Luxembourg, Denmark, Germany, Japan, Canada, Norway, Netherlands and Sweden. The reason these are all advanced industrial nations is that a number of the elements of responsiveness depend strongly on the availability of resources. In addition, many of these countries were the first to begin addressing the responsiveness of their health systems to people's needs.
Notice where the United States ranks? We are No. 1! This, to me, says more about the state of health care in the United States than any of the other statistical analyses contained in the WHO report.
  • Distribution of Financing: There are good and bad ways to raise the resources for a health system, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is only concerned with distribution. It is not related to the total resource bill, nor to how the funds are used. The objectives of the health system do not include any particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending there are other possible uses for the resources devoted to health. The level of funding to allocate to the health system is a social choice – with no correct answer. Nonetheless, the report suggests that countries spending less than around 60 dollars per person per year on health find that their populations are unable to access health services from an adequately performing health system.

    In order to reflect these attributes, health systems have to carry out certain functions. They build human resources through investment and training, they deliver services, they finance all these activities. They act as the overall stewards of the resources and powers entrusted to them. In focusing on these few universal functions of health systems, the report provides evidence to assist policy-makers as they make choices to improve health system performance.
Well, I think we can guess what this means. It is all about how socialized the financing is, because it is so much more fair to derive a pound of flesh by way of increased tax burden on the “haves” as opposed to the “have nots.” now, don't get me wrong--I do believe that healthcare is not solely the purview of those that can afford it. But, well that is a thought to continue at a later date...

Well, all well and good, I suppose, but they are still reducing a TON of DISPARATE information down to ONE number—and it, in the end, doesn't mean a whole lot. And, of course, the US will come out near the bottom of the top--the statistical analysis is stacked such that we will REGARDLESS OF HOW EXCELLENT HEALTHCARE IS IN THE U.S.! (Like you all hadn't figured THAT out yet!)

For those of you interested in taking a gander at the WHO report yourself (and please do!) here it is: “World Health Organization.”)