Commonwealth Puts Focus on Challenge of Value in American Health Care
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
The Commonwealth Fund (here) continues the debate over high cost and low value in the American health care system, finding “The U.S. spends nearly 18 percent of GDP on health care, yet Americans die younger and are less healthy than residents of other high-income countries,” and that “Not only does the U.S. have the lowest life expectancy among high-income countries, but it also has the highest rates of avoidable deaths.”
The Fund has previously published U.S. Health Care from a Global Perspective, in which it “reported that people in the United States experience the worst health outcomes overall of any high-income nation. Americans are more likely to die younger, and from avoidable causes, than residents of peer countries.”
Now, “We have updated our 2019 cross-national comparison of health care systems to assess U.S. health spending, outcomes, status, and service use relative to Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, Norway, South Korea, Sweden, Switzerland, and the United Kingdom. We also compare U.S. health system performance to the OECD average for the 38 high-income countries for which data are available.”
The results:
“Health care spending, both per person and as a share of GDP, continues to be far higher in the United States than in other high-income countries. Yet the U.S. is the only country that doesn’t have universal health coverage. The U.S. has the lowest life expectancy at birth, the highest death rates for avoidable or treatable conditions, the highest maternal and infant mortality, and among the highest suicide rates. The U.S. has the highest rate of people with multiple chronic conditions and an obesity rate nearly twice the OECD average. Americans see physicians less often than people in most other countries and have among the lowest rate of practicing physicians and hospital beds per 1,000 population.”
“Health spending per person in the U.S. was nearly two times higher than in the closest country, Germany, and four times higher than in South Korea. Despite high U.S. spending, Americans experience worse health outcomes than their peers around world. For example, life expectancy at birth in the U.S. was 77 years in 2020 — three years lower than the OECD average. Provisional data shows life expectancy in the US dropped even further in 2021. In the U.S., life expectancy masks racial and ethnic disparities. Average life expectancy in 2019 for non-Hispanic Black Americans (74.8 years) and non-Hispanic American Indians or Alaska Natives (71.8 years) is four and seven years lower, respectively, than it is for non-Hispanic whites (78.8 years).”
“In 2020, the infant mortality rate in the U.S. was 5.4 deaths per 1,000 live births, the highest rate of all the countries in our analysis. In contrast, there were 1.6 deaths per 1,000 live births in Norway. Women in the U.S. have long had the highest rate of maternal mortality related to complications of pregnancy and childbirth. In 2020, there were nearly 24 maternal deaths for every 100,000 live births in the U.S., more than three times the rate in most of the other high-income countries we studied. A high rate of cesarean section, inadequate prenatal care, and socioeconomic inequalities contributing to chronic illnesses like obesity, diabetes, and heart disease may all help explain high U.S. infant and maternal mortality.”
“The U.S. is an outlier in deaths from physical assault, which includes gun violence. Its 7.4 deaths per 100,000 people is far above the OECD average of 2.7, and at least seven times higher than all other high-income countries in our study, except New Zealand [at 1.3 deaths per 100,000].”
Americans overall visit physicians less frequently than residents of most other high-income countries. At four visits per person per year, Americans see the doctor less often than the OECD average. Less-frequent physician visits may be related to the comparatively low supply of physicians in the U.S., which is below the average number of practicing physicians in OECD countries. “The average length of a hospital stay in the U.S. for all inpatient care was 4.8 days, far lower than the OECD average [of 7.3 days]. The U.S. had 2.8 hospital beds per 1,000 population, lower than the OECD average of 4.3.”
DOCTORS, NURSES AND OTHER HEALTH CARE PROFESSIONALS
Physician Work Hours Decline, Mostly Among Men, Over Two Decades
An original study in JAMA Internal Medicine (here) shows that physician work hours consistently declined over the past 20 years in the U.S., with physician workforce hours per capita lagging behind the general population growth. This was partly offset by the growth in Advanced Practice Practitioner (APP) nurses.
The study involved “A total of 87,297 monthly surveys of physicians from 17,599 unique households” and showed that
“The number of active physicians grew 32.9% from 2001 to 2021, peaking in 2019 at 989,684, then falling 6.7% to
923,419 by 2021, with disproportionate loss of physicians in rural areas. Average weekly work hours for individual physicians declined by 7.6%, from 52.6 to 48.6 hours per week from 2001 to 2021. The downward trend was driven by decreasing hours among male physicians, particularly fathers (11.9% decline in work hours), rural physicians (−9.7%), and physicians aged 45 to 54 years (−9.8%). Physician mothers were the only examined subgroup to experience a statistically significant increase in work hours (3.0%).”
Surgical Training With Reduced Number of Cases, Minimally Invasive Techniques
A study (here) in JAMA Surgery examined the consequences of reducing training opportunities for surgical residents, finding that “Opportunities for resident independence in Veterans Affairs training facilities were found to be progressively eroded. Cases performed by senior trainees without the attending surgeon scrubbed were being done safely with almost no measurable difference in rates of postoperative complication.”
“External socioeconomic pressures have worked to limit the number of hours residents spend training and have forced attending physicians to have greater involvement in cases. The upshot is that current surgical trainees must learn more with less time and with fewer opportunities for independent practice.”
HOSPITALS, NURSING HOMES AND OTHER HEALTH CARE FACILITIES
Quality on a Budget
The federal Agency for Health Care Quality and Research announces (here) that “The Consolidated Appropriations Act, 2023, Public Law 117-328, signed into law on December 29, 2022, restricts the amount of direct salary which may be paid to an individual under an HHS grant, cooperative agreement, or applicable contract to a rate no greater than Executive Level II of the Federal Executive Pay Scale. Effective January 1, 2023, the Executive Level II salary level is $212,100.”
Restoring Physician Authority: Are Unions the Answer?
An opinion in JAMA (here) notes that “Currently, physician employment by corporate hospital systems poses a challenge not just to professional control but also to physicians’ long-standing devotion to patient welfare. Although health system leaders may have personal compassion . . . their loyalties are focused on the fiscal concerns of the organization. Professional ethics . . . may be seen as correctives that counter market incentives.”
“Although only 6% to 8% of current physicians are union members or employed under a union contract, harnessing physician influence through unions might advance interests that extend beyond pay and benefits. They might also improve the governance of health care systems and foster the delivery of ethical, high-value medical care.”
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Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org