Sunday, August 23, 2009

America Has the Best Health Care in the World?

Let's get honest, OK? American does not have the best health care in the world. Europeans and Canadians are not flocking to our borders to get to our health care. It is time we realize that we can learn from our neighbors and we don't have to claim we are the "best" at everything. It makes us look really stupid in the eyes of the world.

Here are some facts. We do spend the most money on health care in the world. We do spend the highest percentage of Gross National Product (GDP) on health care and we do spend more dollars per capita than any other country on Earth.

The claim that the United States has the best health care in the world has been proven false by every broad metric used. The World Health Organization and the nonpartisan Commonwealth Fund rankings rate the U.S. last of the Western industrialized countries. The WHO ranks us 37th of all measured countries.

The Commonwealth Fund says, "Among the six nations studied—Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2006 and 2004. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, efficiency, and equity. The 2007 edition includes data from the six countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care."

The U.S. also lags in information technology. (We have been awaiting a robust electronic medical record for 10 years) and in coordination of care and in measured quality outcomes.

One of the ways we improve in health care is when we face the brutal truth. How can you make improvements if you don't know where you are starting from? If you truly believe you are the best in the world...there would be no need for health care reform.

Perhaps that is why these myths and lies are being propagated.


David said...

Medical Tourism ~ Ensuring an Economic Boost

Medical tourism represents an opportunity for U.S. hospitals to diversify revenue - usually hospitals with dedicated international centers generate five to ten percent of total revenue from international patients. Inbound medical tourism to the U.S. is approximately $5 billion or 400,000 patients annually, according to the Deloitte Center for Health Solutions.

Patients come mainly from Latin America, the Caribbean, Europe and the Middle East. Many are cash paying patients, usually wealthy people traveling to the U.S. looking for high tech care, but the largest medical tourism group consists of patients with international insurance policies.

I like you blog, but…
In order to fix a system one must understand it. Making inaccurate statement based on emotion does not help. Would you want someone fixing a nuclear power plant, make a change to a Boeing airplane, or design a 60-story skyscraper not understand the system they are working with?
You have people living in Europe and the Middle East that prefer to come the longer distance to be treated in the US than to use their own systems or other systems in Europe. People who can afford any medical care they desire prefer to come to the US.

Toni Brayer MD said...

David: I would consider your remarks more credible if you weren't promoting medical tourism to the USA.

I am well aware that American hospitals love patients from other countries because they are wealthy and represent great cash flow. The wealthy from many countries travel the world and price is no , provide VIP treatment and everyone goes away happy. This in no way reflects the state of Health Care in America.

Toni Brayer MD said...

David: Just for clarity, I meant to say "The wealthy from many countries travel the world and price is of no concern. Hospitals are happy to take their money, provide VIP treatment and everyone goes away happy."

David said...

I meant to add the following but I was interrupted (and I am not promoting medical tourism I am simply stating information that demonstrates that the best medical care is in the US).

Table 1. Five-Year Relative Survival Rates for Cancer of Different Sites, US and European Cancer Registries*

5-year survival rate (%)

Site The first number is US. The second is Europe.

Prostate 99.3 77.5
Skin melanoma 92.3 86.7
Breast 90.1 79.0
Corpus uturi 82.3 78.0
Colorectum 65.5 56.2
Non-Hodgkin lymphoma 62.0 54.6
Stomach 25.0 24.9
Lung 15.7 10.9

All malignancies (men) 66.3 47.3
All malignancies (women) 62.9 55.8

Survival Rates Significantly Higher in United States Than in Europe

One of the reports compares the statistics from Europe with those from the United States and shows that for most solid tumors, survival rates were significantly higher in US patients than in European patients. This analysis, headed by Arduino Verdecchia, PhD, from the National Center for Epidemiology, Health Surveillance, and Promotion, in Rome, Italy, was based on the most recent data available. It involved about 6.7 million patients from 21 countries, who were diagnosed with cancer between 2000 and 2002.

The age-adjusted 5-year survival rates for all cancers combined was 47.3% for men and 55.8% for women, which is significantly lower than the estimates of 66.3% for men and 62.9% for women from the US Surveillance, Epidemiology, and End Results (SEER) program ( P < .001).

Patterns and trends in prostate cancer incidence, survival, prevalence and mortality. Part I: international comparisons.

National Cancer Intelligence Centre, Office for National Statistics, London, UK.

“There were wide differences in survival across Europe, with rates in the UK well below the average, but all European rates were far below those in the USA.”

Life expectancy in the United States fares poorly in international comparisons, primarily because of high mortality rates above age 50. Its low ranking is often blamed on a poor performance by the health care system rather than on behavioral or social factors. This paper presents evidence on the relative performance of the US health care system using death avoidance as the sole criterion. We find that, by standards of OECD countries, the US does well in terms of screening for cancer, survival rates from cancer, survival rates after heart attacks and strokes, and medication of individuals with high levels of blood pressure or cholesterol. We consider in greater depth mortality from prostate cancer and breast cancer, diseases for which effective methods of identification and treatment have been developed and where behavioral factors do not play a dominant role. We show that the US has had significantly faster declines in mortality from these two diseases than comparison countries. We conclude that the low longevity ranking of the United States is not likely to be a result of a poorly functioning health care system.

David MD

Anonymous said...

David, what speciality of a doctor are you?

shadowfax said...

Health care quality is great in America -- if you have access to care. So it's fair to say that we have very very good (the best? I dunno) health care in the world. However, it's equally true to say that we have the worst health care system in the developed world.

It's also true to say that for as much as we spend on health care, we do not get much value on the dollar compared to the rest of the world.

Raymond Bouchayer said...

40 + millions of Americans payer not Insured does not show that we have the best ....David .... You have lots of words and statistics , but we are ranked 39 or 40 right behind Morocco as far as medical care . More hospital infections , mistakes etc... But yes very wealthy clients will come from the world over because here in the good old USA ...Money is King and they'll kiss your ....for it .Without it you can Kiss your .....good buy.

Sunnydalai said...

The argument has never been that there aren't quality doctors and nurses in the United States. Who cares about that if only the wealthiest can get access to their treatment. There has to be a parallel system with access for ALL regardless of financial resources.

Sunnydalai said...


The gentleman you quoted, University of Michigan professor Mark J. Perry, is not an objective or relevant source. Just because he's in academia doesn't make him any less likely to be influenced by his own views. Furthermore, and in light of the above, it's ironic that you would accuse dr. brayer of letting her personal opinons cloud her understanding of the matter. Professor Perry's recent post was a diatribe on why health care is not a right but a privilege, with the usual rant of a healthy does of paranoid right-wing "thinking". The healthcare industry is not even close to Mr. Perry's specialty and his lack of understanding could therefore be easily understood and excused. In his own field as professor of economics and finance, he appears to have been one of the cheerleaders of the freemarket back in 2007, completely oblivious to what was about to hit.
This leads me to believe that the good professor's time (and his "followers'") would be better spent educating himself continuously and properly in his specialty instead of pontificating on subjects where he is hopelessly overwhelmed. I'm afraid we can probably all cite studies that agree with our viewpoint. It is therefore of utmost importance that we consider the sources carefully.

David said...

I have been waiting for Toni to comment on this (relative) good news that American health care is far superior to European health care. The truth is that it is very bad news for the Europeans because millions are dying needlessly.

Please, please never attack the messenger but attack the data presented. I simply googled for this information and the medical tourism site came up as did the other sites. What is important is to address the data as presented and the data on the perry website was simply quoting a study that was also mentioned in less statistical detail in medscape. I could not give you the link to the original papers because most of you don't have access to journals.

For Americans that are living under the fallacy that Europeans have better health care and that our system is totally messed up this is really good news yet you have not read about it in the NYTimes, Wash Post, etc. Dr. Brayer was not aware of it.

For men the 5-year survival is 66.3% vs. 47.3% in Europe for a spread of 19 percentage points or almost 1/5. That is 1/5 more men in the US have a chance of surviving malignancy than do those of Europe. That means millions of lives saved in the US compared with Europe. Yet nobody reported this. For women it is 62.9% in the US vs. 55.8% in Europe or a 7.1% spread or 7 out of every 100 more surviving in the US than in Europe. That is again millions of people. Why wasn't this reported?

Black women in the US are more likely to have premature births for reasons that we don't know about. American health care for premature infants is second to none in the world even if mom doesn't have insurance. Statistically more black children born prematurely in the US will survive than in other countries supposedly providing better medical care than the US (Morocco?).

I know young physicians from German, UK, Israel that have come to the US to practice medicine because the opportunities are better here. I had part of my medical training in London at a tertiary center and the public hospital in America that I also had training in had better equipment than the tertiary center in London and the poor in America had better access. E.g. an MRI in the public hospital in the US was used for torn ACLs. Physicians get paid a fair wage here which doesn't always happen overseas (e.g. Israel) and this is one reason why health care is more expensive here than in other countries. Another reason is that other countries bargain down the cost of medicines and instruments than the US -- that is the US is subsidizing the R&D costs of that the other wealthy countries should be sharing the costs of. This should change so that Big pharma cannot charge the US much more than they charge other wealthy countries for the same products. Another reason why costs are higher here is that there are more facilities so that there is not rationing like there is in other countries. Wait times for "elective" orthopedic surgery can be very long in some of these countries.

David MD (continued)

David said...

(continued from previous comment)

Are there problems in the US health care system? Certainly. Can we do better? Most certainly. But it is very important that there are people who have never taken care of a patient, who have perhaps never stayed up all night even once in their entire life (except when partying) that simply cannot understand health care and yet they seem to understand more than people who have dedicated their life to taking care of patients.

Obama is a very bright man. Both of his parents have (had) PhDs. He is Columbia and Harvard educated. His wife was an executive at U. Chicago hospitals. His chief adviser Axelrod also has worked in health care. These people all know that there are not really 45 million uninsured yet they continue to quote this number. Many of the uninsured simply have not signed up for Medicaid which they are entitled to. Perhaps 10 million aren't even US citizens or legal residents. Millions more are young and in a sense don't feel they really need it.

In cities like New York and Chicago (and many others) people without insurance don't have to go to the emergency room. There are federally, state, and city funded clinics that offer top notch medical care and are proud of it and some of these are far more advanced than private clinics using the most up-to-date electronic medical record systems. People want you to believe otherwise because they have an agenda of "single payer" health care, socialized medicine. They think we should be more like Europe so that 1/5 more men and 7/100 more women can die from cancer (not really of course).

In addition, according to the Institute of Medicine, only 10% of health is determined by lack of access to health care. 20% by genetics, 20% by environment (e.g. air pollution) and a whopping 50% by lifestyle (smoking, obesity, firearms, alcoholism and resulting auto accidents, ....).

CDC estimates that $100 billion of health care costs are from smoking, $150 billion or so from obesity and lack of exercise, and so on. This is another reason why health care is so expensive.

Quoting again from the NBER study that I quoted earlier:

" by standards of OECD countries, the US does well in terms of screening for cancer, survival rates from cancer, survival rates after heart attacks and strokes, and medication of individuals with high levels of blood pressure or cholesterol. We consider in greater depth mortality from prostate cancer and breast cancer, diseases for which effective methods of identification and treatment have been developed and where behavioral factors do not play a dominant role. We show that the US has had significantly faster declines in mortality from these two diseases than comparison countries."

Remember, in order to fix something be it a nuclear power plant, an airplane design, a building, a bridge, one has to understand it and not use emotions and political agendas. Keep the politicians out of designing nuclear power plants. Keep the politicians out of designing health care systems. (I am writing a report and this sort of thing is part of it).

IOM has stated that 1/2 of all health is determined by lifestyle and only 1/10 by lack of access yet the government is focused on the 1/10 and not the 1/2. Does this make sense? It is important to address the 1/10 but lets first do the following:
1. Rigidly enforce laws prohibiting minors from smoking and raise the cost of cigarettes which induces people to never start and others to quit. Obama should spend $1 billion giving money to states to help enforce the law.
2. Give away free nicotine replacement patches and anti-smoking counseling, to smokers, etc.
3. Ensure that all children of pediatric age have daily exercise in school.
4. Improve labeling on foods so that people understand that drinking a 20oz bottle of sugar coke a day is the same as consuming 45 lbs of sugar per year.

See Ken Thorpe's site:

Raymond Bouchayer said...

French Success Story
Indeed, a May 15 study from the Commonwealth Fund study comparing the quality of the U.S. system with five other countries found that despite spending twice as much per capita, the U.S. ranks last or near last on basic performance measures of quality, access, efficiency, equity, and healthy lives. "The U.S. stands out as the only nation in these studies that does not ensure access to health care through universal coverage," says Commonwealth Fund President Karen Davis (see, 6/12/07, "Universal Health Care: Say Yes").

Gazing across the Atlantic won't lead Americans to a model that fits everyone's requirements. Britain, in particular, suffers myriad problems in its National Health Service (NHS). But in some respects, France comes pretty close to the ideal. Not only are its 62 million citizens healthier than the U.S. population, but per capita spending on health care is also roughly half as much.

France relies on a mixture of public and private funding, as does the U.S. But unlike Americans, every French citizen has access to basic health-care coverage through national insurance funds, to which both employers and employees contribute. Some 90% of the population also buys supplementary private insurance to provide benefits that aren't covered, and the government picks up the tab for those out of work who cannot gain coverage through a family member. "We pay higher taxes in France, but at least we get something for our money," says Leslie Charbonnel, an American who has lived in Paris for two decades.

The key to France's success is that its system, like the U.S.'s, values patient choice and physician control over medical decision-making. But France does it for far less, with per capita health-care spending in 2004 at just $3,500, compared with $6,100 in the U.S., according to the World Health Organization. All told, France spends 10.7% of gross domestic product on health care, vs. 16.5% in the U.S.

Toni Brayer MD said...

David: I have enjoyed reading the comments of readers but must respond to your direct challenge to me, the author.

I am sorry, I cannot rejoice in your (unfounded) statement that "American health care is far superior to European health care." There are far too many studies over the past 15 years that do not back up your claim. I do, however, appreciate your civilized manner and debate on this subject and this blog.

The Robert Woods Johnson Foundation just (August 2009) issued an analysis (14 pages) of how the U.S. compares with 30 other OECD countries. Here is a synopsis:

Life expectancy - below average

Preventive care (pap tests, mammograms)- above average

Flu vaccines - above average

Childhood vaccines - below average

Adult asthma care - below average

Asthma mortality - 5th highest (not good)

End Stage Renal disease - worse than Canada

Hypertension tests and treatment - better than average

US had highest rate of deaths from conditions that could have been prevented or treated successfully.

U.S.had best survival rates for cancer of the colon, rectum, lung, breast and prostate. We are ninth in stomach cancer and 5th in ovarian cancer.

U.S. had highest rates of coronary revascularization procedures with equal mortality rates from heart disease.

Finally, U.S. doctors were less likely to agree that their health care system works well compared to Australia, Canada, New Zealand and the U.K.

1/5 of the U.S. population under age 65 is uninsured in the United States and we are one of only three countries in OECD, with Mexico and Turkey which has this large share of its population lacking coverage.

The Roberts Woods Johnson analysis concludes; "it is clear that the argument that reform of the U.S. health system stands to endanger 'the best health care quality in the world' lacks foundation. On the basis of this review it is safe to say that U.S. health care is not pre-eminent on quality; furthermore, one can surely argue that U.S. health care quality is not at risk from the kinds of health reform proposals receiving attention."

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Dr. Locke Political Science said...

Read the healthcare bill before any of you even talk. It's 1019 pages including amendments and it's online. (99% of you won't understand it but atleast try) It takes away many of your rights. It's not time for a change...its time to get back to our roots. What we were built on. We are the only TRUE revolution in the world...ever. All other countries were just replaced by other leaders. Balance is key. Re-read the previous sentance slower and truly think what balance means. Spend more than 2 seconds passing over read it again.

Regardless of how good the healthcare system is...if you let your government take over the healthcare system then you gave up your quit and gave up. Ben Franklin is quoted saying that he has given us a Republic if we can keep it. Every other country that has healthcare is democratic/socialized/communist. We are not a democracy (angry mob) you may think so but...we are a republic DONT EVER FORGET THAT. I pledge allegiance to the flag of the United States of America and to the REPUBLIC for which it stands...can you keep it?

1927 Normal Thomas (an American Socialist) and 6 time runner for President said this, "The American people will never vote for Socialist ways, but under the name of Liberalism the American people will adopt every fragment of the Socialist program." First step social security. He literally said this stuff. This has been around for decades. Healthcare is not new.

This is exactly what is going on. WHEN WAS IT LEGAL TO FIRE THE CEO OF GM? Obama has broken so many rights...and now the people are standing up..We can't take this BS anymore. I get called racists because I want my border closed.. Are you kidding me? My second amendment right is going out the door. Incase you all forgot we started the Revolution because the Redcoats tried to take our muskets away...remember the first shots fired?? DONT TRED ON ME. I don’t need the government to tell me what to do with my money. I know better then they do.

David is a smart man and I'd listen to him for your children’s sake.

And all of you that love the other countries healthcare systems...then move there. The United States isn’t stopping you. Just get your stuff and move there. Many people move to the US and then they want to bring their country with them...get out.

And no people shouldn’t get free healthcare I have to work hard for my money and so should you. 85% of America's people have healthcare and you want to take that away so that the 15% that doesn’t work or is illegal can have it too. F U. We already have welfare (which was tried in Rome and it didn’t work). Why don’t we drug test the welfare crowed?? See how many people actually give the money to their kids and not their drug dealer. I'm so tired of lazy people wanting a handout.

Democracy has been tried...Athens was a strong supporter of this...And its leader Socrates (you might know him) was voted to death by his own people. Hemlock

Don't listen to who your favorite movie star research. Read about past civilizations. You will see through this. I know were smarter than this.

I've studied too long and hard to let my liberties be taken away. And most of all I want my liberties and I will fight for them and so will the rest of the true Americans. Get out and vote this November

sunnydalai said...

It's just sad and depressing that we share the country with people like this. Aside from the lunatic rant and the adventurous spelling, the last sentence and sentiment is proof of the writer's extremely limited grasp on reality, and it actually made me laugh out loud.

Toni Brayer MD said...

Dr. Locke: Your rambling comment says it all. You brought in guns, immigrants, illegals,General Motors, the Redcoats, welfare drug use and Socrates. I am sure all of the "lazy people" who lack health care or are denied insurance or have chronic illnesses would have something to say back to you.

Orac said...

"For men the 5-year survival is 66.3% vs. 47.3% in Europe for a spread of 19 percentage points or almost 1/5. That is 1/5 more men in the US have a chance of surviving malignancy than do those of Europe. That means millions of lives saved in the US compared with Europe. Yet nobody reported this. For women it is 62.9% in the US vs. 55.8% in Europe or a 7.1% spread or 7 out of every 100 more surviving in the US than in Europe. That is again millions of people. Why wasn't this reported?"

You clearly aren't a cancer doc, or you wouldn't interpret the data so simplistically. A lot of this, particularly the prostate numbers are due to phenomena known as lead time bias and length bia:

Prostate's the best example. Autopsy studies have shown that approximately 75% of octogenarians have evidence of prostate cancer. Yet nowhere near that many ever develop clinically relevant prostate cancer; most men die of old age or something else. However, PSA screening detects a lot of that asymptomatic cancer that would never cause a problem in the patient's lifetime, and, because we don't know which tumors will and will not progress, we tend to treat them all. We basically overtreat, and lots of men whose tumor would never have endangered their lives undergo surgery and radiation. They're also counted as "cures" even though the treatment made no difference. Over the last several years, prostate cancer docs have come to appreciate this and are learning to tell when watchful waiting is the appropriate management for a screening detected prostate cancer.

A recent study showed that perhaps as many as one in three mammographically detected breast cancers may represent overdiagnosis:

The bottom line is that your interpretation of the differences in reported survival rates between the U.S. and Europe for cancer is woefully simplistic and does not take into account very obvious factors that likely explain them.

Indeed, the study you cite has a number of absolute howlers about cancer. The one that struck me as the purest bullshit was, "Population-level data on mortality have one distinct advantage over data on survival rates among those newly diagnosed: they are not subject to lead-time bias. If one country is diagnosing cancer sooner than another but early diagnosis does not alter the clinical course of the disease and delay or prevent death, then that country will enjoy no advantage in mortality as a result of its earlier diagnoses. When early diagnosis improves prognosis, population-level mortality is responsive to the timeliness of diagnosis."

This howler ignores the biology of, in particular, breast and prostate cancer. Tumors diagnosed "earlier" that would never have threatened the patient's life increase the apparent number of diagnoses for that cancer, even if the absolute number of deaths remains the same. That alone increases the apparent survival rate. More intensive imaging also leads to the "Will Rogers effect" described in my first link above.

Color me unimpressed with this study as evidence that the U.S. takes better care of cancer patients than Europe.

Anonymous said...

Dr. Brayer..

So, do you think "lazy people" or those illegal immigrants who lack health care deserve "free" health care coverages??

What if 150 million people decide to be "lazy" and prefer govt. to take care of their health? who is to check? how do you know or the govt. know they are not taking advantage of the "free" healthcare??

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Bobby said...

I see a lot of comments comparing US healthcare to Europe. I'm sure you guys are aware that Europe isn't actually a country. It's a Continent. Your figures are being manipulated by grouping all the countries in Europe as one. Its like grouping all the countries within North and South America (or the Americas depending on where your from) into one and then presenting these figures.

Try breaking these figures down by using countries within Europe, see how these figures change. said...

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