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Ranking Healthcare Systems

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In your posting of October 6, Robert Garrett asked about a report ranking healthcare systems, possibly from the WHO. I think he was probably referring to this widely cited report which ranked the United States thirty-seventh?

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Dr. Marc Siegel
Dr. Marc Siegel is a practicing internist and an associate professor of medicine and a fellow in the Master Scholars...

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The city lacks the resources to address its residents' urgent mental health needs.

The United States has fueled a worldwide overreaction to the threat of a bird
flu pandemic, putting AIDS, malaria, malnutrition and other crucial
global health programs at risk.

The ranking used "five indicators: overall level of population health; health inequalities ...; overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts); distribution of responsiveness within the population...; and the distribution of the health system's financial burden within the population (who pays the costs)." On some, nations were measured against what should be achievable with the available resources. So even though technical capabilities here are great, the large numbers of people excluded and the great inequalities in our system undermined the US ranking.

Some news coverage and comment is available from ABC, the American Medical Association and from Watson Wyatt.

The rankings drew heated criticism from some quarters and pressure on the WHO to change its methods:

I hope this is helpful!

Boston, MA

Dear Deborah,

This is excellent. Thanks for the references. You're right to point out that even with a big modern engine of technology and state-of-the-art training, we should still be given crucial demerit points for excluding huge segments of our population from adequate healthcare. I still maintain, however, that by definition, quality is difficult to study and difficult to compare.

Do you know why "individual and spouse" healthcare coverage is many times more expensive than individual healthcare coverage on its own?

For example, I have individual healthcare coverage through my workplace; it costs $76 a month. However, if my husband wants to be covered by my plan, the cost will be $262 a month, which is more than three times the cost of individual health coverage!

I would understand the price increase if it doubled, but tripled? Shouldn't health insurance companies be offering discounted rates, or at least equally priced rates, to customers' spouses or their families?

Washington, DC

Dear Rhea,

They absolutely should provide reasonable spousal coverage. The tiers of rates you cite are a function of the current trend in insurance coverage. Costs are transferred from the insurance company to the employer who, in turn, transfers them to the employee. This goes on just below the radar (though recently the trend has been reported in the Wall Street Journal and the New York Times). The employers can easily maintain that they are not responsible for a spouse, which then lets the insurance company off the hook. Meanwhile, one of the central purposes of this kind of insurance is to provide family coverage. The person not working for the firm may well be the one getting sick, or having a child, for example. I'm not sure what the solution is. But clearly this is an example of why we need some form of universal coverage. Perhaps patients need a strong union together with their doctors.

The insurance companies have done a healthcare cost/benefit analysis and discovered that spouses tend to cost them much more in general than the actual worker. So they look at worst-case scenarios and dump this exaggerated cost onto the employer, who immediately transfers it to the employee and his or her family. Profit and greed take the place of reward, responsibility and loyalty to those who work for you. Heaven forbid anyone should see their margins shrinking.

I have asked my dentist about the need to take X-rays of the teeth when there is no sign of trouble. I refuse to let my children be exposed to dental X-rays if there is not a clear need to do so, although I take them every couple of years. What is your opinion on the use of X-rays when there are no symptoms of dental problems?

I read with interest the response you gave to Ivana regarding a mammogram. The last figure that I remember seeing indicated an 80 percent effectiveness of mammograms in detecting breast cancer. Living in South Africa I am unfamiliar with any controversy over mammograms.

A person I was close to developed breast cancer, which was only detected by biopsy, after two mammograms showed no sign of a lump. A magnetic resonance scan was also effective. BRENDON WOLFF-PIGGOTT
Doringkloof, Pretoria, South Africa

Dear Brendon,

It's really the same story. Periodic dental X-rays are for the most part benign, and should help a dentist pick up tooth decay and other problems that can't be determined by simple probing. The key question here is how frequently to have them done, but I'm afraid I don't know a proper answer to that.

Affordable healthcare is indeed possible simply by using the law of supply and demand. If the government were to open a huge medical college and educate any committed individual for free there would be a doctor in every apartment building, on every block in every neighborhood treating people in exchange for chickens! Anyone with the desire to serve humanity would have his/her opportunity to do so--not for the money to be made, but for truly altruistic reasons. Fifty thousand new doctors a year, year after year! Would the medical profession support such a radical idea? I think not--not at the risk of the gold mine they've allotted to themselves by cornering the market in "professional compassion."

Will it work? Ask the Chinese.

Denver, CO

Dear Kim,

I agree with the spirit of your comment, though I don't think that controlling the size of the doctor group is truly a central problem in today's healthcare market. Doctors still make a decent living, but are not making the bundle of loot you think they are. The "goldmine" has been rapidly shrinking of late. The managed-care morass, with its pressures on doctors to see more patients and do more paperwork, has seen to that. Finally, universities may well keep their class sizes down for their own reasons, mainly financial, but not necessarily because of undue influence from doctors' groups.

Are your familiar with the concept of using a low-fat diet to treat multiple sclerosis? Swank reports that about ten of his original patients are alive and ambulatory fifty years after starting this diet. The National Multiple Sclerosis Society downplays this diet; has research been performed that shows that a low-fat diet is ineffective?

I was diagnosed with MS eight and a half years ago (after having three relapses in five months), and I have tried to keep my total fat intake to less than twenty grams a day since then. This was recommended by my neurologist, who told me that a low-fat diet is often used in England and France, while it is mostly ignored in America. I have had no further relapses since starting this diet, I work full time and I feel slow improvement over the years. I have not used steroids or any of the ABC drugs (Avonex, Betaseron and Copaxone) since diagnosis.

I find it ironic that countries that have national health insurance inform their patients about this therapy, while America, with the "best medical care in the world" keeps its patients on expensive and relatively ineffective drugs instead. Ten years ago I was strongly against national health insurance; now I want to know more about it.

Bristol, TN

Dear John,

The benefits of a low-fat diet seem plausible, but in my opinion have not been sufficiently studied. Multiple sclerosis remains an elusive, mysterious illness, with an autoimmune component likely, though standard immunotherapy doesn't appear to work. Betaseron (a form of interferon) does seem to work at preventing recurrence, and gamma globulin seems to have a role in some cases, along with early intervention with steroids in acute exacerbations. A lot of this data comes from Europe, but is accepted here in the United States. A low-fat diet is of potential benefit, if fats are provoking that pathological response, but I don't think there's enough evidence to support this right now as a comprehensive treatment for MS.

I'm puzzled about the connection between blood pressure and the kidneys. Does high-blood pressure cause kidney problems...or vice versa?

Sanford, ME

Dear Marilyn,

The answer is both. An afflicted kidney can cause more resistance for the bloodstream, leading to an elevation in blood pressure. Essential hypertension, or primary resistance in the arteries, is the common condition of elevated blood pressure, which over time causes the kidneys to wear down and start spilling protein from too much pressure. Kind of like what happens to a politician who lies for a long period of time. This builds up pressure and eventually the lies catch up to him. Or at least we hope they do.

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