Islands of Excellence in a Sea of Mediocrity

03/18/2010 05:12 am ET | Updated May 25, 2011
  • D. Brad Wright Assistant Professor in the Department of Health Management and Policy at the University of Iowa

A short time ago, I wrote a series of posts about the relative cost of a variety of health care services in the United States as compared to other industrialized western nations. The results, you might recall, indicated that prices in the U.S. are far and away higher than they are in the other countries considered, which more than likely explains why per capita health care spending in the U.S. is roughly double that of the next closest "competitor."

Some people are unfazed by that. In fact, as if to support my recent post on the psychology behind cost-control, many people are of the opinion that we are getting what we pay for. To them, our extremely high per capita health care spending is the price we pay for having the "best health care in the world." To the extent that it is true, such a claim would be quite reasonable. We value health care, our health care is of an exceptionally high quality, ergo we pay a lot for our health care. But what if the middle part of that statement isn't quite true?

In politics, there are three sides to every coin: the obverse (heads), the reverse (tails), and the edge. In the health reform debate, in particular, there are those who oppose reform, because they are worried that changing the status quo will jeopardize the "world's best health care" (as if there's a coffee mug with this slogan printed on it somewhere beneath the dome of the capitol building) and those who push for reform because they see large swaths of the population with limited access to care, which they translate into low quality. As you might guess, neither extreme has cornered the market on the truth. When it comes to assessing health care quality in the United States in comparison to health care quality in other wealthy nations, the truth is somewhere in the middle: We do some things well and other things terribly.

I could use this space to expound on Cicero and the etymology of "quality" or share the seminal work of Avedis Donabedian, but I will spare you for now. (If you're interested, let me know, and if I hear from enough of you, I'll tackle these subjects in future posts.) Instead, I want to draw your attention to an August 2009 report issued by the Urban Institute. It's about a dozen pages long, so I'll just hit the high points for you.

In short: The United States isn't getting what it's paying for. Compared to other developed nations, we're in the bottom third when it comes to life expectancy. Our medical care is a mixed bag. We're relatively poor at preventive medicine and care of chronic conditions, but good at treating cancer, for example. What's especially notable, given the pejorative manner in which references are made to the "socialized" Canadian health care system, is that the evidence strongly supports that the quality of health care in Canada is better than the quality of health care here at home.

The bottom line is that many definitions of quality introduce quite subjective elements into the analysis, making it hard to draw conclusions about the level of health care quality in the United States, let alone to determine how we compare to other countries. In reading the Urban Institute report--and synthesizing its findings with the rest of my experience of health care quality in the U.S.--here's what I would consider to be a "fair and balanced" assessment of U.S. health care quality: It's highly variable. The quality of care you receive depends on a host of factors ranging from what care you require to who provides it and from where you go for care to what kind of insurance coverage you have. The experience of someone--Ted Kennedy, say--who has the means to pick up from Washington, DC or Massachusetts and go to the Cancer Center at Duke University in Durham, NC will be quite different from the experience of someone in Brunswick, GA who is uninsured, has poorly controlled diabetes, and has their foot amputated as a result in the local community hospital.

Without a more universal system in place, we are left drawing straws when it comes to health care quality. Actually, that's a bit too generous. Our system is such that it allows you to buy better odds of drawing a longer straw. They don't do business like that in other countries. To quote from the Urban Institute report, the "best U.S. health care is the best in the world"--but most Americans don't receive anything close to the best U.S. health care. Consequently, the results produced by our health care system--weighted by who does and who doesn't have access to the best care--fall far short of being the "best health care in the world." On the contrary, we have islands of excellence in a sea of mediocrity. It's time to start bringing everyone ashore.

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