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What's Most Likely to Kill Us? Not a Disease, but the U.S. Health Care System

I used to joke that waiting on hold to get a doctor's appointment, a referral to a specialist, the results of a lab test or the answer to an urgent medical question made my blood pressure rise more than any amount of overeating or lack of exercise. It turns out that I wasn't far off the mark, according to a study in the November issue of Health Affairs. What's most likely to kill us aren't our slovenly habits but our free-wheeling, everybody-does-his-own-thing health care system.

If their statistics are to be believed, medical care outcomes in the U.S. have been sliding for decades. The authors, Peter A. Muennig and Sheryl Gilad, both professors at the Mailman School of Public Health at Columbia University, point out that in 1950, the U.S. ranked fifth in female life expectancy; since then we've fallen to 46th. Life expectancy for both sexes in the U.S. has dropped to 49th -- 78.1 years. That places us behind many modern industrialized nations but also Bosnia, Jordan and Hong Kong.

Typically up for blame are obesity and smoking as well as traffic accidents and gun violence. To listen to Sanjay Gupta and other medical celebs, if Americans would straighten out and live right, they would last forever. Muennig and Gilad set out to learn whether that makes sense. First, they examined the 15-year survival data of men and women aged 45 and 65 from the U.S. and 12 fairly wealthy nations (Australia, Austria, Belgium, Canada, France, Germany, Italy, Japan, the Netherlands, Sweden, Switzerland and the United Kingdom) and compared them to per capita health care spending. Even though the U.S. was spending more than any other country, gains in life expectancy over the years were mingy. In 2005, for example, "not only were fifteen-year survival rates for 45-year-old U.S. white women lower than in all comparison countries but they had not even surpassed 1975 fifteen-year survival rates for Swiss, Swedish Dutch or Japanese women." Improvements in survival for women aged 65 and men of both age groups were also pathetic. Only large gains in survival among nonwhites in the U.S. kept the nation from complete life expectancy stagnation.

Smoking, the usual whipping boy, provides no explanation for such poor performance. In fact, mortality from lung cancer has improved in the U.S. compared to other countries. Ditto for obesity. While Americans have been getting fatter, they have been doing so at slower rates than people in other industrialized nations. And even Australia and England whose overweight citizens can match ours pound for pound (or ton for ton) showed greater gains in 15-year survival rates. Americans' proclivity to die in traffic accidents or homicide hasn't changed for decades and isn't high enough to depress survival rates. What about lack of health insurance? Studies have shown that having it may give people only an extra few weeks of life expectancy.

So what's the deal? "Unregulated fee-for-service reimbursement and an emphasis on specialty care may contribute to high US health spending, while leading to unneeded procedures and fragmentation of care." According to Einer Elhauge, editor of The Fragmentation of U.S. Health Care, a batch of essays published this year by Oxford University Press, fragmentation manifests itself in a number of invidious dimensions:

Fragmentation in treating particular illnesses, such as the lack of coordination among the various professionals involved in treating a patient during a single hospital stay. This might occur if, for example, a patient tells one nurse she is allergic to some medicine, but the nurse does not communicate this information, so the nurse on the next shift administers that medicine. A somewhat broader conception would focus on fragmentation in treatments for particular patients at any given time, such as a lack of coordination between different providers that a patient might see for different illnesses. This might occur if, say, a surgeon used a high-sugar intravenous therapy after an operation on a diabetic patient without consulting with the diabetic specialist treating the patient. Even more broadly, we might worry about fragmentation for patients over time, such as when a private health insurer underfunds preventive care because the costs will be borne later by Medicare. Most broadly of all, we might worry about fragmentation for a patient group. This would be the case if disintegration resulted in care being misallocated to patients in the group who needed it less than others.
Studies have shown that the average Medicare beneficiary sees two physicians and five specialists a year, and that those with chronic illnesses see an average of thirteen physicians a year -- each one focused on one body part. Medicare nor other insurers pay physicians to coordinate care, and very few medical practices can or do transmit records to each other electronically to make sure that mistakes aren't made. Patients or their families -- who rarely have the medical expertise or the hutzpah to make sure that co-ordination occurs-- are left with the responsibility of making sure that there are no gaps or mistakes. Generally, the greater the number of physicians treating a Medicare patient following a heart attack, the higher the costs and the lower the survival rates. With a system like this, it's no wonder that gains in longevity in the U.S. give us little to brag about.

Now all this is not to say that people should not take some responsibility for their health -- avoiding smoking, over-eating and unsafe driving. Such precautions can't hurt anybody. And kudos to the Obama administration for trying to get more people health insurance. But it's clear from this new study that only by eliminating the inefficiencies in our health care system will we begin to make real strides in lengthening people's lives and improving their quality.

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