Time, Eben Harrell, Copenhagen, May 20 - High infant mortality, low life expectancy, soaring health-care costs — the symptoms are numerous and the diagnosis unmistakable: America's health-care system is ailing. But like a patient who coughs or limps his way through an illness, the U.S. has often been reluctant to look for help.
That's changing. The Obama Administration promises to offer universal coverage, introduce electronic records and wrestle health-care costs under control — in short, at least part of the health-care revolution that many Americans have advocated for years.
Inevitably, perhaps, that means Americans are looking to European models, hailed by some, dismissed as socialized medicine by others. In truth, European health care is neither the nirvana of Michael Moore's imagination, nor the publicly funded money pits that so scare conservatives. For one thing, Europeans spend less — about $4,000 a person less, in some cases — than Americans on health care annually, and often with better outcomes. The good news is that without reassembling its entire health-care system, there are many relatively simple measures that could help the U.S. get a handle on soaring costs — and keep its population healthier, too. America, here is your prescription:
Denmark: Electronic records save money and improve outcomes
At the Frederiksberg University Hospital in Copenhagen, there are no clipboards. Instead, doctors and nurses carry wireless handheld computers to call up the medical records of each patient, including their prescription history and drug allergies. If a doctor prescribes a medication that may cause complications, the PDA's alarm goes off. In the hospital's department of acute medicine — where patients often arrive unconscious or disorientated — department head Klaus Phanareth's PDA prevents him from prescribing dangerous medications "on a weekly basis," he says. "There's no doubt that it saves lives."
President Obama recently pledged $19 billion to computerize America's medical records by 2014. Denmark has already made the transition. The country has a centralized computer database to which 98% of primary care physicians, all hospital physicians and all pharmacists now have access. While basic records go back to 1977, a detailed history is available of all "patient contacts" since 2000. A recent study by the Commonwealth Fund, a health-care-reform nonprofit, rated the country's health-care IT systems as the most efficient in the world, with computerized record-keeping saving Danish physicians an average 50 minutes a day of administrative work. "That's essential for [U.S.] doctors," says Jeff Harris of the American College of Physicians, who points out that U.S. family physicians have the highest administration costs in the developed world and "are already under strain from all the paperwork required to run an office."
Denmark boasts several advantages that have helped in the early adoption of electronic health records. It is small (population: 5 million) with a tech-savvy citizenry and a public sector-run health system. Trust in the government is high. Most crucially, when the health service established a National Patient Registry in 1977 — a system that required doctors to file patient visit details in order to be reimbursed for their work — the country unknowingly laid the groundwork for electronic health records by putting in place centralized record-keeping.
But there have been slipups. After the government decided to move away from paper records in 1999, a team of officials came up with a coding system that required doctors to insert information and notes in alphanumerical form. The system was never implemented and eventually abandoned in 2006 after physicians and nurses complained. Now, instead of a single system, record-keeping utilizes various compatible systems, linking networks established by regional health agencies. "What we found is that adoption of electronic health records must be done by evolution rather than revolution," says Jens Andersen of Sunded.dk, the state health-care web portal. "You have to work with the systems already in place."
The latest phase of the program focuses on telemedicine. In the past year, the health-care service has piloted two home-monitoring programs for patients with diabetes and those on blood-thinning medication — groups at high risk of emergency hospitalization. At Frederiksberg Hospital, Dr. Phanareth is running a ground-breaking study to test whether patients with exacerbation of chronic obstructive pulmonary disease — responsible for 10% of all hospital admissions in Denmark — can be treated at home using telemedicine technology. "Sometimes, a lack of resistance is all you need for change to happen," Phanareth says.
Germany: Easing the burden of chronic disease; strengthening peer review
Sudden illness may be what scares most people, but chronic conditions place the greatest strain on health care. Around 75% of the U.S.'s $2 trillion annual health-care expenditure goes toward ailments such as heart disease, asthma, diabetes and certain cancers, and the vast majority of that is spent when these conditions require hospitalization and emergency care. The problem is particularly acute in the U.S. public sector: over 20% of U.S. Medicare patients have five or more chronic illnesses.
Preventing these conditions from developing in the first place is helped by a holistic approach to preventive medicine that encourages changes in what people eat or how much exercise they get. But for those patients already battling a chronic illness, there are steps health-care providers can take to keep them stable and out of hospital — as Germany's experience shows. The solutions can be as simple as educating patients about their condition, having nurses call patients to make sure they are staying on top of their medication and allowing doctors to compare their success rate with other physicians.
Germany's "disease-management programs" began in 2002 and cover some 3 million chronic patients. The results are promising. One survey by the University of Heidelberg of some 11,000 patients in the Saxony Anhalt and Rhineland-Palatinate regions found that the death rate in older diabetics in the program was about 8% lower than among diabetics who received regular care. And when one of Germany's largest insurers tracked 20,000 coronary heart disease and diabetes patients enrolled in disease-management programs for 15 months, it found the percentage of patients requiring hospitalization dropped from 4.3 to 2.9 — and 25% of the patients also gave up smoking.
The challenge is finding the funding to implement such schemes. In America's health system, there are few financial incentives for providers to take proactive measures to keep people healthy: the longer and more extensively a doctor or hospital treats a patient, the more income they recoup. That's why the American College of Physicians and others are calling for reform in health-care reimbursement, with the Federal Government and large insurance companies setting up "Patient Centered Medical Homes" in which a portion of doctors' pay will be linked to performance targets. As in Germany, these homes will target chronic diseases by allowing doctors, nurses, dietitians and therapists to educate all patients — especially chronic ones — on how to stay healthy. In 2007, Geisinger Health System began a pilot program in Pennsylvania, hiring nurses to check on patients with diabetes, heart disease and other chronic ailments, as well as linking 20% of physician income to targets in areas such as patient weight loss, smoking cessation and cholesterol levels. After the first year of the study, hospitals reported a 20% fall in admissions in the area and health-care expenditure dropped 7%.
The Germans have also shown how effective it can be to allow physicians to compare their performance against their colleagues. The country has the largest database on hospital performance in the world, which helps spread best practice. Such ideas would prove equally effective in the U.S., according to Karen Davis of the nonprofit Commonwealth Fund, but change needs to come at the policy level. "Right now we can see how successful these programs are in places like Germany and Pennsylvania but then doctors and hospitals come back and ask, 'Who's going to pay for it?'," she says. "It's a fair question."
Britain: How much is a year of life worth?
Placing a cap on drug costs could save U.S. health care billions. But it's not without controversy. England and Wales have set up a body called the National Institute for Health and Clinical Excellence (NICE) which reviews treatments to decide which are the most cost-effective and which the National Health Service (NHS) should pay for. A new drug has to offer value for money — and if it doesn't, whether it is life-saving or not, NICE won't approve it.
NICE uses a metric called "quality-adjusted life year," or Qaly, which grades a person's health-related quality of life from 0 to 1. Say a new drug for a previously untreatable condition comes on the market and the drug is proven to improve a patient's quality of life from .5 to .7 on the scale. A patient on the drug can expect to live an average of 15 years following the treatment. Taking the new drug thus earns patients the equivalent of three quality-adjusted life years (15 years multiplied by the .2 gain in quality of life). If the treatments costs $15,000, then the cost per quality-adjusted life year is $5,000.
Taking its lead from Britain's Department of Transport — which has a cost- per-life-saved threshold for new road schemes of about $2.2 million per life, or around $45,000 per life year gained — NICE rarely approves a drug that costs more than $45,000 per Qaly (the fictitious drug would easily pass).
Not only does the equation make hard-nosed sense in a public-health system, its use can reduce costs in other ways. Eager to gain NICE's approval, drug companies have started giving away portions of expensive treatment for free in Britain in order to ensure their drugs meet the threshold. Sir Michael Rawlins, chairman of NICE, believes that if the U.S. adopted a similar system, it would revolutionize the culture of major pharmaceutical companies, many of which spend more on marketing than research and development. A 2008 study in the New England Journal of Medicine predicted that incorporating information about cost-effectiveness into the design of U.S. insurance would save $368 billion over 10 years.
NICE approves over 90% of new drugs, and those it rejects are rarely life-saving. But it has turned down some expensive treatments that prolong life — most notoriously, the kidney cancer drug Sutent in 2008 — angering patients and oncologists. The organization has since promised to approve more expensive life-saving drugs for illnesses affecting fewer than 7,000 patients a year. Rawlins concedes that NICE is "muddling through" uncharted waters: "The biggest lesson we've learned is to be open and transparent. But you have to be willing to make difficult decisions."
Aware that the idea of "rationing" health care would prove controversial in the U.S., advocates of reform — from the American College of Physicians to the advocacy group Center for Medicine in the Public Interest — have suggested a system of review that doesn't take into account the cost of new treatments. This would help doctors decide a course of treatment, as currently they have no way of comparing the efficacy of different drugs for the same condition. But it could also raise prices. "In a free-market economy the manufacturers may use the effectiveness review to charge higher prices for the best drug," says Jeffrey Harris, president of the American College of Physicians.
Peter Pitts of the Center for Medicine in the Public Interest says higher prices are a risk America will have to take. "Because NICE is concerned about saving money and not what's in the best interest of the patient, its methods are not only imprudent, they are unethical," he says, arguing that pharmaceutical firms use profits to fund research and development. Rawlins has a different take. "All health-care systems have implicitly, if not explicitly, adopted some form of cost control. In the U.S. you do it by not providing health care to some people. That's a rather brutal way of doing it."
France: The benchmark system is neither truly socialized nor fully equal
In 2000 the World Health Organization (WHO) used statistical measures, such as life expectancy and infant mortality, to rank the world's health-care systems. France topped the rankings. In 2008, researchers at the London School of Hygiene and Tropical Medicine followed up the WHO study by showing that France is not only a good place to stay healthy, but also a good place to be sick: of 19 industrialized nations, France has the lowest number of "amenable deaths" — fatalities that could have been prevented by good health care. (The U.S. had the highest.) But France is not immune to the challenges of modern health care. Despite massive government spending, its health-care system regularly runs over budget; in 2009 the deficit is expected to be $10.4 billion. Frustrated with the overstrained public-health sector, many people are now choosing private care.
France's state-run health insurance scheme reimburses 60% to 70% of most medical bills. The remaining costs are assumed by the patient. More than 90% of French citizens pay for supplementary health insurance to cover these costs — mostly from state-run providers called mutuals. But those who can afford it are increasingly abandoning mutuals in favor of private insurance. For most ailments, that makes little difference: 80% of France's general practitioners work under a regime that caps how much they can charge. But the reverse is true for specialists and surgeons — 80% of them set their own fees, often exceeding the reimbursement ceiling of most mutuals.
The result: a two-tiered system that runs counter to the utopian ideals of most health-care reformers. That's inevitable, says Dr. Roger Rua, secretary general of Syndicat des Médecins Libéraux, a union representing private practitioners. "Anywhere you've got a degree of socialization in a nation's health-care system, you'll eventually find people who feel they aren't finding what they want within it and decide to opt out," he says. "This is particularly true when systems begin having trouble financing themselves, and start cutting back on services."
Rua and others say that what's exemplary about France's system is that it has managed to foster patient choice while continuing to provide a generally high level of care for even the most vulnerable. All French citizens have affordable access to a doctor, thanks in part to one of the highest rates of doctors per capita in the world (3.4 per 1,000, compared to 2.4 in the U.S. and 2.5 in Britain). A sick French citizen who stays inside the public funding system might not get to choose from a list of specialists, but he or she will get a referral and the needed care. In some cases, patients even get paid to go to the doctor: for new mothers, a network of prenatal and early childhood facilities, called Protection Maternelle et Infantile, provides basic care, with financial incentives for the poor to attend.
France shows how a health-care system might realistically function in the face of daunting 21st century challenges: find a way to take care of your middle class and poor, and let the rich top up care as they see fit. As Rua puts it: "The [French] system ensures quality treatment for everyone, but it isn't there to eliminate the realities that exist in every country — and in every professional and economic sector — that give the more affluent a wider variety of choices, and the ability to seek élite care."
With reporting by Bruce Crumley / Paris and Stephanie Kirchner / Berlin
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