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Tuesday, May 9, 2023

U.S. Healthcare Outcomes and State Initiatives To Lower Costs

 Due to federal failure to enact meaningful healthcare reforms, this article reviews states that are making a difference. Three states which have taken steps to control the cost of healthcare without adversely impacting patient outcomes are Maryland, Montana, and Oregon and this article reviews what they have done. But before we get to that let’s review the current status of U.S. healthcare.

 Washington State’s 2022 report on evidence-based methods to control costs, increase equity, and improve industry transparency and regulation stated three truths that should shock the nation, if voters were only aware. Globally, U.S. healthcare continues to be the most expensive healthcare but health quality metrics continually show the results are not worth it. In 2019, the U.S. spent 16.8% of all gross national product (GNP) on healthcare. Norway, the top scoring nation for health outcomes spent 10.5%. How much longer are the American people going to have to listen to how more expensive their health care will be in a national healthcare system-clearly this is not the case. Here are the Commonwealth Funds 2021 findings for the latest metrics on global healthcare outcomes compared to the rest of industrialized nations: (Eric C. Schneider, 2021)

 U.S. ranks last in healthcare outcomes (we spend 60% more on healthcare than Norway, the top nation for outcomes)

               1. Highest infant mortality 

               2. lowest life expectancy 

               3. Lowest rate of reduction in avoidable deaths (which is what healthcare is supposed to do)

              4. Last on access to care 

              5. Last in administrative efficiency

              6. Last in health equity (discrimination in health services)

              7. Second on measures of care process (we are tracking it all as the outcomes decline)

The Commonwealth Fund has for years done an excellent job of finding methods to compare different healthcare systems and this latest report reviewed 71 measures for 2019 to arrive at its conclusions. Nations reviewed were: U.S., Switzerland, Germany, France, Sweden, Canada, Norway, United Kingdom, Netherlands, Australia, and New Zealand. Here are the metrics reviewed:

 Cost-U.S. Healthcare is 50% more expensive than other industrialized nations

Gross domestic product, which is essentially a measure of all goods services produced over a specific period of time for the country is a measure of wealth and how much of that wealth is spent on things, such as housing, education, and healthcare. It is one measure to assess a cost comparison for health systems which has been widely used. New Zealand spent the least on its healthcare, at 9.1% and one could argue that it is a tiny nation and not comparable to the complexity of the U.S., but Australia, also spent 9.4%. For nations with larger populations, France spent 11.1% of its GNP on healthcare and Germany spent 11.7%. And unlike the U.S. these nations cover most of their populations and their residents don't pay thousands of dollars out of pocket for services.

 Infant Mortality-U.S. Deaths are 70% higher than other industrialized nations

Infant mortality is a measure of babies who die and is a direct reflection on maternal child healthcare and access to care. In this forlorn measure, the U.S. has 5.7 deaths per 1,000 infant births, compared to the other nations, which had less than 4 deaths. Switzerland boasted only  3.3 deaths per 1,000 births.  

 Maternal Mortality-U.S. deaths are 5 times higher than other industrialized nations

The U.S. also has an abysmal maternal mortality rate, which is going to increase with the latest century rollback of women’s health in many states, which seek to outlaw termination of pregnancy for any reason. To be clear there were 17.4 American women who died as a result of childbirth per 100,00.  France loses only 3.2 women, even if you are math impaired that is five times the number of women who die from childbirth in the USA. Expect more to perish from ectopic pregnancies, hemorrhaging (bleeding out), cardiac conditions, and other preventable causes. In 2020, 24 women per 100,000 died from childbirth in the United States. 

In 2021, 32 women out of 100,000 died from childbirth, an astounding increase of 25% in preventable deaths. The Centers for Disease Control 2022 analysis found that 4 out of 5 pregnancy related deaths are preventable-80%. (Centers for Disease Control and Prevention, 2022) This is an appalling statistic! The U.S. is ranked 55th for maternal mortality-a metric that clearly shows how little our females are valued.  U.S. legislators would rather a women die as a result of childbirth than alter a pregnancy. Current maternal mortality in the U.S. is equivalent to many less developed countries including: Mexico, Egypt, and much worse than Cuba (which has a national healthcare system). (Ritchie, 2023) While evaluating healthcare outcomes for women more than a decade ago I was astounded to learn of the disparities in maternal mortality and the high rate of deaths for pregnant women in Washington D.C. is seared into my mind.[1] Seemingly people don’t want to believe how bad things are for pregnant women in the U.S. or they don’t care. It feels like people are looking away as they do for the poor souls  living in tents in every U.S. city.

 Life Expectancy-Americans pay more for their healthcare and don’t live as long

The Commonwealth metrics uses the number of years attained on average by nation as the measure of life expectancy. All of the top nations had average life expectancies beyond age 80, but Americans (83.1 years) can expect to live 2.5 years less than the rest. And only in the U.S. are there sharp differences based on race, mortality for black (74.9 years) and American Indian (73 years) populations are much worse than the average.

 Reduction of Avoidable Deaths-U.S. ranks the worst

The Commonwealth Fund 2021 Report on global health outcomes reviewed the reduction of avoidable deaths and Switzerland reduced avoidable deaths by 25%,  five times the U.S. rate, which was only 5%. The next worst performer in this group of 11 nations was Germany which still reduced deaths by 13% This is another metric where the residents of the states, who are gouged and underserved for health care should be electing officials who are going to take action. Leaving it to the marketplace isn’t working.

 Administrative Efficiency-U.S. ranks the worst

Anyone who has had to obtain healthcare in the United States knows what a nightmare it is to find affordable insurance, obtain a clinician whom is accepting new patients, and choke down the copayments and fees from excluded charges for anesthesiologists, labs, and other out-of-network care thrust upon them.

 We know what we must do to improve healthcare outcomes:

1. Provide universal coverage to remove cost barriers to obtain health care-stop gearing health care investments just for wealthy suburbs. 

2. Invest in primary health care systems-not money makers for huge hospital corporations 

3. Reduce administrative burdens on patients and clinicians-integrated health systems work best

4.  Invest in social services-nutrition, education, childcare, safety, housing, transportation

 State Actions to Control Healthcare Costs

 Capitation-fixing fees

Maryland enacted a regulatory body to control hospital costs in an all-payor-model and all hospitals must participate. Maryland received a CMS waiver to use this model instead of the DRG system adopted by most other states, which is highly inflationary. The agency reviews hospital rates and has the ultimate authority on approval of changes. This governing authority has not resulted in hospital closures or patient care, but it has produced the lowest hospital prices in the country. This model is a capitation model which has worked for Maryland and was launched in 2014.

 Linking fees to a multiple of Medicare Rates

Montana, through the leadership of Marilyn Bartlett pegged state employee healthcare costs to a percentage of Medicare rates and saved the state thirty million dollars. Even the Republicans in Montana appreciate a taxpayer savings. Barlett had to fight the deep pockets of the healthcare industry, to enact this contract provision, but she won. Prior to her administration, hospitals were charging the Montana State Employees Plan five times the Medicare rates. Barlett, a CPA, has taken her leadership skills on the road advising states and business coalitions on methods to control costs. (Walker, 2021)

 Payment caps and Reference based pricing

Oregon caps state employee health plan payments for 24 of its 62 hospitals, because of differing needs of rural hospitals, critical access hospitals (urban trauma centers), and hospitals that served 40% or more of Medicaid patients (low income). Oregon also plans to limit cost increases to 3.4% per member per year. (Rakotoniaina, 2021)

 Washington’s report concludes with four recommendations to reduce the costs of healthcare including: targeted price growth regulation, expanded transparency and cost-growth benchmarks, strengthened anti-trust enforcement and consumer protection, and improved drug affordability. At least, on the latter, the federal government did finally come out with some affordable insulin mandates. But what really needs to happen is for the government to be restored to the people, by overturning the Citizens United ruling which allows corporations to make unlimited political donations. Given the current makeup of the Supreme Court, who seem intent on settling their own scores versus representing the will of the people, this seems unlikely. However, lifetime appointments does not mean we can't take administrative action under the constitution to remove court members from hearing cases. It’s time to bring in the back bench of the federal courts.

 And this is the healthpolicymaven signing off encouraging you not to sign blanket releases when obtaining medical care, do stipulate that for which you agree and for which you decline. For example, if your hospital refuses to recognize your medical directive, find another one for your procedure.

 Roberta Winter is an independent health policy analyst and journalist, who has published this blog since 2007. In 2013 her guidebook to the U.S. healthcare system was published by Rowman and Littlefield.

References

Centers for Disease Control and Prevention. (2022, September 19). Four in 5 pregnancy-related deaths in the U.S. are preventable. Retrieved from Centers for Disease Control and Prevention: https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html

Eric C. Schneider, A. S. (2021). Mirror Mirror 2021; Healthcare in the U.S. Compared to Other High Income Countries. The Commonwealth Fund. Retrieved May 9, 2023, from https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly

Rakotoniaina, A. (2021, August 31). How Oregon is Limiting Hospital Payments and Cost Growth for State Employee Health Plans. Retrieved from National Academy For State Health Policy: https://nashp.org/how-oregon-is-limiting-hospital-payments-and-cost-growth-for-state-employee-health-plans/

Ritchie, M. R. (2023, May 9). Maternal Deaths By Country. Retrieved from Ourworldindata.org: https://ourworldindata.org/maternal-mortality#maternal-deaths-by-country

Walker, D. G. (2021, February 18). Montanas Health Policy MVP Takes Her Playbook on the Road. Retrieved from Kaiser Family Foundation Health News: https://kffhealthnews.org/news/article/montanas-health-policy-mvp-takes-her-playbook-on-the-road/

 

 

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