Surprise, surprise, the US healthcare system is still the most expensive and lowest performing. That’s the message from the latest Commonwealth Fund report called Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System.
In this episode of CareTalk, John and David dive into the report’s findings to uncover why U.S. healthcare remains so broken—and explore what, if anything, can be done to fix it.
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Episode Transcript:
David Williams: Surprise? Surprise! The U. S. healthcare system is still the most expensive and lowest performing. That's the message from the latest Commonwealth Fund report called Mirror Mirror 2024, a portrait of the failing U. S. health system. Why do we continue to be so terrible, and what, if anything, can be done about it?
Welcome to Care Talk, America's home for incisive debate about healthcare business and policy. I'm David Williams, President of Health Business Group. And I'm John Driscoll, the senior advisor at Walgreens. October is the season for masks and costumes. But some of us feel like we're wearing a mask all the time, whether at work, in social settings, or with family therapy can help you embrace all parts of yourself.
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John Driscoll: So David, this Commonwealth report, I mean, we've talked a lot about how the U S has Worse outcomes and more costs means sort of ad nauseum.
What did we learn anew with the Commonwealth? First of all, who is the Commonwealth Fund and what did they tell us? What are
David Williams: they telling us? Well, you're going to have to tell me the Commonwealth Fund is John. I just know of them as a, as a group that does you know, good public health reporting. They've put this report out now for about 20, 20 years.
They started it. I think they do it every other year. And. They try to measure things in an accurate way. So you've got 10 different countries used to be 11, but Norway dropped out. They measure 70 different performance measures across five different domains in healthcare. The five are access to care, care process, administrative efficiency, and health outcomes.
And they say, like, where does everybody rank on everything? And pretty much we're the worst on all those different elements. And then cost they measure as a percent of gross domestic product. And we're not just the worst. We're actually a big outlier. You look at the charts and they're all bunched together.
And then the U. S. is just off in the wrong corner in each one.
John Driscoll: Yeah, just just to be clear. The Commonwealth Fund is around. I think they're on almost 100 years. It's some great industrialist funded. It's a foundation. It's an independent foundation that does academic research that racks and stacks A number of healthcare issues.
And the one that we keep coming back to is this, this, this evaluation of how well does the United States health care system perform relative to how much it costs. And then it breaks down that performance in the categories that you talked about. And. We continue to do poorly. I frankly miss Norway because Norway was the second most expensive system in the industrialized West, and they left because of privacy reasons, but it's made us look even more extreme just to give people a sense of how expensive our health care system is.
We spend about 16 percent of GDP or gross domestic product on health care. And, you know, the countries, the industrialized countries, countries that kind of look like us, Germany, Switzerland, New Zealand, Australia, the better-performing ones in this survey are spending four to 8 percent of their GDP on health care, and they're getting in general better outcomes.
So spending less, Getting more in terms of measuring morbidity, mortality what's going on here, David?
David Williams: It's a little hard to understand because, you know, sometimes you could say, well, you know, you, you get what you pay for it. Well, we, we pay more, but we get more for it. Or we, we pay more, but we get, you know, maybe we should pay less, but at least we're getting the top.
And it's really kind of the opposite. Australia and the Netherlands are the two highest-performing Countries in this comparison, and they're also the 2 lowest cost. And that does make it perplexing john to try to understand. And you have to start, I guess, searching for things that aren't specifically in the report to understand that 1.
I mean, I guess I could make like a car comparison. Like, so John, like, I think you drive a Lotus or Lamborghini, as I may recall. They're very nice. It's a
John Driscoll: Lexus with 200, 000 miles on it, but thank you very much.
David Williams: All right. So anyway, so you, so the Lexus is like, you get what you pay for, right? It's strong performance.
It's good. I think probably the, the equivalent of the U. S. in healthcare would be the Land Rover. It's the most expensive, but it's always breaking down, I guess. It looks good and people like to brag about it.
John Driscoll: Well, we're not gonna get Land Rover arrange Rover to, to advertise on the po I guess. I guess not John.
David Williams: It it is actually hard to, high
John Driscoll: budget,
David Williams: high breakdown. It is hard to, to understand. So I mean, the way to probe it, I guess, is, is to look, you know, look, is there, so is there anywhere where we're not, you know, the worst? And the answer is yes. The answer to the question, is there anywhere where the best is no, but we do come in second in, in care process and last in everything else.
So care process, we're assumed to be making progress on.
John Driscoll: What, I mean, now that you've struggled to find a category that the United States is okay in, what the heck is care process, David?
David Williams: Well, it's things like prevention, patient safety, care coordination, patient. That sounds good. What, what,
John Driscoll: what, if we're number two there, what, I mean.
Number two, that's a silver. Why aren't we doing well across the other categories of outcomes?
David Williams: You know, let's say about why we are doing well here in this area, which is that, you know, would you say you get what you should pay for sometimes, right? And we have actually been paying for care process, a lot of pay for pay for performance.
Measures are about care process, things like this patient engagement when you get these surveys and they ask you how well engaged you are, you know, there are actually incentives to do these things, right? So maybe the, the positive thing is that if we do put money beyond, behind something specific, we can get there, but maybe we need to put the emphasis in somewhere other places, or these aren't as correlated with outcomes as we might want, or maybe we, we just need to put the incentives into, you know, to the other categories and we can move up there too.
John Driscoll: Well, I think you should also look at where is the United States an outlier in a number of things that aren't going well. One is gun violence. We are a wild outlier in terms of gun violence. The most likely risk of death for kids is increasingly gun violence. We are a, you know, an outlier in terms of care, care, care, consistency of care coverage.
You know, one out of four, I mean, I think there's still 36 million people who are uninsured and they may go on and off the rolls, but when you don't have insurance, you're less likely to go to the doctor and get those preventive care. stuff done. And even for those who are covered, you know, obviously Medicaid expansion and Obamacare have extended coverage for many Americans who didn't have them, you know, about one in four covered Americans is underinsured, which is to say that the, the cost of actually going to get the care you may or may not need is high enough because of copays and deductibles.
But people typically or, or, or, or, or consistently thinking twice and sometimes avoiding the care that they need. So we are paying for it, but not necessarily getting the care access. If you compare our system to others, there is a much more of the, in the developed world. That's, this is, these are all developed world comparisons.
Every other system has more consistency of care. Most other systems, all other systems have significantly lower costs. Although some of them, you know, do, do have a slightly higher cost. I mean, Germany costs, you know, caps its, its cost share at a percentage of income. Most others do as well. You know, we are definitely an outlier also in opioid addiction and deaths of deaths of despair.
Increasingly, that is a significant category problem, not just for older adults, but younger folks. And I think if you come, if you think about drugs and violence and inconsistency of coverage, Those have got to be feeding into David these statistics
David Williams: for sure, John, and I think that we need to remember that the goal is health, not health care per se.
To be fair, one of the domains that they do cover is health outcomes. So it's not as though it's completely forgotten about. I mean, maybe we can look to what does the U S do differently. So we might turn it into a positive force or reinforce it. If it is one area is just the amount of private investment that goes into healthcare.
The report actually does a little bit of a tsk tsk about a private equity ownership. Oh, it's worse than that.
John Driscoll: I think they're kind of insulting private equity ownership, but particularly of primary care primary care docs. And I mean, they refer to them as trading them like commodities, which I don't think is quite fair.
In fact, I think private equity is actually been a significant source of capital. In the primary care area. And if anything, I think that's a, at least from my perspective, a good thing, certainly where primary care risk taking primary care has failed. It's more about the management of those units than actually the capital providers who are, who are helping them or trying to help them grow.
And if anything, David, I think we need to spend and invest more. In primary care, because the in our private system, the vast majority and the in the incentives within the institutions are to put more money into tertiary and quaternary care. The things that happen to you when you're going getting a complex surgery or spending time in the hospital and and those incentives are backwards.
I mean, I, you know, I think that's a that's probably Yeah. an incentive system. That's a problem for the U. S. System.
David Williams: So let's dig into that primary care question a little bit. So primary care has been in crisis or in decline here in the U. S. For some time. And say, if you take private equity aside, what was happening was people either just exiting primary care or We're selling their practices to hospitals that were using those feeder systems into this more expensive care that you're, that you're talking about.
So, you know, absent policymakers actually making investments from the public stance standpoint, it's up to private industry to do something. And in this case, it's done it. Now there's been pushback. First of all, there's been challenges in doing it because you can't fight the overall system and maybe some of them haven't been managed as well as possible.
But you also get then pushback maybe from even from the government saying they don't want private ownership here. And I think it's probably favoring the hospital systems. So can we get, is it, if we look ahead and say primary care is still an issue, what's the role for private investment going forward, would you say?
John Driscoll: Well, I think it really depends on where the incentives are. You know, currently, the reason why people are exiting primary care and hospital systems are still building bigger buildings is not just because of the aging of the population, because older people, as the baby boomers, you know, 10, 000 people turning 65 every day hit the system.
We're going to need more primary care, more continuity of care with nurse practitioners, internists, general practitioners and geriatricians, but we don't pay them enough. In fact, the number of geriatric residences. is going down. That's the those specialty that cares for the elderly, while the number of elderly is skyrocketing.
And so I think we really have to look, given the fact that 52 cents out of every health care dollars. Supported by taxpayers through Medicare and Medicaid and the federal government as to where we put those incentives. We need, I think, fundamentally to set up prominent. And since the government's the biggest payer, it needs to actually think about reinvesting and expanding and increasing.
The how it compensates primary care providers. That's the way I think you'd start to rejigger the system because if the if the incentives in the US, which they kind of are today are the only get paid. Well, if you're really sick, well, guess what? The system is very good at solving very complex, complex illness, but other systems, it would appear are much better at preventing that than providing much more expensive access to primary care because they pay better on a relative basis.
David Williams: So, as you say, the government is actually the main payer over 50 percent or so overall. And so if there are going to be changes, they actually do have to be related to government policy. So, even though there are. A lot of private actors in the US, it's still you know, government is a major, major force government's been pretty dysfunctional too.
So I don't know that we can count on that to bail us out. And 1 of the things that the report does is to provide that kind of roadmap for policymakers. So I think that's useful. So if we can just not just don't despair of whatever the government's going to do. You know, what else can help us? So we've talked a lot about,
John Driscoll: I mean, David, to be fair, your point about, about care access is a really interesting one.
David Williams: Yeah.
John Driscoll: Almost 20 years ago, a little bit more than that. The Institute of Medicine put out a report called to her as human regarding all of the, it was a very methodical study of all the preventable, preventable medical errors. I think the estimate was that there are two things whether it's adverse drug events or poor processes around surgeries that, you know, we had the equivalent of two 747s a week crashing and killing everyone aboard.
If you added up all of the preventable deaths in the healthcare system, that report had a really big impact. It was methodically done by doctors. It was pushed out and changed the way people you know, hat tip to Togolondi on his checklist manifesto, the way people prepared and manage surgeries, it opened the door to, to to people questioning whether, Folks, teams of medicine, of doctors and nurses could actually have an open conversation about what was going right and wrong.
It opened the door to the standardization of drug information, so we could prevent drug-drug interactions. And I think if you look at where we are performing so well in care, care process, I think you could tie it pretty much, pretty closely back to those early studies of what, what we can do. And that was really a information and cultural change.
Because the incentives really, I mean, there were slight changes of incentives at the federal government, they would no longer, the federal government no longer pay for avoidable hospital readmission, which is to say if they were supposed to fix something the first time and the hospital screwed up and you had to go back and fix it, they wouldn't pay for it twice, they wouldn't pay for a botched surgery, the incentives were on the margin, but I do think that David, David.
That was a remarkable example of where the culture changed based on data. And I think if we can find similar things, most people go into medicine and health care wanting to do the right thing. And that strikes me as an example over the last 20 years of a pretty material improvement in the way our healthcare system performs.
And maybe there's something else that can be done there from the, you know, the, the August ivory tower of the place like the Commonwealth Fund.
David Williams: Well, John, maybe if we combine that sort of end on a happy note or an optimistic note, maybe that same sort of call to action combined with some new tools and think about AI which is just starting to show its potential.
Always look for AI. I look for AI, John. Yeah,
John Driscoll: you don't? Well, no, I just, I think maybe, but like, why, why should the compute, you really think the computer's going to help us here, David?
David Williams: A lot of the issues here having to do with cost and with consistency are things that you might want to address with what you do with people.
Now, there is, so the population is aging. Birth rate is declining. Immigration is declining. And so how are we going to address these things and not make them worse, which is probably that the track that they're on. And I think I has that potential. So, for example, if you want to be diagnosed correctly, the 1st time without going to a lot of specialists and costing a lot of money, proper use of AI, including by primary care.
Can have that impact and so I do see the option to, you know, sort of to change to change the trajectory of that technology in particular, if applied in the right way, if we're aiming it at the right things, instead of aiming at it, how can we drive up cost or or or some other, Well,
John Driscoll: I'll give you one more positive there, David.
I'll give you a slight one, which is, I think that the other place where we massively underperform, we the United States system, is it administrative efficiency? We're massively inefficient because of all of the different parties in our semi-public, semi-private system. And you the things the Commonwealth Report complains about is the complexity of all the different insurance products.
That's not going to change. But I do, I could see a path where artificial intelligence, big commute, compute, and just more technology applied to the administrative back end could significantly reduce cost and complexity in the supply chain, because it'll, it'll, it'll massively move through the complexity and simplify things so that we can actually.
get the care we need and get the bills paid the right way the first time. I mean, there's some basic things that I think AI and big compute could really contribute to. So there, there's a positive.
David Williams: There we are, John. All right. Well, that's it for yet another episode of Care Talk. We've been talking today about the latest Commonwealth Fund report called Mirror, Mirror, Mirror.
2024. So take a good look at that, Mayor John, and I hope you like what you see. And I'm sure as you get a little bit older, you'll like it even more. I'm David Williams, President of Health Business Group.
John Driscoll: And I'm John Driscoll, Senior Advisor at Walgreens. If you like what you heard and you didn't, we'd like you to subscribe on your favorite service.
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