The New York Times reported yesterday on the thousands of people lining up for a free health clinic in L.A. Many came for routine medical care, like breast exams, TB tests, and Pap smears. Reading this report reminded me of a recent conversation I had with Karen Davis, president of the Commonwealth Fund. The fund conducts a range of comparative analyses of First World health-care systems. Their findings are often surprising, and usually provide striking illustrations of the inadequacies of the American system. I discussed with Davis the difficulties many Americans have with accessing primary care, compared with their international peers. Davis believes the problems can be accounted for, in large measure, by the type of physicians available to Americans. "We have about the same number of doctors per capita as other countries, but a higher proportion of our doctors are specialists," she says. This shortage has led to a squeeze on other services, and a yawning gap in after-hours and weekend care. In a 2008 survey, the fund reports that 18 percent of Americans end up in the emergency room for a condition that could have been treated by their primary physician, if available. In Germany, only 7 percent of people end up in that predicament, and in the Netherlands it's 8 percent. Only Canada performed worse than the U.S. on this measure. Similarly, only 40 percent of American primary-care physicians said they have arrangements for taking care of patients on nights and weekends, a much lower proportion than in other countries.
Primary-care providers are in short supply in the U.S. largely because specialists earn significantly higher sums, which makes it more attractive to specialize here than in other countries. According to an OECD study, American primary-care physicians are paid very well on average─indeed they were paid better than the 11 other European countries surveyed. But they earn around $90,000 per annum less than specialists. In the U.K., that gap is $32,000, in France it is $60,000 and in Switzerland it is just $15,000. (Admittedly, this data is a few years old, but I can't imagine it changing significantly over the past few years.)
The way American insurers compensate specialists is to blame for much of the international salary difference. Most specialists in the other countries surveyed are salaried. They're affiliated with a particular hospital or provider and work for an annual wage. In the U.S., doctors earn a "fee for service," meaning that private insurers compensate specialists based on the number of procedures they perform, which can provide incentives for unnecessary procedures or overuse of services. This in turn provides more opportunities for mistakes─something The Commonwealth Fund also had data on. In a 2008 study of seven nations, Americans reported the highest proportion of medical errors: 32 percent of Americans reported some form of error, including wrongly prescribed medications or dosages, and problems with tests and scans. "We take more drugs than other countries," says Davis, which accounts for some of the difference in errors. She adds that America's fragmented system is also a problem. Without a strongly integrated network, patients are shuffled between doctors and facilities. Many mistakes occur in the handoffs between facilities, where communications can break down. Employer-based health care has also resulted in American patients having shorter relationships with their primary-care providers than in many comparable nations─if you change jobs, you often change health insurance, which may force you to change doctors. The same thing happens if your employer decides to change insurance companies. Longer relationships often mean that doctors have a fuller picture of your history, which can help minimize errors.
In Europe medical mistakes are much less frequent. In the Netherlands just 16 percent of patients reported an error. In France it was 18 percent and Germany 19 percent. Each of those countries has
a robust public health system. With data points like these it becomes difficult to argue that a purely private system, like the one many rowdy town-hall protesters appear to want, results in better care.
(For more reading, my colleague Michael Freedman has written a really interesting take on the rise of Europhobia over on the Wealth of Nations blog.)
