US health care system pronounced healthy

Is it the care (or lack thereof) running up to term that is causing preterm births? Is it the hospitals? The doctors? The lack of education about what it takes to have a child?

Thanks.

I've never seen a good answer to the question of how consistent these comparisons are regarding "pre-term birth" "miscarriage" and "high-risk obstetrics."

From a personal perspective it's not quite academic: two of my children were twins born quite early thanks to pre-eclampsia despite intensive intervention. I've always been curious about how that story would have turned out in other countries.

MK:

It all comes down to lack of affordable medical care.

In countries with universal access to medical care, mothers-to-be can get pre-natal checkups at recommended intervals without worrying about making the rent cheque. In the US with its rationed-by-wealth system, the less well off skimp on the pre-natal care and hope that the birth and post-natal care don't bankrupt them.

Shitty system, eh?

As a physician (although not an obstetrician) who has worked in a number of U.S. Hospitals in three different staes over 40 years, I am, if possible, even more upset by and ashamed of our performance in providing quality healthcare to our citizens than I perceive that you are. Moreover, I consider it ethically unacceptable that anyone within our borders (yes, even illegals) cannot get at least basic health services when they need them. Nevertheless, I must point out that the statistics on preterm birth rates, although appalling, cannot be blamed entirely on our healthcare system. While I know that poor or indigent American patients often choose not to avail themselves of those services that are available to them, it is not always or only because of cost. Other factors, such as certain ethnic biases, variations in life style and family issues, and the very large landmass that we occupy here all must be factored in. Most European health systems deal with much more uniform religious/ethnic/education levels, etc. than we do, not to mention that Europeans are much more likely to live in closer proximity to these services and in many cases also benefit from much more readily available public transportation. Not that any of this excuses what is wrong with our healthcare system (in spite of Mr Limbaugh's disgusting attempt to "spin" his recent experience to scuttle the current efforts in Congress to correct it), but I think it helps to illustrate that lowered cost and/or money alone will be only the beginning of a long, difficult road towards real improvemnet in our system.

Rush is satisfied with our healthcare system because it took care of him. As for all those who can't get health care...they're obviously biased.

Rt

Martin, thanks.

Sounds about right, I guess. Yes, shitty.

Look on the bright side with Rush - he's been a great role model for trying to detect colon cancer early. Afterall, he's had his head up his ass for years!

As to the percent of preterm births ... this overlaps well with your EBM thread and the limits of making solid conclusions from observational studies. It is tempting to conclude that our healthcare system (and lack of access to it) is responsible for our high rate, yet such would be a ... ehem, premature, conclusion. We also differ from these other countries in many other ways that indempendently are associated with prematurity - racial status, SES, marriage rate, and on - and then there are the open questions as to how these factors may interact. To really draw any meaningful conclusions you'd need to be sure that you are making a variety of apples to apples comparisons - Black Middle Class married native born to same; White Urban poor single and native born to same; etc.

See http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=nap11622&part=a20012… for a good start if you want some additional material to play with.

Observational studies CAN be good evidence but interpreter beware! It is easy to twist it according to whatever pre-existing conclusion you expected to see, or wanted to see, unless you are very careful.

It was mentioned in passing during a conversation about this that the experience of healthcare in Hawaii is different from that in many other states. While I don't know the details about this it seems to be a possibility that it may account for such a pleasant experience?

From what I've heard, getting insured if you're an obese average sue or joe is pretty difficult( expensive), if not downright financially impossible.

Rush has the luxury of money that most don't. He's not in the same system they are. Had his whole experience unfolded like that of your average american, I suspect he'd either self delude and say it was fantastic, or that he'd be crying his heart out for reform.

Don: You make perfectly valid points. Indeed I've wondered, given the average prenatal visit, how it can affect anything. Perhaps it is a marker for having insurance or care seeking behavior or other things. However this issue has been looked at quite a lot and the relationship with at least some aspects of the health care system, of which access seems to be an important feature, doesn't seem to be in doubt. Pre-term births are a marker for some illness in health care, although exactly which one and how remains unclear.

I don't know who is more mean-spirited, Rush or you guys with what has to be one of the nastiest posts I have seen at ScienceBlogs (and that's really saying something!).

"obese 58 year old media bloviator with enough internal rage to kill a dozen normal sized people"

"So when they looked there was no heart there"

Absolutely shameful.

But what's almost even worse is the acceptance at face value that somehow we don't rank high enough on this or that indicator (infant mortality, etc) than other countries BECAUSE of our health care system. Like my physician colleague Harvey said above, many times these rankings do not account for other societal factors that influence health. We live in a society that values freedom and where people live fast and hard, often with more violence than other countries. But such confounders don't stop the public health crowd from trying to score political points by trotting out this figure or that to show why we need socialized medicine, or the public option, or some 'reform' plan that's essentially a giveaway for insurance companies.

The WSJ's Carl Bialik also recently discussed some of the problems with these international rankings and how overreliance on such results can cheapen our understanding of medicine and societies.

Ill-Conceived Ranking Makes for Unhealthy Debate
http://online.wsj.com/article/SB125608054324397621.html

So when does a calumny-filled, somewhat misleading (at least incomplete) post on ScienceBlogs lose the worthiness of being called 'scientific' and become the same old drivel as seen on FoxNews, the HuffingtonPost, or other biased news sources?

DrYes: Oh, I"m sure you are so right. I should be ashamed of criticizing someone who is himself absolutely shameless. And if you think that was bad, you don't really read ScienceBlogs because that was a powderpuff compared to some of my sciblings. And I shouldn't have said he was obese. Because he is actually morbidly obese. And of course we rank at the bottom of most of these health indices (compared to other industrialized countries) because our health care system is so good compared to theirs. LOL. No, DrYes, no.

revere: "You" and Rush are two sides of the same coin. You both make your self enlightened points and arguments and consider yourselves to be impervious to criticism. And, when a valid criticism does come, you turn to sarcasm as your retort. LOL. The critics are coming, revere, the critics are coming.

David: Really? You say this on the basis of this post? You want to compare the revere record over 5 years with Rush Limbaugh's for intellectually honesty? I won't say it is shameful (such a well considered word). I will say it is idiotic.

ps: See #10

"Enhanced prenatal care (e.g., the March of Dimes Multicenter trial) or early access to care has not generally resulted in a reduction in premature birth.[38] Literature reviews including many of these trials has likewise failed to demonstrate a significant benefit in reducing preterm birth from either strategy.[32-34]" - Prevention of Preterm Birth: Perinatal and Prenatal Care (Denney, Culhane, and Goldenberg).

revere: Yes, really. I say this after reading many "revere" postings and, more to the point, responses to criticism over the past four or so years. When someone points out a shortcoming or failing in a statement or point being made there is rarely (although there have been a couple times) an admission of oversight or the acknowledgement that you may actually be wrong. Instead you nitpick (to be excessively concerned with or critical of inconsequential details) any small part of the argument made against you. I also listened to Rush for a few months, but could not bear him for the same reason... if anyone made an cogent argument counter to his view he would nitpick the caller until he changed the argument. When he was backed into a corner, he would just blow hot air (ignore the man behind the curtain). The difference between you and Rush is that I do feel more often than not Effect Measure does provide valuable information. Rush did not. Unfortunately, you both use the same techniques in making and arguing your point.

David: Let's see if we can parse your complaint (at the risk of being accused of nitpicking). There were two elements in that post. One was the Rush thing, and that can be separated into what I said and how I said it. And the second was the US ranking issue.

I want to know if your complaint (DrYes is so hyperbolic it isn't worth commenting on) is my diciton (i.e., word choice0 or the substance. As to diction, this is the internet and this is a blog. Our word choice is not anything unusual when it is snarky, as it often is. If you don't like snarkiness, then that's an issue for you, but it isn't for us. We like being snarky. Not all the time. But sometimes.

Now to substance. As far as we are concerned, Rush Limbaugh is an entertainer who enriches himself by appealing to the worst instincts in a fearful audience, turning one person against another, a racist, hate and rage filled demagogue. That's what we really think. His attitude is, in our considered opinion, absolutely heartless. That's what we said, even though it was snarky. He has an audience of millions and gets paid handsomely for it. We are a tiny site that's get paid, on an hourly basis, much less than if we were flipping burgers at McDonald. Not even close. Nor do we spew hate filled, venomous and patently untrue crap to millions of people. If you want to equate him with us, all we can say is that it is a false equivalence. A that's an understatement. What we said doesn't qualify for calumny because it wasn't in substance false (even the statement that he had no heart is understood by any fluent English speaker as not meant literally). If you or DrYes want to defend Limbaugh as not being an obese bloviator full of rage, that's your privilege. We said it because we meant it.

Regarding the US ranking issue, an early commenter (Don S.) brought up the objection and we conceded his point about this particular ranking, although on almost any measure you care to name (except cost) the US does worse than other industrialized countries on health care. I've worked in hospitals and medical centers for 4 decades and I have seen other health care systems as well in Europe. Ours sucks, IMHO. The nice thing about a blog is that you get to say that. If you think ours is great, that's OK. Rush thinks so, too. Starting a blog is dead easy. Maybe you'll find a ready audience of people who think we've got pretty good health care in this country.

Meanwhile, I think we have a pretty good record of either engaging people on issues or providing an open forum where others can engage each other and carry on a conversation. As we've explained often enough, the reveres cant' respond to or even read every comment because we have day jobs. But there are lots of side conversations here that take up the slack and lots of pretty smart people with a very, very wide range of political viewpoints. Ours is on the left. Your mileage may vary. But we have the front page. If you want a front page, you'll have to do the heavy lifting of your own blog.

While this particular measure fails because of unaccounted for confounding variables (and is thus poor quality evidence) there are indeed many other lines of evidence that we get very little for our money in America.

Fivethirtyeight.com used a great graphic on life expectancy the other day (http://www.fivethirtyeight.com/2010/01/healthcare-spending-and-life-exp…). We spend lots more but live shorter lives. Now one could make some of the same objections vis a vis life expectancy that I made regarding prematurity, confounding racial, ethnic, and social factors, but one can at least attempt to control for that:

France has an average life expectancy of 81. 78 for males and 84 for females. Compare that with the subpopulation of just White Americans - the group in America most likely to have higher SES, higher education, and more access to healthcare. White American males 76 and White American females 81. We fail against the French even when our highest group is judged against their average of all. And the Brits aren't far behind them. Spain spends even less and does just as well (even with a very high rate of death early on from traffic accidents apparently). Australia better yet. (Albeit the life expectancy for their Aboriginal minority is poor - http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/3302.0.55.003Main+Featur… - at 67 for males and 73 for females. That's even worse than the Native American life expectancy of 71 for males and 75 for females.)

In short the example chosen was not a great one (and it's weakness and the willingness to believe it as a symptom of our poor healthcare system because it fits what we already "know" is illustrative of some pitfalls of observational studies) but the evidence in aggregate is overwhelming that we buy little with our very expensive healthcare.

In short the example chosen was not a great one (and it's weakness and the willingness to believe it as a symptom of our poor healthcare system because it fits what we already "know" is illustrative of some pitfalls of observational studies) but the evidence in aggregate is overwhelming that we buy little with our very expensive healthcare.

Then what exactly are we spending money on that we don't need to? The assumption of the left is that it is all going to insurance companies, but I find that hard to believe. That is the kind of detailed analysis I would love to see, but I never do.

No, I do not believe it is going to the insurance companies, at least not as profits. Their margin really isn't so hot.

Some is that we spend on the care of the uninsured, who still get cared for but usually get cared for when sicker and in more expensive settings - showing up in the ER for both minor illnesses that could have been cared for at a fraction of the cost in a general doc's office setting, and when illnesses that could have been prevented earlier or treated early and cost-effectively erupt into an expensive crisis.

Some is that we spend on an inefficient private administration system in which each private insurer expends resources trying to out cherry pick the other guy. This "goes to the insurance company" but as real expenses, not as profit.

Some is that we are specialist heavy which translates into test, technology, and procedure heavy. In most other countries (such as France) there are MORE physicians per capita but only 20 to 50% max are specialists. In America 70% are specialists. Much of that is attributable to the fact that medical students leave with lots of debt and the siren song of the more highly paid specialties is hard to resist compared to the much less well compensated primary care fields. Pay primary care better for what they do, reward them for the intellectual work they do managing and preventing illnesses, and you can save money over the longer haul.

Related to that last point is that we irration care in America instead of rationing it. The Rush's of the world can buy expensive procedures for minimal indications and could (and would) even if he had a diagnosis that gave him reasonably only a week left to live. What? Not give an artificial heart? The poorer can't afford the basic preventative care that would prevent the need for later costly interventions.

The healthcare reforms currently on the table may not address these issues as completely as single payor would, and some of those issues the American public won't dare to look at (even with NO rationing on the table we had to live throught the lies about "death panels"!) but fortunately they do, IMHO, get us at least 80% of the way there. I am very happy with it as a start.

I have heard newsreports that say there are fewer doctors going into and staying in the practice of obstetrics. There are some hospitals doing away with maternity wards altogether. That leaves many towns without this service, leaving some patients having to drive many miles for care. Is this really true that there are fewer doctors today, than say 10 years ago?
I also wonder if the economy will have an effect on the birth rate. For example, pregnant women feel they have to work as long as possible, regardless of health issues, just to keep paying bills. The uninsured pregnant woman won't have money to take vitamins,etc.

revere: Points well made and well taken. Yes, you do get snarky at times. (Maybe you could add âSnarkyâ as a category under posting titles) It does bug me a bit when you take that tack as I think in detracts from the great service you provide... but, as you say, it is YOUR blog⦠you do have the front page, and the front page does say, âEFFECT MEASURE IS A FORUM FOR PROGRESSIVE PUBLIC HEALTH DISCUSSION AND ARGUMENT AS WELL AS A SOURCE OF PUBLIC HEALT INFORMATION FROM AROUND THE WEB THAT INTERESTS THE EDITOR(S).â In this âprogressive public health discussionâ you make the valid point that being a multimillionaire in America probably affords you better health care. I guess the European multimillionaires have to wait in the queue with everyone elseâ¦

Obstetrics is being hit by a few factors.

One is that their malpractice rates are just nuts. That expense drives many out (and keeps more from choosing it), especially in rural areas. It particularly keeps many FPs from offering OB services and in many rural areas they used to provide most of the care. The fear of lawsuits also keeps some away. You can be sued (and even lose) just for a bad outcome even when you did everything right. Even if you do not lose it takes away from practice time and is a huge emotional and psychological trauma. And if you settle to avoid the risk of losing even though you did nothing wrong and to avoid the loss of practice time you have even more psychological upset.

Another (and this is very not PC) is that OB is becoming a female predominant specialty. Women prefer women OBs to no small degree. And women in our society are statistically more likely to want to work fewer hours and to take more time off to fulfill their own expectation of being a mother. That translates into fewer working hours over the course of a career per physician compared to the avaerage male physician and a harder road to hoe to make a practice financially successful given the malpractice coverage fee albatross in OB.

As to birth rates, anecdotally in my suburban pediatric practice I have not seen any drop off in the birth rate. But that's not even an observational study!

David,

As you note, we just have to accept this blog for what it is. At least I have learned to. The reveres do a great job presenting some items of medical interest and are generally fairly open to discussion and polite debate regarding those mostly non-political items. They bring us information, analysis and education regarding those medical subjects that are hard to find elsewhere.

The other, more explicitly political aspect of this blog is more of a soapbox for a very specific Left political POV that is held very strongly and which comes more from the gut than from cold-hearted rational analysis. (Aspects regarding international affairs in particular are in this group.) These are subjects that are for the reveres "personal." Career sacrifices have been made. For those who are already of the same exact POV they are fun pontifications to read, fun poems to read, fun songs to hear, but those posts are not really open for much in the way of debates or discussions. They are more posts designed to rally like minded troops. Those of us who are looking for more of a discussion, who are trying to nuance a view that is not at either pole, who may be "liberal" but are moderate-liberal not full-throated "progressives" and who see gray where the reveres see black and white, should just skip those threads and look elsewhere. Revere is too busy with his day job for that. And this is his blog, his front page. It is offered at his pleasure as it should be and we can benefit from the medical issue posts without having to read or participate in any other threads.

Thanks, Don. I think you said it clearly and well.

Don, Revere: Agreed. :-)

Re Post 4 from Harvey "...Europeans are much more likely to live in closer proximity to these services and in many cases also benefit from much more readily available public transportation."

I'm not sure of the numbers this year, but Australia, which has almost the same area as the continental US, had around 6.5% premature births overall last time I saw numbers.

(US: 8 million sq km, roughly and 280 million population, Australia 7.6 million sq km and about 21 million population, and population density in both urban/city and 'country' areas seemed fairly similar going by the numbers I could find - population in Australia is more concentrated than you might expect because of the whacking great deserts filling the middle of it.)

I'm not a professional, so there are probably a whole lot of caveats which these numbers should be hedged with, of which I am not aware. I'll leave that to those who are professionals at such things to point out if needed.

Which is not to say we don't have our shameful spots - like every country we do, and most of them have needed fixing for years, again like most countries! Australia has its pockets of neglect and there are certainly services and difficulties that need longterm actual solutions rather than quick fix look good politician's 'answers'. EVERYWHERE and every system has problems!

Most of the population is also concentrated in cities and towns, but a fair proportion is still scattered far less densely than in the US. Still, compared to the 'richest country on earth' with its 'best healthcare' ... I know where I'd rather a member of my family was having a baby.

But then again, if I lived in the US I'd possibly feel differently.

What's up with Austria?

Don S @20,

Some is that we spend on the care of the uninsured, who still get cared for but usually get cared for when sicker and in more expensive settings - showing up in the ER for both minor illnesses that could have been cared for at a fraction of the cost in a general doc's office setting, and when illnesses that could have been prevented earlier or treated early and cost-effectively erupt into an expensive crisis.

Extending coverage will not lower overall total spending. According to this 2004 Kaiser study I found, not only do the uninsured use less preventative health care, but they receive less treatment once diagnosed with a serious illness as well. It also states that uncompensated care is just under 3% of all health care spending. There can be little or no doubt that increasing insurance coverage to the uninsured is going to increase total health care spending in this country. However, in the sense that the uninsured will then be able to lead longer and healthier lives, that will be a good thing. It might even be a net benefit to the economy as those people will be more productive than they otherwise would have been. I am just pointing out that it seems that the data doesn't back up the argument you made.

Some is that we spend on an inefficient private administration system in which each private insurer expends resources trying to out cherry pick the other guy. This "goes to the insurance company" but as real expenses, not as profit.

I believe that this is 'underwriting' in insurance company language, correct? That certainly is a cost that does not improve patient care. But then, so would efforts the insurance company undertakes to reduce how much fraud is committed against them. The reason such practices exist is because no insurance company can operate without being able to ensure that its investors come away with a profit. Efforts to control costs and balance them against revenues will not end even if we get rid of private insurance and go full single payer.

The U.S. government relies on people buying the debt it is incurring to cover spending more than it is taking in. That will only continue as long as those investors are getting a decent deal for their money. If costs weren't controlled in a single payer system, they could outpace whatever dedicated revenue streams are put in place. It would then either crowd out other government priorities or push the debt to a point that investors would stop buying it.

My point is that there will always be some kind of bureaucracy attempting to control costs, whether that is private insurance or the government. I don't know which would be more efficient or fair. That is a very important part of the debate, for sure, but I don't think that we can necessarily point to underwriting as a major source of waste in our system without more data.

Something that probably is a big source of waste, is the extra administrative costs of having to deal with multiple payment systems, various state and federal laws regarding patient information (HIPPA? is it?), etc. From your statement at the end of #23, it seems that you are a pediatrician with your own practice; is that correct? I'm sure you can say a lot more about that than I could, if so.

Regarding specialists, it certainly makes sense that we spend more due to the extra specialists, but how much more? The big issue I have with the way the health care reform debate has proceeded over the last year is that kind of problem. Rarely does anyone making arguments either way really try to quantify things in a comprehensive way.

Also, in regards to rationing and the original topic of this thread - the ability of a very rich person to afford great care: I think David put it best,

In this âprogressive public health discussionâ you make the valid point that being a multimillionaire in America probably affords you better health care. I guess the European multimillionaires have to wait in the queue with everyone elseâ¦

The very rich are going to get the best of anything if it is something money can buy. I don't see that as a tragedy or injustice, though. All solutions need to be aimed at dealing with the 99% or so of Americans that aren't multimillionaires rather than lamenting how unfair it is for them to have so much.

When it comes to the core question that I asked of why we spend so much more than other countries, I strongly disagree that the bills in Congress now "get us at least 80% of the way there." They may increase coverage, but I have read nothing in the media about how these proposals will actually increase efficiency in the health care system.

I am curious to what extent fertility treatments influence the pre-term birth rates and infant mortality. With the cost of IVF so high, and most insurance companies not covering it, it seems that the multiple birth rate has skyrocketed because many can only afford one attempt at IVF. So they implant 6 eggs and if more than 2 take, then complications are pretty much a given.

Seems to me it would cheaper for the insurance company to pay for a single embryo IVF than 22 week sextuplets, but what do I know!