Playing with numbers in the health care game
f you visit a country as a tourist you will see the points of interest, historical places, the most beautiful sights, and get an instant impression of that country. This impression will stick to your brain for the rest of your life. Usually it is wrong. Only if you live in a country for at least one year, do you realize the true attitudes and problems of the country and its population.
During the last twelve years I have lived and worked as a physician in five countries in Europe and America. I have also suffered from the healthcare systems of all these countries, giving me reason to believe I know these systems to a certain extent. None of them functions in an exemplary manner.
Recently I have been exposed to Japan's healthcare system, which is different from Europe and the United States.
In 1990, Japan spent 4.7 percent of its gross national product (GNP) on medical care, which includes research and construction costs. This is an extremely small sum for a highly developed country. In the same year, the United States spent 10.7% of its GNP on healthcare and related costs; it presently spends more than 14%. In Europe, Germany is spending 9%, Italy 8.5%, and the United Kingdom 6%.
It is very difficult to measure whether the money spent in healthcare is well invested. There are very few reliable outcome studies on medical diagnostics and therapy. Quantification of medicine is nearly impossible because medicine is not an exact science.
In which unit do you measure “I am feeling well”?
Some people have chosen life expectancy as the measurement of how well a healthcare system performs. If you accept this yardstick, the results are sobering: Japan wins. The average life expectancy at birth for a woman in Japan is 83 years, for a man 76 years. That is seven years longer than average life expectancy in the United States, Denmark, the United Kingdom, or Germany. Or ten years more than in Albania, Poland, or Bulgaria.
People in Portugal and the United States have the same life expectancy. The difference is that Portugal invests less than one third in medical care per inhabitant. In other words, a nation spending more on health care does not necessarily bring its residents longer living.
Let’s play with different numbers: There are 5,500 pharmacies for the 10 million inhabitants of Belgium but only 1,400 for the 15 million Dutch. Not surprisingly, the consumption of pharmaceuticals is lower in the Netherlands. Life expectancy in the Netherlands is two years longer than in Belgium.
Looking at something else, closer to radiology: In Belgium, more than 1,500 radiological examinations are performed per 1,000 inhabitants and year. In Portugal, it is less than 400. The average life expectancy differs by one year.
The number of magnetic resonance machines per one million inhabitants is 14.5 in Japan, 14 in the United States, 6.8 in Switzerland, 5.5 in Germany, and 2 in the United Kingdom. The average reimbursement rates are 170 ECU (predecessor of the euro) in Japan, 830 ECU in the United States, with most of the European countries somewhere in between.
In other words, Japan has the highest density of MR machines in the world, the lowest reimbursement rates, the lowest per capita healthcare expenditure – and the highest life expectancy.
Japan, by the way, also has the lowest prices for MR machines. Manufacturers outside of Japan claim they lose money with every machine sold there. But with one-third of the world's MR machines, I cannot believe that Japan is a losers' market.
Europe is full of Japanese cars, cameras, electronic equipment … should we also try the Japanese healthcare system?
Personally, I do not believe this is a solution for Europe. The Japanese system has a lot of trade-offs. It is impersonal, although perhaps no more impersonal than the healthcare systems of the United Kingdom and the Scandinavian countries. The system is supported by a uniquely Japanese attitude towards their state and their employers. Japan does not have a large impoverished low class of people and the Japanese diet is healthier than that of most European countries.
Nonetheless, playing with numbers and observing what is happening on the other side of the world might help us. Some readers will argue that playing with numbers is nonsense. Normally, I would agree. But think again about the numbers mentioned above. Something is wrong somewhere. We do not want to talk about it because there are so many taboos in our health system.
The Times of London requested in an article published in its issue of 20 December, 1992:
“... what is needed is an open, patient-driven system on the basis of accurate information on needs and outcomes ...”
Two terms here are important: “patient-driven”, which means that the patient must be the center of medical thinking; and “outcomes” because that is what is important for the patient. To many administrators, politicians, radiologists and industries, patient outcomes are secondary.
We hardly know anything about the outcomes of what we are doing in diagnostics and therapy. Do we need the preoperative chest x-ray in all hospital patients? What about coronary angiography? What about ultrasound in pregnant women? What about ...?
Why can the Japanese perform MR examinations at one fifth of the price of the United States or one fourth of Germany? Why do radiologists in one country use more contrast agent than in the neighboring country?
These are questions begging for an answer.