Healthcare Metrics

Harder to measure is the opportunity cost of doing option A rather than option B within the system because if B is never tried then some aspects of B will always remain speculative even if they are worked out in considerable detail hypothetically. Would Americans live longer (statistically) and better (qualitatively) if they took a trillion dollars out of American health care expenditure, and spent every penny of it trying to reduce obesity — you can certainly make a case for this. But, we will probably never know.

It would seem at first glance that life expectancy is the uber-metric. We provide medical services that we may live, live longer and be healthier. As the OECD’s Health at a Glance, 50 year retrospective tells us, we have knocked this one out of the park. (At least on the pure longevity aspect we have). As recently as the Second World War, average life expectancy in the industrial world was hovering around fifty. Now, it is approaching eighty. In South Korea, LE rose 28 years between 1960 and 2009.

The development of antibiotics and anti-tuberculosis therapies and vaccines account for a large percentage of this astonishing achievement. It is difficult to overstate the impact of antibiotics. As P.E. Gobry recently put it:

I might add that in this time of COVID 19, the aptness of this quote could be extended to include anti-viralsI without in any way altering the main point.  Life expectancy may not tell us as much as we think about the healthcare “system” we inhabit, although it does tell us something about the progress of modern science. If this is true then LE is not a very useful tool for judging the comparative effectiveness of HC systems across countries. If most of the improvement in LE is due to antibiotics, and it is, then how your healthcare system is structured doesn’t matter much in the longevity stakes. Make these little pills widely and cheaply available and life expectancy will go up, and go up a lot, whether you are in Albania, Botswana, Cuba, Singapore or the U.S.A

Infant mortality is another tricky one. Much of infant mortality was actually death during or very shortly after, birth, largely infection-related. Better sanitation, clean water, better natal education, those ubiquitous antibiotics again, these account for most of the improvement here. The infant fatalities prevented by high tech interventions associated with quote unquote more advanced healthcare systems, even though we hear about them a good deal, make virtually no statistical impact on the fluctuations in infant mortality rates. The United States, which has the most technology per patient of any country in the world is way down the OECD list on infant mortality per thousand live births. (Canada is also below the OECD average on this one.)

So the Big Two don’t help us system judgers very much. Where shall we find metrics for judging better from worse in health care? We may have to resort to the economics of cost/benefit to make some progress here. The United States spends more money on healthcare than any other country on the planet, although this fact may surprise some. (I know it has surprised a number of my fellow Canadians.) So if we measure any bundle of U.S. outcome metrics and compare them with say, France, and they are no better, or actually worse; then we have an analytical basis for some kind of efficacy judgement. We can, of course, extend this method to broader generalizations among more countries.

Since what I just said is no doubt, tempting some of my readers, those prone to statistical indigestion, to turn their attention to the nearest banner ad listing the names of Hollywood starlets under 16 who got pregnant last year, let me plead that this OECD document is actually quite fascinating and would make a lovely basis for lively and somewhat better informed cocktail party chatter.. You can spice up your conversation with amazing and little-known nuggets such as the fact that Canada leads the OECD in leaving surgical instruments inside patients after surgeries. What could be more fun than that?

Like one of those irritating souls who spoils a book for you by revealing the ending; I am going to say right up front, that the major conclusion we will arrive at after looking at some of the more revealing cross-national comparisons is this: somewhere other than where you and I live, healthcare outcomes markedly better than ours are being achieved along some important dimension or other. Are all of these outcomes and the practices that make them work, neatly transferable to other systems? No, but some are, and the difference these could make might be very consequential indeed.

On this key issue of what is transferable between different countries’ HC systems and what isn’t; I would like to say one more thing by way of framing the comparisons we will make. All healthcare systems are a historical patchwork and thus in some sense uniquely adapted to the conditions in which they developed. They constitute a series of situational adjustments developed over a timeframe measured in decades and there is always an improvisational character to these “systems” that is not often noted by policy wonks working in the area. The “system” is often imposingly complex and impressively pervasive; but nowhere on the planet has an HCS ever been constructed by generalizing from comparative experience and somehow going back and re-examining basic presuppositions. This may seem blatantly obvious, but the obvious becomes less obvious if it is never stated.

Consider this supremely impractical thought experiment. I have $5 trillion dollars in my jeans, and I decide to strike a committee to create a healthcare system from scratch. I give the committee members three simple guidelines: Everyone has to have access, political and interest group concerns are to be considered only peripherally, and best practices are to be tracked down and scrutinized with a fanatical zeal wherever they are found in the world. What would this spanking new HCS look like? I have no idea. But, what I would say, is that this system would not resemble either the Canadian or the American models as they now operate; or for that matter, any extant system anywhere.

Okay, let us stop playing an abstract game of Moneyball with HC systems and admit that something so complex, so political and so connected with life and death will never be a completely rational construct. Let us think about making things better in light of the useful, adaptable comparisons we can make.

Please comment on what we should be measuring and what we are not, (or at least what never shows up in the headlines as being important for evaluating health care.) Are you surprised by where your own system ranks on an international ranking basis?

— UPDATED APRIL 2020 —