 The President needs to introduce our speaker today, Dr. Ashish Jha. Ashish Jha is the Senior Associate Dean for Research, Translation, and Global Strategy, the Directorate of the Harvard Global Health Institute and the AP Lead Professor of Global Health at the Harvard School of Public Health. Jha also is a practice in general interest at the B.A. Boston Health Care System and his professor of medicine at the Harvard Medical School. Ashish Jha received his M.D. from Harvard, trained in internal medicine at the University of California in San Francisco, completed his general medicine fellowship at the Brigham, and received his M.D.H. from the Harvard School of Public Health. He's published more than 200 empirical papers and writes with deep insight about ways to improve health care systems both in the U.S. and globally. Ashish Jha, whose record is a member of the National Cabinet of Medicine in 2013 and recently has appointed the British Medical Journal's International Advisory Board. I could go on, I think I made it in time for Dr. Jha to speak. Today's title, as you see behind me, is One Face Good Health Care System, Lives and Facts about U.S. Health Care. Please join me in giving a warm welcome to Dr. Jha. Can people hear me a little bit and ask the question? As I get hooked up here, questions for you. How many of you guys were here yesterday? That's around right there. I like the fact that you're all sitting together. That's helpful because some, about 20 to 25% of the data you'll see you saw yesterday, I'm sorry, but it's hard to do everything and take everything back by yesterday out. But this is a slightly different problem. And as with yesterday, for those of you who were here, we're going to make this very interactive, okay? So it's going to be a lot of questions and answers. I'll ask you questions, you guys will get some answers and we'll pop you guys' questions. So it's going to be very interactive. It's going to be just a discussion oriented. And what I want to do at the end of it all is hope that as a group, we can come to start thinking about health care, health systems a little bit more sharp. Because this is a topic that we all care about, whether you're a practicing clinician or just work within the health system. And there are a lot of issues of boundaries. Boundaries of what counts, what's in, what's not. I want to talk a bit about that over the next hour or so. There are a lot of issues around why we spent so much and a lot of confusion around that and I want to get some clarity on that. So I have a bunch of goals that I want to accomplish. But I want to start off with a simple question, which is, let's say your mom calls and she's moving to Europe. Now she's got to pick a country, because during this time of the country she's got to pick a specific spot and she's trying to figure out where to go. And obviously lots of things go into this, like language and culture and food, and we're going to ignore all of that. I wouldn't advise ignoring all of that, by the way, but just for today's sake, we're going to ignore all of that. And we're going to say, you are going to give her advice based on the healthcare system of the country. Now I don't actually want you to tell me which country though I'm happy to hear which country you recommend. But I want you to tell me what would matter when you were thinking about which country she should go to, which health system would be good for her. What are features? What are things that you want to be careful of? Anybody? Yes? No barriers to access, either financial or geographic. Fantastic. So you want a system that's completely barrier-less, free of annually, and easy to access. Geographic means you just have to travel far. Any other part of access? It's fine. So it could mean that there is an opera right next door, but if there's a three-month wait to see for her or him, then it's not a geographic barrier, but it is a barrier. So you want a system that's got, I'm just asking, there's no financial barriers, cheaper, free, available next door, no meaningful wait. 37. 37 next door. Oh, close enough. She's not having to travel 30 miles or 100 miles. Close enough. Well, I also, I'm not certain but let's say she's planning to go and become a citizen, so we're going to make that important addition and we're going to take it off the table here. We're going to take a lot of, like, important context, preventive services. You want her to get preventive services from the health care system, like dental care. Dental care is important. Nutrition services from the health care system. Like, what kind of nutrition services do you want her doctor to be giving you? Nutrition. She should have access to a nutritionist. Okay, what else would you, any other kind of preventive services, backer plans? I agree with that. Mental health. The ability of mental health services. You may know something more about your mom than I do. I mean, we all need mental health services. We all need mental health services. Back there. More current health care. I'm sorry, two different questions. Good quality health care, I'd like that. More current health care. Most current technology. I want a system that has the latest MRI. Thank you. What's that? It's right here. You want a system that has a high immunization rate. Anything else you guys want? Dental vision. Dental vision, okay. We're not going to get to all the details of all this stuff. But I do want to lay out some principles. So access is certainly very important. And part of access you brought up costs that you want to be about a system that's not super duper expensive for her or for them. And then you want really good quality. Right? You want to be pretty comprehensive. That all right? That sounds about right. There's a lot of details on each of these. But what I want to do is if these are the three big things that everybody talks about. And I won't just say as a side point about three years ago I was at a I was visiting a western province of China. A relatively small province of about eight million people. And I was speaking to the guy who runs the health system of that province. He was being challenged as you face in this western relatively poor province of China. And he said, I think of our problems with three buckets cost quality and access. And what I found remarkable about that state is that is exactly what you would hear in Washington is exactly what you would hear in every national capital. The issues around what makes a good health system it sort of triangulates around those kinds of issues which you guys hopefully are identifying. So thinking about that I want to spend a little time and I want to begin by talking about a paper of ours that we published about six months ago. And I want to tell you a little bit about this paper. It's almost all the data I show you comes from this paper. And the background of this paper is about a year and a half ago a phenomenal economist at Princeton a gentleman named Huvee Reinhardt who very sadly passed away about a year ago. And Howard Bogdor was the energy of JAMA began talking about the fact that there hadn't been a good international comparison about how America stacks up other countries in a long time. The last one that I believe had been done was back in 2003 when Huvee did it. Published a public fair it's called and it's quite a good paper. And so that began a process by which Howard and Huvee and I talked and we decided we were going to take this on and I'll explain our approach a little bit more in a second. But fundamentally we were interested in looking at a broad set of metrics in the U.S. and in ten other high-income countries. And our approach was pretty straightforward. We first picked ten very high-income countries. Big countries and wealthy countries. So we were interested in comparing America through U.P. and France and Germany and Denmark. I'll show you the list. Australia, Canada, Japan. The idea was we want countries that are really high-income. We want middle-income countries. And we want countries of some size. We don't want to think like Monaco. Monaco is a lovely place. It's very but it's really not very high-income. So we picked ten countries. I'll show you what they are. It wasn't taken with any specific approach beyond that. We used data from the OECD. How many people in the room have heard of the OECD? So that has a view. OECD stands for the organization for economic cooperation and development. It's a multi-lateral organization what that means is it's made up of member states. There are other countries that are members. They're all high and some middle-income countries. Canada, U.S., most of western Europe and almost every international comparison you ever see of America, of other almost all that data comes from OECD. OECD is made up of countries, member states we have a representative of the OECD and they work with ministers of health, statistics offices to get data. They do other stuff too but they're like the source of all international comparison data from America. They're really, really good. They are the goals here. And then we supplemented it a little bit with some stuff from the Commonwealth Fund which is a non-profit organization in New York that does some international comparisons. And then here's the last part because I'm going to show you a bunch of data and some of it you're not going to want to believe. And you're going to get skeptical. I made it up. The answer is it didn't. OECD you know they were very trustworthy. Especially on data that seemed hard to believe. We went back to the country on statistics offices. We went to experts in each of those countries and we verified and there was this agreement we got people on the phone and we worked it out. This is our best effort because a year to do this it was our best effort to try to get the data right. And the last one I'm going to make about methods is getting the data right for me and getting the single most accurate it was to make sure we were comparing our assessments. So if we had made a certain change in definition for one country we might make sure we made the same definition for every other country because we wanted to get the comparison right. So the primary goal was get the comparison right. And you'll see in some of the numbers what I mean by that. So that's our approach. That's my higher method slide. I have no more methods to get started. So access to data how might we measure access to data? We've heard that some of this do you want to think about access to data? How would you measure that? Yeah I'm from So that's one measure. I'm the access. I've heard that earlier. How about at a broad national level what do you usually hear about access to data? I'm sure that's the closet so let's start there. For such a few people covered here's what it looks like. I'm just pointing to the countries Denmark, UK, Japan, Switzerland, Canada, Australia, Sweden, Netherlands, France, the deepest in Germany not that one, that's here's the media here's America. One of these doesn't look like the others but the reason it appears is because it was mean to drop a little more. The bottom line is pretty much everything is close to 100%. We're not. This is not a surprise to anybody. This was close to 84%. When the Affordable Care Act was passed you know is it 90? Is it 91? The latest CDC surveys that might actually be like 91.3 doesn't matter. We're somewhere around 90 to 92. 8 to 10% of Americans remain uncovered. Let me make one point which I'm not going to get into but I'm happy to discuss which is coverage is not coverage is not coverage. So we're not even talking about access once you're out of coverage which is the identity to see a dog or possible. But what's cover is a really important because you can have coverage but it doesn't cover it. That is a really critical issue that we're going to struggle with all the time. So one of the things that people love putting out is that China has 95% coverage but the insurance schemes that cover China so China is ahead of us is very shallow and shallow coverage means if you need to go to the doctor sure that's covered but if you need bypass surgery it's not covered. It's the opposite of insurance and really expensive stuff. Chinese coverage is shallow coverage almost everybody's covered but not for the really expensive stuff that has people to follow. So I think you can certainly go to the cost column you can have deep coverage but if you have such areas of cost to use it you're way under insured. Right and though it's interesting what does one mean by under insured typically under insured that's additional because they don't have deep coverage and then you get your path and then all of a sudden you're knitted as they say but about 60 million Americans are now in high level health plans and that has all sorts of implications for how people use health care systems which I'm happy to talk about other countries generally don't have that Did you talk a little bit about cutting edge like pharmaceutical coverage in the United States? Yeah. So the answer is it varies but there are treatments that are available here that are not in some of these countries so if you're thinking about your mom moving to the UK or Netherlands or France for most basic stuff it's fine but if she needs certain super expensive treatments it may not be available and that's because part of the reason to keep their costs down we'll get to the cost in about a minute is they restrict formulas they negotiate so here's the key thing about negotiation you make your lots of people say you should deal with negotiation sure but negotiation requires one very important thing which is that you can walk away if you can't walk away from negotiation you can't negotiate does that make sense? the other part he knows you have to say yes then you can negotiate because they will keep speaking to you so in other countries people walk away the ministry of health walks away says we're not covering that and that is a really critical part of what allows them to talk about negotiation I've literally never seen anywhere in the literature an international comparison of exactly what we chose of what's not covered so it's funky how they do it something that's not covered like NICE just says it's not happening it's just not covered and it's not covered a lot of the times the way they do it is they say it's covered but only these doctors can use it only if they've done ABCD&E first so sure it's technically covered but almost no one can get it so it has to be a really technical comparison that has to be done like a lot of what you did it's almost the input of how to work somebody would have to like take a year just do that yeah starting now over 19 but that would be super interesting to do I have not seen that done so just understand that negotiation is great you've got to walk away and other countries do so countries have 100% coverage but not everything is covered and that's just it is what it is I just want to take a minute to talk about what's not covered in America this is obviously not precise this is just rough I want you guys to sort of understand this is kind of where we are right now if you look at the 10% of Americans that are not covered about a third of them are required young relatively healthy people about a third of them are undocumented individuals and about a third of that hard work if we expanded Medicaid it's like Texas we would make a huge impact on this group we would almost be wiped out I'm sure it does look cool we want to help people get insurance expanding Medicaid would do that this requires really I think a bunch of people basically increasing the fines for not participating in the ACA exchanges and a bunch of other stuff and there is absolutely zero political veil for healing that's kind of where we are but you know the 10% that remain that's who they are all of them not exactly a very good group but I figured I want you to have the deal broken up for sure questions on that so somebody said that they want their mom to have the way very well to see a specialist in terms of that data this is people having to wait two months or more to see a specialist and this is a survey of individuals so this is not actually looking to see if we're waiting how long it's actually asking people hey the last time we needed a specialist how long did you have to wait 13% of people that said they said they had to wait two months or longer that was really high in Canada and it's pretty low in the US so one measure of access not the only but by one measure of access it's not that American but if you love your mom then I believe that all of you do that France, Germany are good places for her to go she doesn't have one but UK and Sweden get a little bit quicker question is that only for the people who have actually made an appointment what's the counter wealth fund survey of people who are active users of an offer I have to go back and look at the original sample but it's people who are doing so it's not asking the general population this is also a survey for the counter wealth fund asking people who have seen that physician in the past year whether they thought that added good time to the physician what's really interesting about this is that 86% of people in UK don't quite offer only 81% in the US so we're a little below average not terrible in Canada but what's really interesting is which country has the longest visit length among all these countries where do you actually get to spend the most amount of money anybody know America by a lot average visit time in the UK that's actually how it's scheduled if you go 12 you're running over right for us it's closer to 20 minutes 20 minutes feels pretty rushed for both of you right these places visits are 5, 7 10 minutes that's it so many UK where they use 10 minutes visit they haven't much time to come for our visit there do they document those 10 minutes visits for half a day and spend the rest of the day done it's supposed to be documenting during of course it's challenging so people break you don't get to do half a day of playing that'd be great that's an imagine one topic we have not mentioned in terms of access you may mention is availability of primary care physicians so I live in UK for a year and a half and everybody had a primary care physician including non-citizens myself and so it came in at present that someone who's seen for 15 years is not the same as a 10 minute visit as a new patient I'll get back to that in a short while ability to get same day appointment against a discriminating question from the top of all fun or a little below it's interesting 51% Americans are between a doctor but most countries around have 50% in other words it's really being a little high that's great my take on these is you know we're a little below average but we're not like crazy outcries access once you're in the system seems to be okay and so access won't be fasted for the 90% of Americans I'm sure I would argue the access is terrible because every time you go see it somebody you can follow up with a big bill but for the each word access goes to that of course in some areas it's better in others so certain American other countries access that's kind of how I see it okay okay everything goes this right which is we spend a lot of money on it's a point I mean I'm re-iterated if America did not exist on this graph you look at this and your eyes would wander and sort of look at the fact that you face not a low it's within this high it's sweet it's a little high it's interesting there's actually a good amount of variation it's just that it all gets completely swamped by America we just spend so much more than everybody else and if you live in Europe you actually spend quite a bit of time thinking about positions like if I believe for instance a few days under spending and there's going to have to just relieve that to get Switzerland and it's a little bit off the high side it always has it's always been a bit of an expensive system and there's so much of it but again none of that subtlety shows up once you start looking at America these are 2016 data and 2017 that number for America has gone up but we just didn't have any comparable numbers for every other system it's not showing you the last set of data okay so the big question is why do we spend so much more and this part is no repetition I'm looking at that graph over there it was there yesterday and another few of the others but why do we spend so much more and then this is the one equation that David let me get out of that way with putting out an equation yesterday and then the very game was around especially when you're like just a doctor but the point that I want to make and David's going to push back on this I know but I'm going to go ahead and make it anyway and he doesn't have a mic so I'm going to use that to my advantage is because you look at total spending it's made up of two things and so I said the same thing yesterday let's say we think that David spends twice as much on doughnuts then I let's say he's spending twice as much on doughnuts as me there are two ways essentially that you could be spending twice as much on doughnuts he could be buying twice as many doughnuts he loves doughnuts twice as many I eat a doughnut a day and he eats two doughnuts a day that's a quantity issue it could be that we both just eat one doughnut a day he goes to a gourmet doughnut shop and his doughnuts are twice as expensive or it could be some combination there or it could be some combination there and price has a lot of things built into it which I'll get into but basically total spending is one and times price everybody kind of buy that how much you spend is made up of how many and how much you pay for it so one of the things that's been kind of brought up over and over again every health policy today is that the problem of American public spending is a problem of overuse our culture of overuse Americans love health care we go to health care and use it all the time whether it's Americans demanding it or doctors giving it or the fee for service system that encourages it it's all about quantity so I'm going to show you some data about quantity so one thing that I certainly heard over years like many many times is we're really quick to go to the doctor like you know we get a little back made to the doctor and a little simple I'm going to the doctor whereas the Europeans they don't go to the doctor so one simple thing is just to look at the doctor business and here's the mean and here's the mirror so Americans on average go to the doctor four times a year the mean across these countries is 1.6 and here's Japan the average Japanese other than once a month that's average so there is a lot of variation but we are at the low end so it certainly doesn't seem like a problem but we're going to the doctor and I can tell you our doctor business is a bit longer but in terms of this idea that we're just over medicalizing going to the doctor for everything at least this one small statistic makes you wonder maybe that's average and is this a good business or not? This is just physician providers good question because we have non-physician providers MPs, VA's, etc they make up a small number in the US they make up a small number in other countries it varies from country to country how much but there just wasn't reliable data on non-physicians across all these countries so all we could do is but a vast majority of physicians in other countries physicians, non-physicians they make up a small number so one is part of the doctor business in Japan is that doctors play a role in Japan is a little bit like pharmacists they spend drugs so it's a reminder that you need to look at the whole system the other thing is that I don't know, Alan Barber he's a federal secretary he's just a pan-doctor gentleman so you should know this so he tells this joke apparently this is the 20th joke a Japanese doctor has ever heard so basically it's like this doctor comes every day and no day after day the doctor is encouraging her not to come and she's there every day so one day she doesn't show up so the doctor is very concerned so he urgently calls it's not more why he comes it's that I didn't feel good he's an expert I don't know that happens Alan will know that alright that's a good joke alright doctor business so people look at this data they say, oh yeah, but problem is that we don't have enough doctor business and we don't have enough prevention and we don't have enough primary care and the problem is we're not doing enough doctor stuff and everybody's ending up in the hospital and hospitals are much more expensive and so one theory has been that we don't do enough prevention too much acute and intensive care so we looked at hospital disruptions for population and this is what we found Neem is 149 per thousand people here's the good old us of A 125 Germans love spending time at the hospital a lot and it's discharges but this is not language today this is how many times people have admitted to the hospital somebody's been asking about observation status and the answer is if you include an observation status that will prompt this up to about 135 and I had no data on observation status but observation status doesn't get us from 125 to 250 it's a small so the big point here is the length of stage which country has the shortest length of stay? among these countries America so if you then do discharges times length of stay that's a good variation but I didn't put it up if you think about the number of days people actually spend at the hospital we're way near the bottom Japan is a little lower on discharges but their length of stay is about three times ours our average of medication three to four days at the hospital average of medication in Japan about 14 days at this point that I was in Japan and I saw patients who were on oral antibiotics once a day they were on oral antibiotics still in the hospital being observed make sure that people flock to Japan I'm gonna watch them for the rest of the day to make sure that the pharmacokinetics of that drug is working well with them it's just to me it's insane to make a hospital for 14 days in front of normal ammonia but if the hospital starts off with it's okay to stay at least that part of it okay so it's not doctor visits, it's not hospital visits so so maybe it's it'll be used to any testing procedures there's a little bit of evidence here that the answer is to be made so here's MRIs MRIs for the population here's America sorry this is the me, here's America we're hot, there's adjournments on MRIs but big variations right and we're on the high side for MRIs we've got a lot of knee replacements why would we do so many knee replacements in America? because we can because we can obesity leads to osteoarthritis it leads to the knee for knee replacement actually obesity makes the population pretty close to the knee replacement and we're right there so that's high and then we throw in different replacements the low average that's interesting different replacements from slightly different set of stuff, obesity matters but it's not the only thing one new data point for those who were here yesterday to see this which is coronary angioplasty in TCA, here's me and here's America we're a little on the high side look at a French everybody's getting an angioplasty they look there cheese at the wine you know but the rates of angioplasty in France are very high but the point on this is sure we're a little above but it doesn't look like that's the dominant story that gets us $3 trillion of health care spending where everybody else has had enough right? so my story my take on utilization on the whole price quantity thing is it utilization? we're spending so much more on health care I believe that higher U.S. costs are not primarily about utilization after all we have fewer hospitalizations fewer doctor visits and tested procedures are a bit of a big spack we do more of some things we do fewer of other things and the way I've always thought of that is the bottom line is we're above average on some below average on others and on average if you look across 20 different utilization measures 10 of them were below average that's what average looks like that's slacks so I don't think that's a dominant part of how we get to higher health care and this is this is disturbing to me because for 10 plus years certainly by my friends and colleagues who were deeply involved in crafting the Affordable Care Act the story has been that higher health care spending is out of control because of over utilization deeper service drives doctors like you and me to put our own financial interests ahead of those of patients too many to do tests admit too many patients and we get to a system that's high control on utilization it's a very good story in my mind it just turns out not to be correct right in countries that don't have paper service utilization doesn't look that different and so that should that bothers me a little bit because it's just very antithetical to the broader story I'm going to get into what does drive some of the higher spending but let me see if I can take questions on this sense anybody surprised, bothered, annoyed totally expected the crowd was here yesterday, well please expected back there I think this is striking because you talked a lot of changes in insurance policy and deductible plans these are all centered around reducing utilization and giving the patient financial incentives to spend less and I think this is really interesting because it suggests that that is just completely ineffective if over utilization is not the problem so let me make one really important thing right I made the same decision yesterday with the American Rural Medicine Foundation who have launched a choosing wisely campaign and they get very upset when I showed the slides because a lot of the equation is overuse is not a problem so let me kind of make the subtle point that I've used an important here nuance issue which is I think we do have over utilization in America we all as practicing clinicians know we have over utilization we've all seen tests that were unnecessary, tests that were repeated that shouldn't have to be repeated we had a really well-functioned system people who have hospitalized in a better world would not need to get hospitalized right the point is over utilization is not a uniquely American problem we still have it we can still do better by reducing some of that unnecessary stuff it's just a slightly unique American and the reason why that becomes so important is you can't look towards uniquely American causes for over utilization you can't blame American culture for over utilization in general when you can, that would be weird right you can't blame our medical non-practice system when the hospitalization rates in Japan look so much different so that's my point is that the international comparisons don't tell us that there's no realisation, we add it it's not uniquely American the causes are not uniquely American in my mind in my mind there are a bunch of causes of over utilization but a lot of it is ideally conservative on the physician side a lot of it is what's your risk tolerance for this patient at this moment that's what makes this order test that in retrospect probably more necessary where it makes somebody that boy that probably could have gotten away with being animal but these are tough things to balance there's an all country struggle it seems to be like that a lot of tribes care is facing the standards of the care what is standard and where you're operating and it seems to me that America, the US is sort of creating a lot of the standards of care that would be prompted to national standards and so that even if they don't have a fee for service that the standard of care was created in an environment that in which the service forces were operating that that was then exported internationally and so it's no longer the standard of care and I think that thing of uncertainty is that's built into the standard of care what degree of certainty you need to do anything so it's an interesting question that we sort of exported American style medicine to all of these countries from Japan to Canada I mean again there are two points that I guess I could say one is when something transfers from here to another country no country adopts a wholesale so I would have expected some influence but not a complete adoption of our our practice style and there is one American practice style there's so much variation within our own country there's so much variation in these countries that I don't know how to reconcile that but it is entirely possible as a mechanism that American medicine has taken over the world yes along with that are you sure this is an apples to apples comparison I mean there's a lot more people in the United States so is it I don't know I'm thinking like compare Minnesota to Germany or something or compare Massachusetts but these are all populations and a lot of them like these are 1,000 people so of course if I just put up like a whole number of Andrew classes Austria so sweetly would be like 40 times so this is population adjusted there's sometimes we do age adjustment sometimes we don't but it starts getting a little tricky this is our best apple to apples your point about states I'm going to come back to in a few minutes because it's a really critical part of the discussion I want to go into anything else yes this is a quick comment I appreciate that you said it seems the fee for service is not the problem because many of the solutions that have been put forward in the last decade have been targeting the fee for service model and that seems like people have got the problem wrong because fee for service can be done successfully in other places and it costs low quality hot and we're spending a lot of effort to reframe how we pay for health care without effectively identifying the right problem so yeah and I want to just be a bit more nuanced on this because it's not that fee for service isn't the problem fee for service is a problem in the way that we do it but fee for service does not need to put more quality over utilization it's which fee for what service so I always say if fee for service doesn't give us enough mammograms because we think mammograms are good pay the doctor $10,000 for every mammogram they work every name moment a child will get a mammogram right? the point is if the fee is wrong you get the quantity wrong so a lot of it is what do we pay for and how much not the fee for service team itself people like fee for service doesn't need to pay for the prevention pay for prevention again give the doctor $1000 bonus for every nutritionist they refer to the patient if you think that's a good thing to do you'll get a lot of nutrition business my point is that we need simplistic approaches like fee for service bad accountable care you know capitation putting doctors at risk good and these are subtle I'm not a fan of ACO's business I think ACO's are doing a lot of good but there's even subtlety there of how they do I know this is the right time to raise the question but it always redirect how is the seminal contribution of the economics in terms of past 15 or 20 years that led us to what you're describing to state right in the same color do you have a look at the prices part of it what they show basically is that the prices that we pay a heart attack until we're time risen more quickly than inflation yet each way in which we are treating heart attacks is gotten cheaper the average has risen and we have moved towards more intensive things compared to less intensive and so that in fact appears to be a constant quantity of heart attacks in fact in standard quality or quantity of services so I think about the cost of the angioplasty well in the United States unless you have backup finance and so that is a huge cost to have some effect on quality so is this the right time to have that can I come back about 15 minutes to that I'm going to spend 5 minutes I'm just going to blow through a bunch of new data to make 2 points and then we'll stop and then we'll spend the rest of the time following the population which is going to Europe so if it's not quantity or it's not primarily quantity what is it so one thing I'm going to talk about is administrative waste this is from our paper there are lots of ways of measuring administrative waste this is the way the OACD does it looks at government's administration spending primarily around payment how we're paying for health care the mean across these countries is 3% here's to the US of A really kind of as an outlier the big point I'm going to make is Netherlands and Switzerland are both primarily private private systems with private insurance and they figure out how to do it and not do it so in my mind this is not a public versus private argument public systems certainly are often much cheaper but the point is here's Switzerland as primarily private here's Canada as single payer you see a 1% difference so you can get much more efficient in a public system or a private system just we do it there's a bunch of administrative things we do that are particularly bulk headed and this is just one way to measure it there are other people who measure administrative costs at much higher numbers but this is what we can do from a company so administrative costs start to come here ok so we're talking about this administrative cost goes into prices but let's talk about prices the prices of what so the thing everybody focuses on these days because it's sort of a politically caught topic is price of hormone and it doesn't prevent protection it doesn't test the technology and it's what we're spending on what we're spending for Canada on hormone here's the mean here's the merit we spend a lot more on pharmaceuticals by the way we don't use a lot of pharmaceuticals we just spend a lot on pharmaceuticals and about twice as much and this really relative to an audience we start to look at individual drug prices I initially in the first draft of the slides had like 10 of these and I was like I'm going to kill you guys so I'll show you two but they're all the same pattern this is how other countries pay for best stores this is how other countries pay for best stores this is a biologic this is how we pay compared to other countries basically I can do this all day and keep showing you that almost every pharmaceutical we're just paying a lot but far enough it makes out about 15% of all health risks pharma actually argues it only makes out 10% but that's bogus because they don't count like in hospital and other types of pharmaceuticals so this is the real number this is from the ASCII report this is kind of 15-16% of all health care spending pharmaceuticals so even if we're paying a lot more for pharma that can't explain it all because by that that would be something more than just pharma prices that can be a whole story so let's look at some other prices here is generalist physician salaries in America and elsewhere our primary care doctors can pay a lot more our specialists can pay a lot more and that's a that number really hides a lot of variation if you're a pediatric infectious disease doctor you're not technically 16 but if you're an orthopedist in private practice you're not going to be 16 right only in a bad year actually not in a bad year kids aren't going to be that bad a year so the point is there's a lot of variation in other countries you don't see specialists making 6,700,000 dollars almost never enough a very small number that are in a very elite private but generally you don't get that you get that much more so both for specialists and generalists I see a hand which I'll give you in 5 seconds let me just make one point as it comes up we our doctors pay for our own medical education they're doctors it's taken out with a bunch of debt average debt $200 to $250 if you advertise that over a lifetime Sherry Lee who's one of my favorite health economists after David of course but really brilliant she does a really nice work looking at how much of a physician salary bump would you have to provide to make up for medical education debt it's about $25,000 because amortized over a lifetime that would pay for the medical education so that doesn't explain this but it does contribute a little bit now that people get into the psychological costs of having them this can't be just a price that she was going to be I'm just saying the salaries are higher I'm not saying that the doctors are just as good or just as bad or whatever so we don't have yesterday I showed a different set of full medical I'm going from that to this and by the way it's not just doctors it's nurses too like the French nurses they pay $22,000 a year on average you know it makes them lower than us not nurses oh what about other stuff let me spend two minutes and just quote through some numbers this all comes from the International Federation of Health Plans this is looking at private insurance rates in our country and other countries here are Pat's games and I made this joke yesterday and I'll say it again look at Spain everybody should get an economic CT at that price like a little discomfort here just scan scan I'm kidding I thought it was radiation and all sorts of announcements I actually argued that everybody should get some scan scan everyday but you can do it appendectomies cheap in Spain less cheap in America you're Switzerland anybody fit in Switzerland cheap country right like the dollar goes so far no actually I was in Geneva last week went to a Starbucks true story went to a Starbucks got a latte not even with any of the dollar shots just straight up latte granted but not what we will make of you anybody not too costy nine bucks and I was hungry and hadn't had breakfast I got a bagel and cream cheese three bucks for a latte and a bagel everything in Switzerland is really expensive but if not appendectomies Switzerland Switzerland is really expensive except it's cheaper for us bypassed and you see like these are like not cheap countries but Spain is kind of less expensive but and they're all crumpled I mean my answer includes party excursions salarades and nursing salarades so all the stuff I show to you shows up okay so yes can you talk about resource costs that we talk about in the reimbursement those are reimbursements those are reimbursements I can show you many of the reimbursements which are lower but still higher than the reimbursements in other countries because reimbursements is what shows up in your insurance bill at the end of the year so yes here at the University of Chicago we are always told that it's a tiny fraction of the patients who are responsible for all the profits and all the bills and that that's used to subsidize the fact that people are not assured of anything to essentially under-insure so when we look at reimbursements like that is that really a cost or is it really just for collection of finances so as you know David that's a really complicated question so let's take a minute and think through that so the point is that depends on the system you might have 20% Medicaid 40-50% Medicare and 20% or 30% I'm not sure I don't know what it makes this year but that's not a reasonable grade an academic medical center in the middle of a basic right and so the standard argument that every hospital executive has made is we lose money like we're going out of business if we would on Medicaid we kind of lose money a little but not too much on Medicare thank God we have privately insured patients we kind of find out it's complicated because these are not fixed things what I mean by that is what if you were an old Medicaid provider could you survive you could you would just pay your doctors and nurses a lot less right and your executives would pay less and you have less resources and it's complicated also by the fact that 80% of hospitals are non-profits so every year they want to make sure their expenses come out approximately where their revenues are and you know these hospitals are not allowed to make profits or those 80% are not allowed to make profits but if you really look at their underlying cost structure I would see the cost structure as a big thing like oh my God it costs us $10,000 to do that in that sort of group whether we want it or not that constrains you with financial resources you could have created a credit report back then so it's a very dynamic thing which is why I say it's complicated there are lots of hospitals where 80% of their patient is Medicare and Medicaid and they do just fine for 90% I want to talk about health outcomes because we talk about access we talk about cost we're really expensive, a lot of it is administrative price but I've got health outcomes so this is the data that we've all seen some version of which is my console life expectancy we're different there's Japan I think it's the 2016 data by the way it doesn't matter we're really kind of different another piece of data I took out America and I put in three new places anybody who doesn't know what these three places are numbered accurate these are not countries normal but I say that would be interesting Hawaii Minnesota Connecticut you want Sweden? we've got Sweden and so we're a little tiny bit different than Sweden but essentially the same life expectancy so that's interesting Minnesota's got the same life expectancy as Sweden that's not a big thing Minnesota is Sweden a lot of Swedes or a lot of people from Scandinavian countries in Minnesota it's true Hawaii's interesting but they're ahead of Canada in Denmark Denmark by the way it's one of my favorite models Denmark they do this and then there's a head right between Denmark and Europe but the point is that America's a really complicated place and when we talk about places like Finland and say Finland's population their health outcomes are awesome we'd be like Finland Finland is awesome it's awesome, it's great probably been much better it's great Finland is 20% smaller than Massachusetts Massachusetts is not a big state so national comparisons are complicated by things like this we have a ton of heterogeneity in our population and if you want me to compare Minnesota to Sweden that's fine but if you want me to compare America to Sweden which I just couldn't think about what we're comparing that is balance but the key point I want to make is that to the extent that we think health care systems has something to do with life expectancy we've got places that hold just as good as Northern and Western Europe questions, comments or thoughts on that we're seeing your nato-mortality another place where we do very bad but here's a different statistic which is your nato-mortality given to a birth rate where we actually tend to do pretty well two very contrasting stories neoliberal mortality is about a whole bunch of stuff stuff we do in the hospital there's a lot of stuff that happens outside of the hospital before the hospital this is a think of a closer measure of what happens in the hospital given no birth if that makes sense to people what I'm doing in terms of contrasting these things because I'm trying to set up a dimension that I want to actually discuss with you stroking of health if you're going to have a stroke and again please avoid it if you're blood pressure medicine strokes are bad but if you're going to do it somewhere it's a good place to do it our 30-day stroke mortality is much better this one I'm just going to say a little caveat I think these numbers are pretty much right how people are measuring this a little variation they won't explain the fact that we're like after mortality of Canada so that's really interesting and that gets in many ways to the point we brought up earlier when I say to you am I here as twice as expensive or stroke here as twice as expensive in America as it is in Canada am I just comparing apples to apples or is there a lot of stuff that's going on that may or may not explain a higher cost in the United States and then of course it takes all sorts of questions like is it worth it is it worth spending twice as much if we're going to get lower stroke mortality but we won't get better population that's a different question reflections or thoughts on this anybody surprised by this yeah so nobody so this is where what this paper has done is maybe realize all the answers I don't understand but I don't understand what explains this so what we have done since then is we've got individuals from each of these countries and a couple more working in the streets to get a plane stay and now we're working with investigators from each of these countries to look at actual patterns of care across a whole bunch of things outpatient and inpatient how do we manage diabetes versus how do you manage diabetes how do we manage stroke versus how do you manage stroke so as you might imagine getting 13 countries to all collect analyze and report planes in an exact same way is an endeavor but we're probably 6 months away from our first set of answers but I haven't seen any data yet so I don't know where to begin what's that yeah, g2 rates there's a bunch of stuff we can look at here we just have to come here and that is particularly true in the age of so these are these are these are challenges in international comparison where you're trying to get the same population but it's complicated so for your neonatal data I really wonder if part of it as a pediatrician we hear from our European colleagues that the rate of pregnancy terminations for genetic malformations is much higher in Europe than it is in the United States we have more children being born with genetic disorders that have a higher rate of death within the first year of life in those countries these are all the subtleties that should make you very careful about international comparisons because it's easy to say we suck our numbers are thorough because what do you compare and what do you want to make sure you get to that anyway, let me see what else I have data wise somebody brought up mannequins earlier as like a preventive thing so we're pretty good at Denmark that's very well and we're not like like there are places where the numbers are much much lower we're pretty good so I'm basically done let me just make a couple of summary points that I didn't have for questions I think Dave here is supposed to come up here and join or whatever we're the only country without universal health coverage once you're in the system our access looks okay not awesome but not bad we have a really high cost health care system which used to be a project I've already heard about administrative costs and health outcomes for people who are in operation or work but if people were to get sick and the last kind of question I want to ask and I want to finish with this is when I started off this talk I talked about what are good health systems what are good health care systems where do you want your mom to get her help I didn't begin the question by saying what's a good society to live which is a related but different question so let's talk what about things like life expectancy what drives life expectancy the health care system how many people think what your doctor does what the hospital does are the primary drivers of life expectancy anyway now, right? no, wait your education, where you live, the neighborhood the environment, the food you eat and then 20 other things are more important than how good your doctor is or whether you even get in this year how long will we wait for that those are important issues but they're not as important but it's interesting that whenever we talk about American health care system we pop up life expectancy and say our life expectancy is lower our health care system is less effective so one really important issue to think about is what is within the boundaries of the health care system what are we going to hold doctors and hospitals accountable for versus what are we not going to hold doctors and my general take and I will stop it is once people get into the system as pricey as it is as difficult it can be at this time we're a pretty good health care system by the way, that somehow American health policy makes me deeply unpopular because in the American health policy the mindset has been our health care system is growing and my argument is all sorts of societal problems in our health care system but once you get into the health care system stroke mortality AMI mortality look pretty good mammogram look pretty good access looks pretty good you can go specialist weeks you can take a lot for it but it's not so bad push back tell me why you disagree with that you were really very nice to look at to look at these priorities with the same context of those countries if you look at quality of health care in all of those countries that you're comparing to the United States don't see the huge disparities that we see here on the average do I think the health care here is good for people who have access but many don't have access and if you look at downtown you know how well for 8 months 14-16 years but I don't think you see that kind of huge disparities in all these other countries but you've got to be careful wouldn't you say that we're pretty good we're not good at all there I'm looking at averages an average is high variation you're seeing it in a much more elegant way but that's fundamentally your point and I agree with that two kind of points I want to make is one is some of the minimal work on life expectancy and social determinants who start in the UK where you find that two stops make a 10-year life expectancy difference so and that has been replicated in Boston I don't know if it's been replicated in Chicago but I'm sure the data will be the same that neighborhood to neighborhood we see five 10-year life expectancy differences we can beat the outside concept so that kind of variation of life expectancy does exist in some other countries it doesn't seem to exist in Sweden it doesn't exist in Finland but it does exist in the UK where life expectancy in Manchester is 50 years less than the average life expectancy in London and in London there's a 15-year life expectancy variation between one neighborhood and another so you do see that in some places but not in lots of other places you see it some in Germany but not as much and you'll see it in Switzerland but the only issue is Switzerland Denmark Sweden are really they're very homogenous, they're small they're very low and so for me the more correct comparison of the US is that UK, France and Germany they are especially France and Germany more homogenous than we are the second point is absolutely right I didn't show you any data on disparities we have data on disparities in our paper and the numbers do not look very good we have populations in our country but the last point I want to come back to is do you want to use life expectancy as your measure of that health care system or do you want to use life expectancy as a broader measure of our