Editor’s Note: Best in the World?

Charles Kenney thinks American healthcare can probably be fixed without wholesale changes in the way it’s paid for. We can have the system we want, he figures, without killing insurance companies, or detonating Medicare, or any of the other proposed remedies.

But then, he’s certainly a contrarian: Kenney argues that high costs and low access for the uninsured and underinsured are not the things that most need fixing. The biggest problem with American healthcare, he says, is that it simply is not good enough or safe enough - not even for people with the best coverage.

“It’s an article of faith in public discussion about healthcare: Someone will always say that ‘America has the greatest healthcare system in the world,’” the former Boston Globe reporter told me. “I think most Americans believe that, and most physicians believe that. What’s odd about it is that just about everyone who believes that can also tell you about their Aunt Millie and the awful experience she had …”

It’s a bit like the public’s thinking about Congress - that the institution’s a mess but their guy’s a gem - only in reverse: “My personal experience at the hospital was horrible, but, hey, it beats being Swedish.” Kenney’s new book, “The Best Practice,” argues persuasively that, in fact, getting sick in the United States doesn’t beat getting sick in Sweden - or in Denmark, England, Germany, Canada, or just about anywhere else in the developed world, for that matter.

On the contrary, he writes, American healthcare is “deeply flawed.” The research firm RAND found, for example, that “Americans receive the right care” - that is, the consensus standard of care - “only about half the time,” regardless of race or class. Hypertensive patients receive recommended treatments only two out of three times, and diabetics get less than half the care they need. He reminds us (as if we could forget) of the Institute of Medicine’s 1999 study, “To Err Is Human,” which famously estimated that some 98,000 Americans die annually due to preventable medical errors.

My own view is that America does have most of the world’s best-trained doctors, nurses, and other providers; many of the best research institutions; and access to cutting-edge technologies and many of the most-advanced treatments. But the outputs don’t match the inputs: American life expectancy and childhood-immunization rates are below-average for industrialized nations. Our infant mortality rate is among the worst in the industrialized world. The World Health Organization ranked America’s health system as the world’s 37th-best in 2000.

“When you have people flying in from the Middle East and elsewhere for exotic, cutting-edge treatment, it does create that impression” that America’s system is tops, says Kenney. “But there’s a difference between having great clinicians and having a great system.”

And it is the disjointed and archaic system, not its doctors that Kenney blames for our underperformance, as well as a medical culture that encourages silence about mistakes, doesn’t like being measured, and fervently resists change.

Kenney’s book, though, focuses less on healthcare’s problems and more on the band of physicians, academics, and system executives who have dedicated themselves to a healthcare transformation. They envision a system in which providers everywhere use sophisticated information technology to measure their own progress in providing evidence-based care every time - because they should, and also because they’re paid more to do so. This group, who compose the “quality movement,” is still small. But the transformation they’ve started is already underway, it’s growing, and there’s no stopping it: “It’s inevitable.”

Kenney doesn’t think that a wholly new healthcare economic system is necessary for the transformation to proceed. But common-sense economic incentives for physicians, such as reimbursement aligned with outcomes, is necessary. Everyone needs an EMR, but expecting small-practice docs to pay for them on their own is just nuts. “We have to get them help,” he says. “You can’t just say to a [small] group of docs, ‘Hey, you’ve got to pony up.’”

Bob Keaveney is the executive editor of Physicians Practice. Tell him what you think at bkeaveney@physicianspractice.com.

This article originally appeared in the October 2008 issue of Physicians Practice.