Assessing the performance of an entire national health system—if “system” is the word for any country’s amalgam doctors’ offices, walk-in clinics, imaging labs, hospitals and more—is notoriously difficult.
If you just look at how long people live or what illnesses they’re susceptible to, the big variables are what sort of food they eat, whether they exercise much, if they smoke, and how rich they are. Examining outcomes alone doesn’t reveal much about the narrow contribution of the health system.
If, on the other hand, if you simply tally up the number of medical procedures performed, you’re probably not going to discover much about what you’re really getting for your health care dollar. It would be like crediting your mechanic for the frequency with which he replaces car parts, rather than his success in actually keeping the vehicle on the road.
These are the sorts of tricky considerations I waded into yesterday with a post critical of the Fraser Institute’s recent report Value for Money from Health Insurance Systems in Canada and the OECD.
To rehash a bit, that report looks at 18 diagnostic and surgical procedures, relying on OECD data for how often they are performed in Canada relative to other developed nations. Canada scored above the OECD average for only a third of the 18 indicators, despite ranking sixth on health spending. The report’s authors, Brett Skinner and Mark Rovere, conclude that this shows Canadians aren’t getting good value for their health insurance dollars.
But I don’t think these indicators indicate any such thing. They show, for example, that in Canada doctors perform fewer caesareans, tonsillectomies and appendectomies per capita than the OECD average. Why should this be counted as underperforming? If anything, these numbers suggest that Canadian physicians exercise proper discretion before cutting.
The Fraser Institute’s list of 18 indicators also shows that Canada has fewer MRI and CT scanners than the OECD average. But what is the cost-effective number of scanners? The OECD says: “Many studies have attempted to assess tangible medical benefits of the substantial increase in CT and MRI examinations in the United States but found no conclusive evidence suggesting such benefits.” Maybe having fewer machines means Canada is getting better value for its health dollars, not worse.
Among the indicators used by the Fraser Institute, several are inarguably important, especially the numbers of physicians and hospital beds—two key categories in which Canada lags. But taken as a bundle, it’s hard to see how the data from this very mixed bag tells a coherent story.
In my posting yesterday, I pointed to a readily available alternative. In Health at a Glance 2009, in a chapter entitled “Quality of Care,” the OECD provides 11 relevant statistics. These range from your chances of surviving a heart attack or stroke in hospital, to how well your doctor manages your diabetes, to whether you’re likely to be screened for cervical and breast cancer. Canada performs better the OECD average on eight of these carefully selected measures, worse on just one, and posts mixed data on two.
The Fraser Institute’s Skinner, in a comment on my blog post, said that by citing the OECD “Quality of Care” numbers, I was displaying my failure to grasp the difference between “the outputs of ‘health insurance’ and the outputs of ‘medical treatment’.”
If I’m following him, he’s saying that looking at the numbers of various procedures performed (as his study does) tells us what we’re getting from health insurance, whereas the outcomes the OECD looks at as “Quality of Care” indicators show what we’re getting from medical treatment. Skinner also says he “used all available data from the OECD for medical goods and services—the things that health insurance buys.”
But health insurance doesn’t just buy MRI scans and appendectomies, and all those other surgeries and procedures listed in the Fraser Institute study. Health insurance also buys emergency care when you’ve had a heart attack, and long-term care when you’re suffering from diabetes, and screening for cancer, and treatment for mental disorders. And how well these sorts of services are provided is captured, in part, by the OECD “Quality of Care” data.
Don’t get me wrong—I’m not arguing that the OECD figures somehow put to rest the debate over Canadian health care. Many Canadians are rightly unhappy about how many hours a moderately sick individual is likely to languish in an overcrowded emergency room before seeing a doc, how many weeks it often takes to see a specialist, and how many months to find a family physician willing to take on new patients.
Against this backdrop of justified discontent, though, it’s important to recognize that Canada’s health system performs well compared to other rich countries when you look at reasonable indicators, such as the OECD’s “Quality of Care” numbers. There’s no evidence that the public insurance model for delivering those key services is broken by international standards.
What’s wrong then? That’s a huge question. But just to get the ball rolling, if our main complaint is that we’re waiting too long to see a doctor, isn’t the underlying problem probably too few doctors? Similarly, if we’re annoyed at long waits in backed-up ERs, isn’t the problem almost certainly too few hospital beds to take the patients who came in before us?