Ellen Nolte and C. Martin McKee have published an update of an earlier analysis of the health of nations. The Commonwealth Fund that supports independent research on health and social issues supported this study. It confirms what many of us have felt for some time.

In this study, the authors compare trends in death considered amenable to health care for patients who are 75 years old or less. They look at the years between 1997 to 1998 and 2002-2003 in the countries who are part of the Organization for Economic Cooperation and Development (OECD). For those who are less than 75 years old, these deaths account for 23% of the total mortality for males and 32% of the females. The average decline for all 19 countries was 17% but if we look at the United States, alone it was 4%. When it comes to not doing much about preventable death, we definitely stand out. Worse, as prior analysis show (and explained in a prior blog); we spend extra to get these results . As a small business owner, this 'warms my heart'! Of course, you may think that perhaps we improved less because we are already doing so well. Wrong again! We are the worst! For deaths that are amenable to health care, we have 109.65 deaths per 100,000. Portugal is our closest competitor for this honor at 104.31 while France whom we all like to vilify has to suffer with only 64.79. Even the less than ideal Canadian system has only 76.83.

It is important to note that there are some caveats. The concept of amenable death requires some judgment although the researchers apply the standard equally. Additionally the data relies on diagnosis coding systems that over time undergo periodic revision. These refinements might be grounds for some argument if we were trying to explain a small difference. However, we are DEAD LAST!

Here is the best part! One way we stand out for not doing as well is in circulatory disease. In particular, stroke! Yes, you read that correctly, STROKE! We spend extra money and still cannot keep up with the rest of the world in one of the most miserable and secondarily expensive conditions.

Health care is more than just your doctor and hospital. It involves public health, clean water, safe food, and the social infrastructure that supports us all. We will not fix this using doctors and hospitals alone. More money is not the answer because we already spend much more than anyone else does. The answer lies deep in the way we approach the problem and perhaps even deeper in ourselves.

Uwe E Reinhardt et al has published reports based on data from the Organization for Economic Cooperation and Development (OECD).The most recent work by Gerard F. Anderson, Bianca K. Frogner and Uwe E. Reinhardt was recently published in Health Affairs [Health Affairs 26, no. 5(2007): 1481-1489]. The new data confirms the findings embodied in their previous report. The earlier report was entitled "It's the Prices, Stupid: Why the United States Is So Different From Other Countries" [Health Affairs 22 no 3(2003):89-105].

Of particular interest is that the United States spends $6,102 per capita which is two and one half times the median. Only two countries (Luxembourg and Switzerland) spend more than $4,000.As a percent of GDP we spent 15.3% in the latest year's data (2004). Our closest rival for spending money is Switzerland at 11.6 %. Only 7 countries break the 10% barrier.

The important question is why are costs in the United States so high? At least based on this data, several of the common explanations would appear to be wrong.

Utilization cannot explain cost! The United States has 30% fewer inpatient hospital days and 36% fewer physician visits per capita than the OECD median. Japan as an example had the highest utilization rates with the longest inpatient length of stay (36.3) and the most physician visits per capita (13.8). Despite Japan's over-utilization by our standards, they spend 63% less per capita.

Technology cannot explain cost! The report doesn't include all technology but it does measure the number of MRI and CT units available. In both of these Japan has the most per million people.

Chronic Disease cannot explain cost! Chronic disease is where we spend 80% of the money. But the United States has nothing that stands out in the report to show that the diseases we face or our outcomes are different from those of our peer countries. We use less alcohol and tobacco but are more obese. It is hard to imagine these can account for the differences.

Lack of prevention doesn't explain cost! While it is fashionable to believe that prevention is the magic bullet that will lead to lower cost, in fact this report shows that the United States spends more on prevention than any other country. We spend about 5 times the OECD median. Our closest spender in this regard is Canada which spends $185 as opposed to the U.S. $224.

What is the explanation?

What stands out is the price! If we are to find the answer we must look at how the medical market works or doesn't. Is this an example of a free market where prices and supply respond to needs or is this an example of a planned economy with resultant scarcity and high cost. Clearly it is more the second than the first.

Until we can achieve a better balance between the necessary protection of the public and the efficiency of free enterprise, services will remain in short supply and costs stay out of reach for most Americans.

The results of an Zogby International email poll published in the October 2007 "Fortune Small Business" indicates that among entrepreneurs a plurality (47%) believe Health Insurance reform is either in first or second place when it comes to presidential candidate priorities. This is significant in that among this group, taxes would be expected to be a higher priority under normal circumstances.

Of possible health care systems, a plurality (34%) preferred Universal Health Care administered by the government. This ranked higher than Consumer driven systems, tax incentives coupled with purchase requirements and Universal Health Care administered by private insurers. If this poll is any indication, small business is coming to the realization that they have no control. Time may be running out to find a better solution.

We need more than plans and ideas. We need demonstration projects that demonstrate effectiveness before the crisis is upon us. Short of that, when the crisis arrives in full force, the risk is that we will continue with the current 'bad' system encased in inflexible rules.