No other country in the world can beat the U.S. in medical technology. No other country spends as much for it either.
The mantra "Americans have the best medical care in the world" is frequently recited by U.S. policymakers and clinicians, according to a study published in the May/June issue of the journal Health Affairs that compares the quality of care in five English-speaking countries. But international data--limited though it is--places the U.S. in the bottom quartile of industrialized countries in terms of life expectancy and infant mortality, according to the report.
The best medical care money can buy does not necessarily translate to the best medical care in the world.
"How do other countries spend statistically less and get better outcomes?" wonders Mark Blatt, manager of healthcare strategies for information technology giant Intel Corp. "The only other country that spends nearly as much as the U.S. is Switzerland." After adjusting for cost-of-living differences, Switzerland--which data from the Organization for Economic Cooperation and Development showed ranked second in spending out of its 30 member countries--spent only 68% as much on healthcare per capita in 2001 as the U.S., according to another Health Affairs study published in the May/June issue.
Ironically, America's seemingly insatiable appetite for the newest and greatest in technology may be contributing to this country's average performance when measured on various healthcare quality indicators in the international arena. The Health Affairs study comparing quality of care found that the U.S. healthcare system performed better than Australia, Canada, New Zealand and England on some quality indicators such as breast cancer survival and cervical cancer screening, but performed distressingly low in other areas such as asthma mortality and transplant survival. While the U.S. in general performed relatively well, "It is difficult to conclude that it is getting good value for its medical-care dollar," the authors say. "The huge difference in the amount the United States spends on healthcare compared with the other countries could very well be justified if the extra money provided extra benefits."
A model hospital
Many hospitals throughout the world have amassed the technology necessary to provide care as good as if not better than hospitals in the U.S.--and at far cheaper costs. Blatt discovered his "favorite hospital in the world," 554-bed Bumrungrad Hospital in Bangkok, Thailand, while perusing an Internet listserv.
Privately owned Bumrungrad boasts some incredible outcomes, Blatt learned. The for-profit hospital treats nearly 1 million patients annually, serving 2,400 outpatients and 350 inpatients daily. Services are offered in 19 specialties and 102 subspecialties, including full-body checkups, plastic surgery and heart transplants. The hospital employs 2,600 full-time employees, not including physicians and a couple hundred security, house-keeping and food service personnel, Ruben Toral, its marketing director, says in an e-mail interview. Bumrungrad features a Starbucks on the first floor and a McDonald's and a "great sushi restaurant" on the second floor, says Blatt, who has visited the hospital twice, most recently last month. The hospital also boasts an in-house spa.
Western-trained physicians at the hospital provide care at a fraction of the cost in the U.S. Inpatient revenue grew by 33.2% from 2003 to 2004 and outpatient revenue rose 22% during the same period, Toral says. Not surprisingly, Bumrungrad, one of 56 hospitals outside the U.S. that have been accredited by the Joint Commission on Accreditation of Healthcare Organizations, treated more than 300,000 international patients from 170 countries in 2003. Revenue from international patients, who constitute 46% of patient volume, climbed by 38.3%. International patients drive approximately 50% of the hospital's revenue, Bumrungrad officials say. The vast majority of patients--75%--are self-paying. Insurance contributes 13% of the hospital's revenue and corporate contracts cover the remaining 12%.
Toral offers one word to explain Bumrungrad's success: "value." Though the service is at least equal to international standards, the prices are as much as 70% less than comparable private hospitals in the U.S., Europe and Japan, he says. Patients have access to more than 600 internationally trained doctors with none of the waiting lists that plague socialist healthcare systems like those found in the United Kingdom, Canada, the Netherlands or Scandinavia, he says.
The clinics move outpatients from registration to discharge in an average of 45 minutes, even though about 65% of the patients show up without an appointment, Toral says. Registration with personnel capable of handling a variety of languages takes place at multiple points throughout the hospital so there is almost always someone ready to help patients, he says. Patients can see specialists without first seeing a generalist; there are as many as 200 specialists working at any given time every day from 8 a.m. until 8 p.m., Toral says. The discharge system is integrated with the hospital information system, which also helps reduce waiting time, he adds.
Founded in 1980 as a 200-bed facility, Bumrungrad burst onto the international scene in 1998. Toral says the hospital suddenly was saddled with the crushing debt of a $90 million replacement hospital just as the country slumped into economic crisis. Patient volume shrank as private medicine became financially unreachable for the local population. Hospital officials decided to take advantage of the slump: with the Thai currency--the baht--severely devalued, they marketed its now very affordable services to countries in Southeast Asia, and later in South Asia.
Riding on technology
Implementing a fully integrated hospital information system complete with electronic medical records and digital radiology was perhaps the biggest and boldest move the hospital made to transform itself into an internationally known facility, Blatt says. The program was custom-designed for Bumrungrad, and it was ushered in after a mere 21-day tryout. The information system "does everything," Blatt says. "You can't find a hole in this hospital. Everything in the hospital is bar-coded--the food trays, everything."
The system was built simply, with only 20 information technology professionals running it vs. the 120 technicians it would take in a similarly sized U.S. hospital, Blatt says. Physicians told him that the IT system allows them to see patients three times faster than they would in the U.S. The hospital's managing director, Linda Lisahapanya, told Blatt she decided to invest in the system simply because a one-year maintenance contract on the old information system cost more than building the new system.
As a result, unlike most U.S. hospitals, Bumrungrad is nearly paperless, with impressive benchmarks for waiting times, says Karen Timmons, chief executive officer of Joint Commission Resources, a not-for-profit subsidiary of the JCAHO that includes the international division, Joint Commission International. "They have done a tremendous job in building the technology," she says.
Other nations are similarly surpassing the U.S. on the information technology front, Blatt says. The German government plans to begin issuing electronic health cards to every citizen by January 2007, an enterprise that is expected to improve efficiency and save up to $1.7 billion in three years. The United Kingdom's National Health Service has already begun an ambitious effort to give every citizen an electronic medical record that will hook up every doctor and hospital in the country. The government is bearing the cost but in return, healthcare organizations are under a mandate to connect to the system or go out and build one of their own, he says.
"That approach probably wouldn't work in the U.S.," where there is little interest in funding such efforts, Blatt says.
In Sweden where cellular networks are more advanced than in the U.S., a pilot project in Umea is arming nurses with wireless technology. The home-care project will allow nurses to make home visits across large rural areas while still being connected to the same electronic medical records that are available to all the healthcare workers that provide care for each patient. Intel is acting as an adviser on the project.
The U.S. is lagging far behind these countries on this particular front. Only last month the Bush administration unveiled a road map for building a system to make electronic health records a universal standard within 10 years. The government estimates that only 13% of the hospitals in the country have adopted the technology to provide electronic medical records (July 26, p. 6). The plan did not include pledges of substantial new funding sources.
Blatt suggests that initiatives such as those in the U.K. and Germany are not politically doable in the U.S. Hospital executives in this country are only now beginning to bring strategic decisions concerning IT to the board level, he says. Unlike Bumrungrad and hospitals in European countries where governments are leading--and funding--IT initiatives, U.S. hospitals are victims of the piecemeal systems they installed years ago when healthcare information systems were in their infancy.
"We still have 20 years of legacy systems to get out of the way," Blatt says.
U.S.: The big spender
There is no question that U.S. healthcare spending dwarfs expenditures of other nations with older populations, according to the study in Health Affairs comparing U.S. spending to other countries. In examining the reasons behind the runaway costs, the authors observe that many countries spend less than the U.S. but boast much more hospital capacity and have higher physician- and nurse-to-population ratios. It may seem counterintuitive to the frenzy that ensues when new medical technologies hit the U.S. marketplace, but the U.S. actually has a relatively low supply of CT scanners and magnetic resonance imaging devices compared with Japan and other industrialized nations. This is even though the U.S. was an early adopter of these technologies and initially was comparatively well-equipped with them, the authors say.
Just as some people are fashion victims, requiring the newest and fanciest accoutrements, some U.S. hospitals may be technology victims, says Gerard Anderson, director of Johns Hopkins University's Center for Hospital Finance and Management and a co-author of both of the Health Affairs studies.
"I think the issue is other countries have access to expensive technologies such as MRI and CT scanners, but their utilization rates are frequently lower than ours, so what we see is availability but not necessarily utilization in other countries," Anderson says.
Other countries may have more of them, but they don't use them as much, he adds. A hospital in this country might have a CT scanner running 12 hours a day compared with eight hours a day in other countries. That would make it seem that technology would be more expensive elsewhere, but it's not. U.S. hospitals may be the earliest adopters of technology, but once a technology matures, which is when premium pricing falls by the wayside--its availability tends to drop off--almost as though we've lost interest if it isn't the latest and greatest technology, he says.
"Technology doesn't seem to be driving cost in other countries as it does in the U.S., and it could be because it has to be new. We have to be the first on the block," Anderson says. "Once it diffuses, it's less expensive. So it's the cost of innovation, the cost of being the first on the block."
Other nations--such as Brazil, South Africa and Thailand--with affluent populations and private hospitals have pockets of excellence, Anderson says. Such hospitals are competing with U.S. healthcare for medical-tourism dollars, and if being an early adopter of technology is going to keep patients at home, they will buy it, he says. "It's very market-driven for these hospitals," Anderson says.
But regardless of who is winning the medical arms race, in terms of the best medical care in the world, the U.S. is "not doing very well," Anderson says. "We've got 43 million uninsured, and we don't have a real healthcare system that many of these other countries have, that integrate the care--especially for chronic conditions. They are not the earliest adopters, they don't spend as much money, but they have access to important technology and are able to get it at a reasonable price."
A role for government
Government intervention also may be helping other nations get the biggest bang from their technology dollars.
"In half of the industrialized countries, the government directly allocates capital and in others there is a strong regulatory impact on capital," Anderson says. "We rely on competition, and the competition is over the newest and fanciest technology and, unfortunately, the most expensive."
Since its launch in 2000, Joint Commission International has accredited 56 hospitals on every continent except Africa and will have accredited 60 hospitals by year-end, Timmons says of the JCR. International hospitals seeking to "emulate care" in the U.S. are driven in part by medical tourism and competition, she says.
Hospitals in the Middle East, where a "strong affinity for Western medicine" historically has sent many to the U.S. for care, are now trying to replicate that care, Timmons says. Last month, 80 participants from 22 countries visited the JCAHO's Chicago-area offices to learn about the accreditation process. Though Joint Commission accreditation does not offer any financial incentives abroad as it does in the U.S., hospitals nevertheless see the stamp of approval as a way to improve the quality of care, Timmons says.
"Everyone wants to do better," Timmons says. Accreditation also affords "recognition that they have achieved an international level of care," she says. That in turn helps attract patients. For example, one unnamed hospital preparing for accreditation in Singapore is now trying to establish itself as a hospital for Middle Eastern citizens after seeing the success of Bumrungrad, Timmons says.
Timmons says she would not say that healthcare around the globe is generally better than in the U.S., but in their quest to replicate the state of healthcare found here, many hospitals have technologically achieved a high level of care that is also "very service-oriented." It rivals the care in the U.S.
Still, "some countries are certainly further ahead in the movement of medical records," Timmons says. Countries such as the U.K., Sweden and Denmark have made great strides in electronic medical records simply "because they made the budgetary commitment and the U.S. hasn't."
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