It’s one thing to say that we have evidence that something works. It’s far more important to know how well it works. —David M. Eddy1
In previous articles in this series on information mastery we outlined the importance of finding, evaluating, and implementing POEMs (Patient-Oriented Evidence that Matters) to maximize patient outcome at the point-of-care. Clinicians practicing as “information masters” will have the information they need when they need it, allowing them to offer their patients the best care.
In this article we take the concept of using POEMs one large and significant step further, and apply it not only to making decisions about individual patients, but also within the context of the entire community and population. Information mastery can improve the value of health delivery systems by increasing quality and controlling costs. By improving the value of health care, physicians should be able to provide universal and equitable health care access for all.
The problem of cost
Our collective complacency for 44 million uninsured is a national disgrace.2
The amount of money spent yearly in the United States for health care continues to rise at a rate faster than the rate of inflation. Whereas in 1960, when 5% of the gross national product was consumed by health care costs, this proportion has increased to 15% in the year 2000.3
Translating this number into actual dollars, the average family of 4 pays at least $10,000 per year in direct and indirect health care costs.4 Direct health care costs include insurance premiums and co-pays, and out-of-pocket expenses for medicines and devices. Additional, indirect, health care costs come in the form of higher costs of purchased goods as a result of the burden of paying for the health care of the workers who manufacture and sell the products.
More money is spent, per person, in the United States on health care than in any other country in the world. Approximately 50% more is spent on health care in the United States than is spent in Canada. The United Kingdom spends only about one-third of this amount of money.5 Despite this increased spending, average life expectancy is not substantially longer here than in other industrialized countries.5,6
Socioeconomic status plays a larger role in the United States than health care spending in determining the length and quality of life.7-12 In a recent study comparing survival rates for 15 “curable” cancers in Toronto, Ontario, and Detroit, Michigan, researchers found that socioeconomic status had no effect on survival for 12 of the 15 cancers occurring in the Canadians. However, patients who were in the lowest economic strata in Detroit had survival rates 40% lower than patients who had greater income did.9 Similar results have been found with heart disease,7 breast cancer,8 and HIV infection,11 and for mortality rates in general across socioeconomic strata.13
It is a common assumption among many US lay persons and clinicians that the increase in mortality among the poor is due to an increase in high risk health behaviors, such as smoking, alcohol and drug abuse, obesity, and sedentary lifestyle. However, controlling for age, sex, race, urbanicity, education level, and health risk behaviors, people in the lowest-income group (family income $30,000 per year) have a mortality rate almost three-fold higher than those in the highest income group.14 This risk is especially high for low-income women, presumably because of inadequate prenatal care.
Despite an unemployment level that is at a 30-year low, more than 44 million people are uninsured, including 11 million children.15 The number of uninsured people grows at a rate of 100,000 people per month. These uninsured people are termed the “working poor”: persons who work in jobs with an income that makes them ineligible for public assistance programs but is insufficient to allow them to afford health care. These are the people who sell us our shirts, our shoes, our fast food, and those who cut our hair. The icon of the middle class—the shopping mall—is staffed largely by the uninsured.
We have a hard time “seeing” these people since they do not walk into our offices. Those who get sick either self-treat or overload our emergency departments. As a result, they become almost invisible to a health care industry in which, despite advances in community medicine, care begins at the time of an office visit.
And so, medical care in America has a seeming incongruity: Americans spend more money on health care than any other people in the world, yet 25% of them do not have adequate care. On the surface we seem to have a free and open system, unlike other countries in which health care is rationed. As we delve below the surface, however, we find that instead of rationing health care, we limit it to those who can afford it.