Thursday, July 3, 2008

The Conference Board: Rank Amateurs with an Agenda? by Steven Lewis

[For the full Conference Board report click here.]

The Conference Board of Canada has published a summary that ranks Canada's health (or is it healthcare, or is it both) as 9th best out of 16 selected rich countries (the least rich is Italy, where the food, wine and climate are so good that it is hard to imagine why anyone so blissfully located would even notice a little less purchasing power). We get a B. The aforementioned Italy, along with Japan, France, Sweden and Switzerland, get As. In a shocking upset, the Americans beat somebody - in this case, get this, Denmark. According to a recent UK survey reported on 60 Minutes, far from being melancholy, the Danes are the happiest people on earth, even though their life expectancy trails ours by 3 years and Japan's by 4.5. Maybe they're too happy to notice. Maybe they have other priorities, like universally free post-secondary education.

As for the A-list, there are two Axis powers (Italy and Japan), and two - Switzerland and Sweden - that stayed out of WW2 (well, 3 if you count France). All 5 are rather social democratic, but so is Denmark. By contrast, joining Denmark on the D-list are Ireland, the UK, and the US. We get a B, but grudgingly, and the Board notes ominously that we are in danger of tumbling to a dreaded C.

Teasingly, the Conference Board released its ranking but not a full-scale report that, one hopes, will, at its promised release in September, reveal the methods, assumptions, and data on which it is based. In polite company this would be termed peculiar; in academic circles, irresponsible and even contemptible; in most of the media (Longwoods of course excepted), as a gift headline story requiring no further work. Based on essentially no information, can we make sense of the Board ratings and rankings?

Tellingly, there are confusions. The lead sentence in the summary is, "Given increasing rates of diabetes and heart disease [this latter is false by the way], Canada has no choice but to adopt a new business model for health care that focuses on both preventing and managing chronic disease." From that a sentient reader would infer that the Board is rating and ranking our health care system. But half-way down, the summary says, "It is important to keep in mind that this grade assesses the overall health status of Canada's population; it is not intended to rank the health-care system (italics mine)." So what's with the new business model for health care if health care isn't being evaluated?

If it's health we're examining, let's look at health. Of the 16 chosen countries, Canada ranks 2nd on life expectancy and 11th on infant mortality - the most commonly used composite measures of health. The Board is alarmed by our relatively high heart disease and escalating diabetes-related mortality rates. OK, but logically, if we're living longer than everyone but the Japanese and if our tickers and pancreases are letting us down, our other organs must be thriving. We have to die of something (perhaps confusion is a leading cause of death at the Board). Why weight some causes over others? There might be a defensible reason, but let us in on it before assigning a number.

Let's compare Italy (A) with Denmark (D). Italy is 7th on life expectancy and 15th on infant mortality rate. Denmark is 15th and 8th respectively. So if we're rating health, not health care, why are these countries at the opposite ends of the scale? The answer, I suspect, is that the Board is conflating elements of both health and health care in its method, and come September we might discover precisely how.

The confusion compounds when we look at the Conference Board's prescriptions for success. The Board correctly points out that the top-performing countries have progressed by addressing the non-medical determinants of health, among them listing: environmental stewardship; health promotion; education; early childhood development; income, and social status. By its own assessment then, social democracy seems to be the pathway to population health, but the Board pointedly refuses to go there. The solutions are "a new business model for health care," "greater receptivity to innovative technologies and health-care delivery systems," better information technology and "new approaches to prevention and management."

I'm a pretty harsh critic of our health care system and advocate a major overhaul. Like the Board, I'm all for investing in health information systems, managing chronic diseases better, and improving accountability. But like anyone familiar with a vast population health literature and a basic understanding of the law of diminishing returns from health care, I know that these measures will not reduce health disparities or greatly improve overall health status. The Board summary is silent on the one element of health care that might make a difference: primary health care reform. Instead it offers up the standard industry tonics of more and fancier gadgets and coded calls for privatization.

Might the Conference Board have an agenda other than improving the health of Canadians? When think tanks promote new business models for health and innovative delivery systems as solutions to problems that on their own analysis originate elsewhere, look for the method in the apparent madness. It's usually a call to feed the beast - the diagnostic imaging and drug manufacturers, the private sector management contractors, the advocates of private and parallel health care systems. It's perfectly legitimate to tout these reforms, but at least do it forthrightly and explain why Canada should choose this route rather than the broader health-enhancement strategies pursued successfully by others.

I'm new to the rating and ranking game, but in the spirit of the Board, I'll give it a go.

Transparency of method: F
Plausibility of ratings and rankings: D
Awareness of factors affecting health: A
Internal coherence: F
Likelihood of prescriptions improving health: F

I'm glad to have the Conference Board in the population health choir, but sad to see its accurate understanding of why some countries are healthier than others dissolve into shilling for industry and solutions destined to raise costs, misallocate resources, and miss real opportunities to make a difference.

No comments: