Friday, July 4, 2008

The Conference Board Answers Steven Lewis by Anne Golden

We at the Conference Board of Canada are avid readers of Longwoods publications and newsletters. We were very surprised after reading the essay prepared by Steven Lewis that appeared on the July 1 e-letter. His essay, titled The Conference Board: Rank Amateurs with an Agenda?, left us perplexed by its snarky and unprofessional tone, its limited ability to appropriately interpret the data presented in the summary, and its poor understanding of benchmarking methodologies—which, by the way, is one of the Conference Board’s core competencies. We have been involved in benchmarking projects for over a decade, and have been hired for our benchmarking expertise in countries such as Australia and Ukraine.

As Mr. Lewis appropriately pointed out, we did not release a full-scale report. What was released on June 30 is, in effect, an executive summary. However, the methodology and list of indicators are included on the website (under Methodology and Details and Analysis, respectively). The rankings and a full analysis of each indicator will be added to the website in September. At that time, a section will be added to the methodology with full details on data sources.

When the Conference Board talks about “health” in the report card, we are talking about “health status”. It is therefore appropriate to make recommendations about the factors that affect our health status—such as the health care system and lifestyle choices. The purpose of the health category in the Report Card on Canada is to assess the health status of average Canadians. We have chosen to include and rank diseases that are the top burdens in Canada. We think that this approach is more appropriate than ranking diseases which do not affect many Canadians. So, for example, we do not include mortality due to malaria. While it may be a health burden in many countries, it is not in Canada.

Mr. Lewis was puzzled by results from Italy (A) and Denmark (D) given that the two indicators he pointed out (life expectancy and infant mortality) were on opposite ends of the scale. Having him be more thorough to review the list of indicators on the web site under Details and Analysis, he would have seen that in addition to life expectancy and infant mortality, there are eight other indicators. Denmark does worse, relative to Italy, on six of these indicators.

Mr. Lewis rightly pointed out that our inclusion of heart disease in a sentence about the increasing rates of chronic diseases, like diabetes, was incorrect. We have made a correction to the website.

We agree with Mr. Lewis that there is undoubtedly an alignment between progressive democratic systems and health outcomes, and we have done work on this subject. However, this report only focused on the examination of 10 health status indicators. In this phase of the research we did not analyze the factors influencing this ranking. However, this will be the purpose of an upcoming phase of this project after the September release.

We also agree with Mr. Lewis that primary health care reform is essential if we want to make a difference—we raised this issue in last year’s report card. Primary health care reform will undoubtedly be referred to again when we expand on the Overviews in the September full release. The Conference Board has been consistently supportive of the publicly-funded health care system and a strong supporter of primary health care reform. In fact, we have provided support to federal and provincial governments over the past few years to advance primary health care in this country and primary health care issues have been studied in depth in several other Conference Board publications. For Mr. Lewis to suggest otherwise is irresponsible and disrespectful.

We are the foremost, independent, not-for-profit applied research organization in Canada. We are objective and non-partisan and we do not lobby for specific interests. Our only agenda is to improve the health of Canadians. The Report Card on Canada clearly states that its overall goal is to assess Canada’s quality of life relative to peer countries, and that “Most Canadians would agree that without health, quality of life is severely compromised.” All of our work in the health care field has one goal—to improve the health, and by extension the quality of life, of Canadians. We are proud of our achievements and firmly believe we are contributing to a better Canada. By exposing Canada’s weaknesses, we aim to bring increased focus to these areas for improvements.

Anne Golden is President and Chief Executive Officer of The Conference Board of Canada.

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.

Wednesday, July 2, 2008

Big cancer bills covered

The Ontario government is set to spend an additional $50 million for greater access to three expensive cancer drugs, sources told the Toronto Star.

Of the three, Avastin may be the best known to Star readers thanks to a front-page story published two years ago yesterday. Reporter Tanya Talaga introduced readers to Esther Hart, a mother of one who succumbed to colon cancer in April 2007 at the age of 39.