What does ‘best’ mean in health care?

Filmmaker Suzanne Garber explains how quality, accessibility, affordability and transparency mean the best health care in the world

We know what makes a ‘best hotel’. We know what makes a ‘best teacher’. And we know what makes a ‘best friend’. But do we know what ‘best in health care’ is?

Filmmaker, author and two-time cancer survivor Suzanne Garber does.

“People don’t think about it enough,” she explains in her warm energetic voice. “We spend longer reviewing which restaurant to eat in than which doctor or hospital to use. One is a potentially life-changing decision. And one is lunch. It’s crazy.”

Suzanne serves on the boards of several for-profit and humanitarian organizations. As part of her work she speaks at international conferences on topics; including medical and security networks and globalization. 

Her first documentary film, GAUZE: Unravelling Global Healthcare draws on the experience of being a cancer survivor, dual-nationality and living in eight countries of the 101 she’s visited. Aetna International spoke to Suzanne to answer the question: what is ‘best’ in health care, regional differences in perception of ‘best’, and, more importantly, the effect of regional differences in access to ‘the best health care’.

What is ‘best’ when it comes to health care?

Health care can be judged on three criteria:

• quality;
• accessibility (including affordability); and
• transparency (pricing and outcomes).

The best health care will score highly in all of these areas. I see it like a three-legged stool; if one leg is missing, the whole thing falls down.

The best health care is also holistic: looking at whole lifestyles, nutrition, mental health, exercise and a whole range of factors. This is more prevalent in the Far East where they see people as a whole — not just a set of symptoms. In US medical schools, aspiring physicians are taught to look for symptoms to define diseases, not the individual holistically with every symptom combined. In fact, 250,000 people die due to medical error in the US.*

[*Source: Johns Hopkins’ Dr. Marty Makary study in the British Medical Journal (May 2016)]

The relationship between provider, physician and patient also has an effect.

Part of your job has been to vet the credentials of hospitals around the world. In your expert opinion, where is ‘the best’ health care?

Nowhere is perfect. I’ve been to 101 countries and there’s no one place that offers perfection in all three areas: transparency, accessibility and quality.

Singapore is good, but they do lack some transparency around outcomes.

France has an exceptional system, as does the UK. There are issues around waiting times but compared to other countries it’s not that bad.

India has decent accessibility, but the quality is lacking in some places. If you have money you can always access quality — but that means there are disparities.

The problems of defining ‘the best’

We talk about ‘the best’ in everything — the best holiday, the best cup of coffee, the best night’s sleep. But we don’t do that with health care. You never hear anyone say, ‘I have the best primary health care physician’, ‘I had the best colonoscopy’. We determine what we wear, what we eat and our hair style. We define everything in our life, except health care. Is it because we don’t know how to define it, is it because we allow other people to define it for us? And if that’s the case… why?

I recently spoke as part of a panel of experts at a university, and I asked the audience: ‘how do you define best in health care?’ And they didn’t really know. We find it hard to define what best is because we’re not used to thinking like that as it’s often easier to assign that responsibility to other people.

We expect what the system gives us. With health care, many patients accept whatever the norm is in that country. You don’t see a lot of grassroots movements in health care — as you do with civil rights. Which brings up the question: is health care a civil right? There’s lots going on about sexual harassment and gender equality, racial right, LGBTQ rights. Health care doesn’t seem to have drawn the same focus. And especially seeing as this is something that can be a matter of life and death, how come we don’t take it more seriously, more personally — and demand better?

We should determine what ‘best’ means to us, but we need to be educated to do that.

Are there regional differences when it comes to the perception of what ‘the best health care’ is?

It depends who you ask. People’s expectations vary from place to place. For example, in India, health care quality is questionable, but access is relatively good.

People’s expectations vary within countries: those who live in urban areas — London, Delhi, Shanghai — expect to be seen quickly because facilities and clinicians are close. Those in rural areas expect to have to travel or wait, so their ideas of what is ‘good’ is different.

People are accustomed to their own environment and societal set up. And so they base ‘best’ on their own experience. I know many people who complain in the UK about waiting lists — sometimes of up to 12 weeks to see specialists — but the quality of that care is very good.

What is the global impact of disparities in health care provision?

One impact is the rise of health tourism — people travelling for health care because they are lacking one of the three primary tenets of health care in their own country.

Cost

Maybe it’s too expensive. America is an example of this: there’s great health care and you can access it, it’s just too expensive. It’s the number one reason Americans travel for health care. We interviewed many Americans receiving care in Latin America or Thailand and this was their primary reason for going abroad.

Transparency

Transparency is the most overlooked aspect of health care quality, and I experienced this issue in the US first-hand. I had power of attorney for my mother’s recent surgery and we requested a breakdown of costs prior to undergoing the surgery. It took four hours to produce a list of costs and a final bill as no one knew how much it would cost. Four hours! For someone who is self-paying or without access to PMI — signing a waiver before you know costs is a red flag. You don’t know what you’re signing. This is a strong driver for those Americans travelling to Costa Rica, Colombia and Mexico for treatment.

Waiting lists

Or maybe you’re avoiding a 12-week wait (like in the UK or Canada where quality is good, but access is missing). In some cases, it might be cancer or a heart issue with an immediate need for treatment.

Quality

Or maybe there is a lack of quality. Many underdeveloped countries see people travelling to UAE, South East Asia and Europe. Those who have the money want to access quality not present at home. Often there’s a lack of confidence in local health care: it’s there and it’s affordable, but citizens don’t trust the quality.   

Ambiguity

I would say that ‘medical tourism’ has a debated definition. What it is gets murky. People crossing a border for teeth whitening or plastic surgery, is that medical tourism? People travelling for IVF, is that medical tourism?

The definition can be very narrow or very broad and there is a lack of concrete numbers. Some countries, like Cuba, catalogue entries for medical reasons while others — like the US — don’t. If governments mandated ‘medical’ as a reason for entering a country it would help to clarify how many are visiting for medical reasons and we could more accurately calculate the financial impact on the economy.

There is a relationship between doctor training, affordability and accessibility. Which countries have the best balance of this and how do they work?

There was a New York Times article in September 2017, called The Best Health Care Systems In The World: Which One Would You Pick? They created a tournament to judge which nation had the best health care (Canada, UK, Singapore, Australia, Switzerland, France, Germany or the US). Switzerland came top with France second. They’re both very different systems.

Switzerland offers private pay mandated through government taxes; you must get health care and do it through an exchange where you can purchase it. Everyone has to pay for it and there’s more choice.

In France, there is minimal choice. It’s a single-payer system for the majority, with a small number of people purchasing private insurance. The two systems are very different from each other but they both offer accessibility, quality, affordability and transparency.

If you have a private medical plan — with someone like Aetna — then you’ll have a choice from a big network. But if you don’t your choices will be limited.

But there are problems with these systems. I don’t like to get political, but it must be said that these systems can’t continue at current output with increased utilization from those unable to contribute to the tax system, which is how many healthcare systems are set up.

What changes to health care can we expect in the next 10 years? And what is the role of technology (wearable tech, virtual health etc) in changing what constitutes ‘best’ in health care?

People are becoming interested in their own health from a performance or aesthetic point of view, and [consumer] technology is facilitating that. People want to take care of their health over the long-term and tech is playing a key role in educating them.

Wearables and electronic medicine is on the rise and telehealth is huge! There will be fewer people going to actual doctors. This will cut costs for providers, but we will lose some of that doctor/patient relationship… but that’s a sign of the times. Millennials form relationships, they just do it in a different way. Children (I don’t have my own children. We care for our nephew and nieces - it’s complicated) sit in the back of the car — not talking, just giggling, because they’re texting each other. While some generations may prefer face-to-face appointments, younger people prefer to do things online.

Whether you’re buying a car, a home or stocks and bonds, knowledge is power. Information about our steps or cholesterol can only lead to greater engagement, increased personal accountability and the ability to take positive steps. That said, privacy issues are a challenge.

People are becoming more aware of health care. Maybe it’s age… you hit 40 and you start to care about your health. But the information is more accessible, so people can find out.

Challenges

Having been a cancer and congenital heart defect survivor, I have become an educated consumer and an advocate for my own health. I’m at an age and stage where your sense of mortality kicks in and you become aware of the workings of your health care systems.

What needs to change is young people need the impetus to find out. They need to build a healthy lifestyle earlier, so that it’s not a problem when they’re older. In your 20s you think you’re invincible, but you shouldn’t have to wait for a life-changing experience to have that consideration, as I did when I was diagnosed with ovarian cancer only six weeks after getting married.  Access to information will play a role in driving younger generations to engage with their health earlier.

While technology has a role in improving accessibility and reducing costs, there is a risk that we lose the important doctor/patient relationship (personal history) and that health care becomes transactional and utilitarian. The key challenge is to provide remote access to quality care while retaining a holistic view of individual circumstances.

What is your call to action for health care providers and those facilitating care, such as insurers and brokers, employers and governments?

I would say three things:

• Educate. This is the number one responsibility for every patient. Find out about the quality of the facility, the clinicians. Research the costs involved in your treatment.
• Champion. Be a champion for others and for yourself. It might be difficult for an individual to grasp the consequences of a situation, so you can be another voice or set of ears for someone else. And, seek out that support if you are in that situation.
• Advocate. There is a lot of passive acceptance in systems – we just say ‘ok’ when someone suggests something because we don’t know any alternative or any better. Advocate for increased transparency and accessibility. We recently created a Change.org petition for transparency in health care pricing that mandates health care providers must proactively furnish patients with total costs prior to service. The petition can be signed here.

About the film

In her film, GAUZE: Unravelling Global Healthcare, Suzanne compares and contrasts health care around the world by visiting 174 hospitals and talking to 65 international health care experts in 24 countries. “My journey was a quest for the best, because I didn’t know I could trust my own judgment on what was best.”

Read more about the film and watch clips at www.gauzethefilm.com/

Conclusion: Aetna International and the best in health care

The New York Times says Switzerland offer the best health care. Their public poll gave the result: France.

While ideas around ‘best’ in terms of health care can be subjective, there are clear markers of great health care; from affordability and accessibility to the quality of that care and transparency on a range of issues from costs to outcomes.

Suzanne says we need to learn more about what makes great health care, so we can better choose it for ourselves.

How does Aetna International measure up? And how do we ensure the best health care for our members? Our health care plans are very competitively priced, and we offer high-quality health care through our extensive network of hospitals and clinicians, which means you can access care wherever you are, whenever you need.

Aetna International have also adopted an approach that Suzanne says is key to good quality health care: the holistic approach. At Aetna, we call it ‘value-based care’. What does this mean and how does it work? Value-based care means supporting the health and wellbeing of individuals, rather than simply paying for treatment they need. We’re focused on health outcomes via personalised intervention, quality of care and reduction of duplication and waste. Our data analysis enables personalised, precision intervention that helps result in individual participation, building towards longer healthier lives.

Read more about value-based care here.

How organisations benefit

For employers this means getting the best value care for their employees at the best price. Aetna International can provide your employees with access to quality care no matter where they are. Engaged, healthy employees mean lower claim costs — and lower claim costs lead to improved operating margins and better business outcomes.

Value-based care also allows early identification of at-risk members. This in turn means early intervention, care coordination, wellness programmes and condition management combining to keep the health costs of ageing in check.

How employees benefit:

• Interactive health clinics and group coaching programmes keep them healthy
• Data-based identification and intervention help catch problems and risks early, leading to healthier outcomes
• Specific initiatives improve their health by educating, engaging and empowering them
• Chronic condition management can help lessen symptom severity and development of co-occurring conditions
• Peace of mind for themselves and their families when it comes to accessing quality care no matter where they are in the world

Many thanks to Suzanne Garber for speaking to us for this piece.

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