Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute, published an op-ed in the Wall Street Journal last week that returned to the much-exploited story of Nataline Sarkisyan, the 17-year-old Californian who died before receiving a liver transplant. Gottlieb used the story to make the argument that “the U.S. has the best health care in the world.”

Gottlieb is squaring off against John Edwards, who has been suggesting that if Nataline had lived in a European country she might have lived.  Edwards blames CIGNA, her for-profit insurer, for refusing to cover the procedure. Dr.  Gottlieb, who is a former FDA official, responds with a double-barreled argument: “Americans are more likely than Europeans to get an organ transplant, and more likely to survive it too.”  He sounds confident, and at first glance, his argument seems persuasive.

But a closer look reveals that Gottlieb makes his case by carefully culling the numbers that fit his argument, while omitting those that don’t. Unfortunately, too many people involved in the healthcare debate play fast and loose with the facts. Everyone interested in reform should be on the look-out for those who don’t cite solid evidence for their assertions. If they don’t give you their source, it may be because they don’t want you to look it up—and because they realize that they are cherry-picking the numbers.

Before engaging Gottlieb’s argument, I should acknowledge that, as I have said in an earlier post, I think Edwards has picked a bad case to make his argument for healthcare reform. I am not at all certain that the transplant would have helped this particular patient.  And while Edwards puts all of the blame on CIGNA, Nataline’s insurer, I am bothered by the fact that the hospital asked for a $75,000 down payment on the surgery and then refused to go forward without it. As one physician/blogger from the very same hospital where Nataline was treated asked: “Why didn’t the hospital simply perform the surgery and defer payment from the family or CIGNA [Nataline’s insurer] until later? If it was such a great idea, why didn’t they exhibit the outrage and strength of conviction to go ahead regardless of CIGNA’s assessment?” 

That said, I agree with Edwards and other proponents of health care reform that, in other countries, decisions about whether or not to pay for expensive procedures like transplants are not based on whether the patient has the money or the insurance to pay for the operation. Instead, in other developed countries, such decisions turn on whether the benefits of the treatment outweigh the risks—and whether the procedure is cost-effective.

After all, in every country (including the U.S), we all pay for
high-priced procedures, either in the form of spiraling insurance
premiums or steeper taxes.  Thus, it makes sense to ask: “if we go
ahead with this procedure, are we wasting resources on a futile
treatment, or using money that could be used for the preventive care
that would extend other lives?

Following this line of thinking, European countries put more money into
preventive care and are less likely to give liver transplants to
patients who are seriously ill—or appear close to death.  Gottleib
himself points out that a 2004 study published in Liver Transplantation
shows that “no transplant patients in the U.K. were in intensive care
before transplantation, one marker for how sick patients are, compared
with 19.3% of recipients in the U.S. . . . On the whole,” he notes,
“the U.S. also performs more transplants per capita, giving patients
better odds of getting new organs…In 2002… U.S. doctors performed 18.5
liver transplants per one million Americans. This is significantly more
than in the U.K. or in single-payer France, which performed 4.6 per
million citizens, or in Canada, which performed 10 per million.”

But– is the fact that we perform more transplants on sicker patients proof that we have a superior healthcare system?

Here, let me acknowledge that Dr. Gottlieb is generally more
enthusiastic about experimental, long-odds medical treatments than I
am. As the Seattle Times pointed out,
when Gottlieb was appointed to  a  high-powered job at the FDA in
2005,  he came to the agency from Wall Street, where he “promoted hot
biotech stocks to investors. Now Gottlieb holds the No. 2 job at the
federal agency . . . that approves new drugs, oversees their safety and
affects the fortunes of companies he once touted. Wall Street likes the
appointment of Gottlieb, 33, who believes in faster drug approval and
fewer news-release warnings to the public about potential side effects
of drug,” the Seattle paper observed. “But some medical experts are
shocked by his July 29 appointment, coming at a time when the public is
increasingly concerned about the safety of popular medicines.”  (When
Gottlieb left the FDA he returned to the American Enterprise Institute
and started the Forbes / Gottlieb Medical Technology Report.)

Returning to my question: Is the fact that we perform a greater number
of transplants on seriously ill patients reason to claim that U.S.
health care is “superior”—or does it simply mean that we are more
inclined to experiment on our sickest patients?

It all depends on how well the average patient who is plucked out of
the ICU to undergo a liver transplant fares.  If he or she goes on to
enjoy several years of high quality life, one would be inclined to say
“yes”—our more aggressive care equals better care.   But if too many
patients suffer complications and then die in great pain twelve or 15
months later, it would be much harder to argue that “doing more” makes
U.S. healthcare “better”—especially when both the money and the liver
could have been spent on another patient who had a better chance of
surviving.

Gottlieb realizes that everything hinges on outcomes. And so he points
to “one recent study” which  “found that patients’ five-year mortality
after transplants for acute liver failure, the type from which Ms.
Sarkisyan presumably suffered, was about 5% higher in the U.K. and
Ireland than the U.S. ”  Moreover, he observes, “the same study also
found that in the period right after surgery, death rates were as much
as 27% higher in the U.K. and Ireland than in the U.S., although
differences in longer-term outcomes equilibrated once patients survived
the first year of their transplant.”

Wait a minute—what is he saying in the last part of that final
sentence: “differences in longer-term outcomes equilibrated once
patients survived the first year?”   

“Equilibrated” is a not a verb I would normally choose to use. It’s
just one of those very ugly words that fairly bristle on the page; you
know there must be a simpler, clearer way to say whatever you are
trying to say. And indeed there is. “Equilibrated” means “came into
equilibrium” or “canceled each other out.”  In other words, Gottlieb
seems to be saying, once patients survived the first year, the
differences between outcomes in the U.K. and the U.S. disappeared.

When people use $10 words that are hard on the ear, I become suspicious
that they they’re trying to hide behind jargon. I also was bothered
that Dr. Gottleib didn’t name the journal where the outcomes study was
published.  In the preceding paragraph where he talked about how many
more liver transplants the U.S. does, he did cite his source (“a study
published in 2004 in the journal Liver Transplantation.”) Why didn’t he
name his source when contrasting outcomes? 

I decided to do a little research. It turns out that Gottlieb is referring to research that appeared in GUT online,
a journal published by BMJ (formerly the British Medical Journal), on
March 13, 2007 comparing survival rates for transplant patients in the
U.K/Ireland to outcomes for patients in the U.S. (Patients in the two
groups were similar in term so age, gender and race and the comparisons
adjusted for risk.)

By reading the study I discovered what Gottlieb had left out. First,
the researchers looked at how the patients were doing at three points
in time: during the 90 days immediately following the transplant, one
year after the transplant, and five years after the transplant.
Secondly, they followed patients suffering from two types of disease: chronic liver disease and acute liver disease.

Begin with how the patients were faring during the first 90 days. As
Gottlieb points out, during this time, mortality rates in the U.S. were
lower (regardless of whether patients had originally suffered from
acute or chronic liver diseases.) This is, in large part, the article
suggests, due to lower nurse/patient ratios in the U.S. and more
intensive care during the first weeks following surgery.

But what Gottlieb omits is the crucial fact that, when the researchers
went back and  looked at “patients who survived the first
post-transplant year,” they discovered that  “patients who had suffered
from chronic liver disease in the U.K. and Ireland had a lower overall
risk-adjusted mortality” than patients in the U.S.  In other words, survival rates for patients who had a chronic disease before the transplant  were better in the U.K. and Ireland. As for patients suffering from acute liver disease, longer-term survival rates past one year were just as good in the U.K. and Ireland as in the U.S.
Moreover, if you checked patients in the interval between 90 days and
one year, outcomes were similar in the two health care systems.

So “equilibrated” wasn’t just a dodgy piece of jargon; it was
inaccurate. When researchers checked on  patients more than a year
after they had the transplant, outcomes in the U.K/Ireland and the U.S.
weren’t in perfect balance (or in equilibrium) with results in the
U.S.  Outcomes in the U.K./Ireland were just as good for one group and decidedly better for the second —assuming
that if you go through the trauma of a liver transplant, the outcome
you are hoping for is to live more than a year, rather than just 90
days.

Why is chronic care better in the U.K. in the years following surgery?
Because the “primary care infrastructure” is stronger in the U.K. and
Ireland, the article explains. Add in the fact that patients have
“equal access” to health care and that the cost of care is “lower,” and
this helps explain superior long-term results.  As the researchers
point out, “the 2002 Commonwealth Fund International Health Policy
Survey found that sicker adults in the US are far more likely than
those in the UK to forgo medical care and fail to comply with
recommended follow-up and treatment because of costs. In the U.S., it
seems, outcomes tend to turn on whether the patient has money.

Finally, what about outcomes after five years? What Gottlieb forgot to
mention is that survival rates for patients who had originally suffered
from chronic liver disease were similar in the two countries, while
mortality rates for patients suffering from acute liver disease were
higher in the U.K. and Ireland.

But when summing up their findings, the researchers underlined the
importance of survival rates during the first 90 days and after one
year. “These results highlight interesting differences between two
health systems funded by entirely different mechanisms," one of the
report’s authors told Reuters Health.
"A predominantly privately funded healthcare system, such as the one in
the United States, was demonstrated to have a better short-term outcome
for liver transplantation, but a system of universal publicly funded
healthcare, as in the U.K. had a better outcome after the first
post-transplant year."

"Our results therefore could have important implications for health policymakers in those countries and beyond," he concluded.