History is filled with examples of countries that were once the zenith of civilization that then fall prey to decay and waste. The Persian Empire of old was considered the center of civilization, only to fall to an upstart Macedonian and his delusions of grandeur. India and China once controlled more than half the world’s GDP prior to seventeenth century, only to be subjugated in mere decades to enterprising European colonialists.

The lesson is clear – even the mighty may fall over time as conditions change. And those who fail to learn the lessons of history are doomed to repeat it. An adage as old as time, yet one that remains ever relevant.

Especially for the United State’s healthcare system, which was ranked as the worst performing healthcare system in an evaluation by The Commonwealth Fund that compared the healthcare systems of eleven high-income countries.

For a country with a cultural obsession of coming in first place, last place is tough. A circumstance made more difficult by the fact that we spend the most money – the greatest percent of our GDP – on healthcare when compared with other high-income countries.

There is nothing more American than trying to win at something by throwing money at it. This means despite trying to be the best healthcare system, we came in dead last.

The evaluation compared seventy-one metrics across five categories, ranging from access to care, care process, administrative efficiency, equity, and health care outcomes. The top performing countries are Norway, the Netherlands, and Australia.

According to the report, there are four features separating the top performing countries from the United States:

1) Providing for universal coverage and remove cost barriers

2) Investing in primary care systems to ensure that high-value services are equitably available in all communities to all people

3) Reducing administrative burdens that divert time, efforts, and spending from health improvement efforts

4) Investing in social services, especially for children and working-age adults

It concluded by ranking the United States last on access to care, administrative efficiency, equity, and health care outcomes, but second on measures of care process.

This incongruity revealed how the United States can adjust its healthcare system, to be more cost-effective, to provide better care for its patients, and to be just overall better.

For everything negative that was conveyed in the report, there was one positive – we like to measure healthcare, and develop metrics around the quality of care.

In the past, this tendency has been criticized, but our urge to quantify is not necessarily wrong. We simply need to adjust what we measure and quantify.

Instead of focusing on traditional metrics in isolation like discrete patient outcomes or healthcare utilization, we should study the perceptions of care relative to the traditional metrics. Make healthcare a ratio, a measurement of perceptions of care relative to outcomes of care.

When seen in this vein, healthcare focuses less on data sophistication or technological advancement, and more on the patient outcome – from the perspective of the patient being treated.

It does no good to cure a patient of cancer with the latest chemotherapeutic agents, but then bankrupt the patient in the process. The perceptions of care must balance with the outcomes of care.

From that perspective, healthcare is a ratio, balancing utilization of care relative to the perceptions of that utilization.

It does not matter how effective an anti-hyperglycemic drug can be if the patient does not see value in taking it.

A patient’s perceptions, the underlying implicit biases all patients hold, affect healthcare utilization, which affect the cost of care, and therefore the overall quality of care.

Yet capital markets in the United States measure the market sizes of different diseases daily, correlating drug prices with stock value – effectively benchmarking the value of a drug to its cost.

Instead we should study financial decisions made by patients relative to patient outcomes, since the true value of the drug comes not from the cost of the drug, but from the utilization of the drug.

Utilization is as much a perception as it is an outcome. Something may be effective, but if it is not perceived to be effective, it is useless. The same applies to healthcare.

An artificial intelligence data platform is of no good if patients are not compliant, or if the predictive analytics warning of an impending complication are ignored.

Rather than study healthcare utilization in purely objective terms – hard clinical outcomes or financial metrics – study the subjective perceptions in context of the more traditional metrics.

It is a slight change, but a massive paradigm shift in how we value healthcare. We measure the value of a diabetic drug by the change in blood glucose levels, not by patient compliance. Yet true value is a combination of both.

Therefore we should study these perceptions within the context of healthcare behavior, and how that behavior affects healthcare outcomes – study how grit, or social anxiety influence diabetic compliance. Healthcare utilization is best understood in this way, as a ratio.

This would provide a more realistic approximation of the value gleaned to the patient – and therefore, the value to the healthcare system as a whole.

As it currently stands, healthcare in the United States is inefficient, and embarrassingly bad at improving patient outcomes despite the financial investment made.

We are like the civilizations of lore, perceiving our healthcare to be the best, yet unable to acclimate to our own shortcomings, suffering year after year with worse than expected patient outcomes – yet we continue to pour more and more money, thinking we are solving the problem when we are merely reinforcing it.

And like those civilizations, we will eventually succumb to our shortcomings, unless we change our understanding of healthcare utilization – all it takes is a shift in perception.