"An International Update on the Comparative Performance of American Health Care"

There's a new report out from the Commonwealth Fund comparing health care across six countries, including the U.S. [link to report, link to over 100 pages of graphs, charts,  and tables]:

Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, The Commonwealth Fund, May 2007, by K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea: Overview Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. This report—an update to two earlier editions—includes data from surveys of patients, as well as information from primary care physicians about their medical practices and views of their countries' health systems. Compared with five other nations—Australia, Canada, Germany, New Zealand, the United Kingdom—the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives. The U.S. is the only country in the study without universal health insurance coverage, partly accounting for its poor performance on access, equity, and health outcomes. The inclusion of physician survey data also shows the U.S. lagging in adoption of information technology and use of nurses to improve care coordination for the chronically ill.

Executive Summary
The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance. This report, which includes information from primary care physicians about their medical practices and views of their countries' health systems, confirms the patient survey findings discussed in previous editions of Mirror, Mirror. It also includes information on health care outcomes that were featured in the U.S. health system scorecard issued by the Commonwealth Fund Commission on a High Performance Health System.

Among the six nations studied—Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States—the U.S. ranks last, as it did in the 2006 and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, efficiency, and equity. The 2007 edition includes data from the six countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care.

The most notable way the U.S. differs from other countries is the absence of universal health insurance coverage. Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term "medical home." It is not surprising, therefore, that the U.S. substantially underperforms other countries on measures of access to care and equity in health care between populations with above-average and below average incomes.

With the inclusion of physician survey data in the analysis, it is also apparent that the U.S. is lagging in adoption of information technology and national policies that promote quality improvement. The U.S. can learn from what physicians and patients have to say about practices that can lead to better management of chronic conditions and better coordination of care. Information systems in countries like Germany, New Zealand, and the U.K. enhance the ability of physicians to monitor chronic conditions and medication use. These countries also routinely employ non-physician clinicians such as nurses to assist with managing patients with chronic diseases.

The area where the U.S. health care system performs best is preventive care, an area that has been monitored closely for over a decade by managed care plans. Nonetheless, the U.S. scores particularly poorly on its ability to promote healthy lives, and on the provision of care that is safe and coordinated, as well as accessible, efficient, and equitable.

For all countries, responses indicate room for improvement. Yet, the other five countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving better value for the nation's substantial investment in health.

Key Findings

Quality: The indicators of quality were grouped into four categories: right (or effective) care, safe care, coordinated care, and patient-centered care. Compared with the other five countries, the U.S. fares best on provision and receipt of preventive care, a dimension of "right care." However, its low scores on chronic care management and safe, coordinated, and patient-centered care pull its overall quality score down. Other countries are further along than the U.S. in using information technology and a team approach to manage chronic conditions and coordinate care. Information systems in countries like Germany, New Zealand, and the U.K. enhance the ability of physicians to identify and monitor patients with chronic conditions. Such systems also make it easy for physicians to print out medication lists, including those prescribed by other physicians. Nurses help patients manage their chronic diseases, with those services financed by governmental programs.

Access: Not surprising—given the absence of universal coverage—people in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans were the most likely to say they had access problems related to cost, but if insured, patients in the U.S. have rapid access to specialized health care services. In other countries, like the U.K and Canada, patients have little to no financial burden, but experience long wait times for such specialized services. The U.S. and Canada rank lowest on the prompt accessibility of appointments with physicians, with patients more likely to report waiting six or more days for an appointment when needing care. Germany scores well on patients' perceptions of access to care on nights and weekends and on the ability of primary care practices to make arrangements for patients to receive care when the office is closed. Overall, Germany ranks first on access.

Efficiency: On indicators of efficiency, the U.S. ranks last among the six countries, with the U.K. and New Zealand ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of the use of information technology and multidisciplinary teams. Also, of sicker respondents who visited the emergency room, those in Germany and New Zealand are less likely to have done so for a condition that could have been treated by a regular doctor, had one been available.

Equity: The U.S. ranks a clear last on all measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick, not getting a recommended test, treatment or follow-up care, not filling a prescription, or not seeing a dentist when needed because of costs. On each of these indicators, more than two-fifths of lower-income adults in the U.S. said they went without needed care because of costs in the past year.

Healthy lives: The U.S. ranks last overall with poor scores on all three indicators of healthy lives. The U.S. and U.K. had much higher death rates in 1998 from conditions amenable to medical care—with rates 25 to 50 percent higher than Canada and Australia. Overall, Australia ranks highest on healthy lives, scoring first or second on all of the indicators.

Summary and Implications
Findings in this report confirm many of the findings from the earlier two editions of Mirror, Mirror. The U.S. ranks last of six nations overall. As in the earlier editions, the U.S. ranks last on indicators of patient safety, efficiency, and equity. New Zealand, Australia, and the U.K. continue to demonstrate superior performance, with Germany joining their ranks of top performers. The U.S. is first on preventive care, and second only to Germany on waiting times for specialist care and non-emergency surgical care, but weak on access to needed services and ability to obtain prompt attention from physicians.

Any attempt to assess the relative performance of countries has inherent limitations. These rankings summarize evidence on measures of high performance based on national mortality data and the perceptions and experiences of patients and physicians. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients' and physicians' assessments might be affected by their experiences and expectations, which could differ by country and culture.

The findings indicate room for improvement across all of the countries, especially in the U.S. If the health care system is to perform according to patients' expectations, the nation will need to remove financial barriers to care and improve the delivery of care. Disparities in terms of access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home. The U.S. must also accelerate its efforts to adopt health information technology and ensure an integrated medical record and information system that is accessible to providers and patients.

While many U.S. hospitals and health systems are dedicated to improving the process of care to achieve better safety and quality, the U.S. can also learn from innovations in other countries—including public reporting of quality data, payment systems that reward high-quality care, and a team approach to management of chronic conditions. Based on these patient and physician reports, the U.S. could improve the delivery, coordination, and equity of the health care system by drawing from best practices both within the U.S. and around the world.

Comments

[bernard Yomtov]

What do you expect from people who have an anti-market bias?

[evagrius]

Fascinating information. I was quite impressed by the lack of IT in the U.S. and Canadian systems.

Ironic, isn't it?

Here's the U.S. bragging about hi-tech and it has a completely paper-driven system.

Must not be a market in it.

[save_the_rustbelt]

There are real problems with the US system, but this looks like a study designed to derive a predetermined result.

Perhaps I am just cynical in my old age.

[Mark Thoma]

I don't like posting studies like that, and I wasn't familiar with the Commonwealth Fund, so before posting I took a look at the Board of Directors (which includes people Republicans are comfortable with, e.g. "Walter E. Massey ... has been president of Morehouse College in Atlanta since 1995 and previously served as director of the National Science Foundation under President George H. W. Bush.") and a description of the researchers.

This was typical:From 1993-1999, Dr. Schoenbaum was the medical director and then president of Harvard Pilgrim Health Care of New England, a mixed model HMO delivery system in Providence, Rhode Island. From 1981–1993, he was deputy medical director at Harvard Community Health Plan in the Boston area, where his roles included developing specialty services, disease management programs, clinical guidelines, and enhancing the Plan's computerized clinical information systems. Nationally, he also played a significant role in the development of HEDIS. He is currently a lecturer in the department of ambulatory care and prevention at Harvard Medical School, a department he helped to found, and the author of over 125 medical publications.

Dr. Schoenbaum is a board member of the Alliance for the Prudent Use of Antibiotics, the American College of Physician Executives, and the Picker Institute. He is also a longstanding member of the International Advisory Committee to the Joyce and Irving Goldman Medical School, Ben Gurion University, Beer Sheva, Israel, an honorary member of the British Association of Medical Managers, and an honorary fellow of the Royal College of Physicians.OrKaren Davis is a nationally recognized economist, with a distinguished career in public policy and research. In recognition of her work, she received the 2006 AcademyHealth Distinguished Investigator Award. Before joining the Fund, she served as chairman of the Department of Health Policy and Management at The Johns Hopkins Bloomberg School of Public Health, where she also held an appointment as professor of economics. She served as deputy assistant secretary for health policy in the Department of Health and Human Services from 1977–1980, making her the first woman to head a U.S. public health service agency.

Prior to her government career, Ms. Davis was a senior fellow at the Brookings Institution in Washington, D.C., a visiting lecturer at Harvard University, and an assistant professor of economics at Rice University. A native of Oklahoma, she received her Ph.D. in economics from Rice University, which recognized her achievements with a Distinguished Alumna Award in 1991. Ms. Davis is the recipient of the 2000 Baxter-Allegiance Foundation Prize for Health Services Research. In the spring of 2001, Ms. Davis received an honorary doctorate in humane letters from John Hopkins University.

Ms. Davis has published a number of significant books, monographs, and articles on health and social policy issues, including the landmark books Health Care Cost Containment, Medicare Policy, National Health Insurance: Benefits, Costs, and Consequences, and Health and the War on Poverty.

She serves on the Overseer's Committee to Visit the School of Public Health, Harvard University; the Board of Visitors of Columbia University, School of Nursing; the Geisinger Health System Board of Directors; and the Columbia Presbyterian Medical Center Advisory Committee for the Center for Women's Health. She was elected to the Institute of Medicine in 1975 and has served two terms on the IOM governing Council (1986–90 and 1997–2000). She is a past president of the AcademyHealth (formerly AHSRHP) and an AcademyHealth distinguished fellow; a member of the Kaiser Commission on Medicaid and the Uninsured; a current member of the New York City Mayor's Commission on Women's Issues, and a former member of the Agency for Healthcare Quality and Research (AHRQ) National Advisory Committee.But I can't say a lot more than that.

[An ICU perspective]

Critical Care medicine, which is the US generally surpasses the world is expensive.

The expense is made worse by several things. I might be putting myself out of a job by telling you this.

1-Make more physicians. Notice I say make more, not lower quality. A layering of specialist pseudo-physicians has developed in North America as the cost of becoming a physician is such, that it does not make sense for one to go into an unprofitable area, even if altruistic. This pseudo-physicians still need a physician supervision. These are Nurse Anesthetist, Nurse Practioner, Physician Assistant, Respiratory Therapist. - Many of the above names don't exist outside of North America, because a physician specialist does it. -- So make medical education FREE, encourage people to go into medicine for the challenge and altruism and you do it with a ZERO loan balance.

2- Life is precious, but really - a 95 year old grandpa, with no functioning kidneys, brain, lung, immune & hearts to match so he can live to 95 and 5 months at $5K a day, and the creation and spreading of multiple antibiotic resistant organisms (MRSA, C Diff, Klebsiella, VRE) to the rest of the population, because of giving the required antibiotics to keep grandpa alive ensures that the organism do as evolution ensures they do -develop resistance to their killer. Somebody or something has to make FORCEFUL decisions to end care. Families sometimes do, most even if they patient have a written request, do not tend to do it, because of guilt. In Europe ( I hear the hisses already) the medical community makes the decision. We need a medical parking meter or magic 8 ball.

The above are 2 things that would help ensure a much efficient & cheaper system. The rest are technology, prevention, research and other things people have already talked about it.

[mrrunangun]

Sorry Mark, but a Harvard Pilgrim doctor and a Brookings economist ought not to be assumed free of bias in the direction of the report's conslusions. Quite the contrary IMHO.

[Mark Thoma]

Editorial Policies and Processes

The Commonwealth Fund is a private foundation that supports independent research on health care issues and makes grants to improve health care practice and policy. It also has a lengthy history as a professional publisher, developing and publishing books, reports, and other material dating back to 1924.

The Fund produces more than 100 reports, issue briefs, and other professional and scholarly publications each year. The Fund no longer uses traditional printing and mailing to produce and disseminate its publications; all are posted on the Fund Web site and are available free of charge to any interested parties. These publications are written by Fund grantees, staff, and invited expert authors from the health policy community. In addition, Fund staff and grantees author dozens of articles published in the peer-reviewed literature each year.

The Fund employs a professional staff of editors who oversee the report development and production process. All Fund publications undergo an internal peer review and quality assurance process; a substantial number, including all staff-written reports, also undergo independent external peer review. This process, similar to that undertaken at major scientific journals, is designed to ensure that Fund publications are authoritative, credible, complete, balanced, timely, and based on appropriate data and evidence. Neither staff- nor grantee-written reports are guaranteed publication if they do not meet the Fund's quality standards.

Many of the Fund publications, such as journal articles and issue briefs, are indexed in PubMed, the National Library of Medicine's database of major biomedical publications. Commonwealth Fund reports are in the NLM Catalog. Unless otherwise noted, views expressed in Fund publications are those of the author(s) and not necessarily those of the Fund or its directors, officers, or staff...

[rana]

The reports conclusions should be unsurprising. The very basic data agreed to by all would argue that the U.S. system must rank quite low.
--We spend a lot more money and have lower life expectancies.
Now perhaps we are genetically inferior or lead less healthy life styles and thus the huge additional dollars in the U.S. is needed to even get the poor outcomes that we have. But, I doubt that genetic differences account for much as we have common ancestors. As to healthy life styles, we smoke less, but are fatter--a toss up?
Given the spending differences, the burden of proof is on the supportors of the U.S. system to show that there are valuable returns. Having lived in France for three years, I would say that the only advantage to the U.S. system is better art and more modern facilities. I don't think that either factor is important for health care.

[dissent]

YES: we spend more money and get lower life expectancies. Thank you, rana.

It's discouraging, how many people resist the facts when it comes to our privatized system versus nationalized health care. The influence of ideology on reality perception is exposed for all to see, yet it stubbornly persists. Those of you who by ideology resist this by now obvious point (that nationalized systems deliver superior public health), I wonder how many had to die before you got over the neo-con ideology that led us to war in Iraq?

And this IS an issue where life is at stake.

For heaven's sake, people, the NSF did a study that found that 17,000 Americans die every year solely because they lack insurance.

[Fred]

"Based on these patient and physician reports, the U.S. could improve the delivery, coordination, and equity of the health care system by drawing from best practices both within the U.S. and around the world."

Good grief, someone got paid to write such drivel?

[Outside the Box]

ICU...Make more physicians.

Yes. Supply and demand. Shortage of physicians equals more pay per physician. The medical lobbies thus pressure politicians to make too few doctors. 1/3 of US doctors were trained overseas, and still we have shortages. Many youngsters aspire to doctor people, but are prevented by politics. Many competent foreign trained doctors aspire to practice in the US, but are prevented by politics.

Regulations that produce artificial physician shortages are only the tip of the regulatory iceberg:

...the total cost of health services regulation exceeds $339.2 billion. This figure takes into account regulation of health facilities, health professionals, health insurance, drugs and medical devices, and the medical tort system, including the costs of defensive medicine. Moreover, this approach allows for a calculation of some important tangible benefits of regulation. Yet even after subtracting $170.1 billion in benefits, the net burden of health services regulation is considerable, amounting to $169.1 billion annually. In other words, the costs of health services regulation outweigh benefits by two-to-one and cost the average household over $1,500 per year.

The high cost of health services regulation is responsible for more than seven million Americans lacking health insurance, or one in six of the average daily uninsured. Moreover, 4,000 more Americans die every year from costs associated with health services regulation (22,000) than from lack of health insurance (18,000).

Cato Health Care Study

[reason]

OTB...
Why is this problem so much worse in the US than elsewhere? (Is there a study from somewhere more reputable than CATO?)

I don't disbelieve you by the way - I think you are probably right as far as it goes, but it is just part of the problem - and I happen to think for emergency information reasons some sort of regulation is needed.

[Outside the Box]

Nations with national health care are motivated to regulate in an organized manner. The gov has to pay for the costs of all regulations, so this imposes some discipline in choosing regs. In the US, the gov regulates, but someone else pays most of the cost of the regs. Politicians don't have to be as concerned with which regulations are actually efficient.

I agree that some regs promote efficiency and the general welfare. My point is that efficient regs should be kept, or even expanded. Inefficient regs should be dropped. The current chaotic mess where half the regs promote inefficiency is no longer affordable to the nation. If the report is correct, inefficient regs are actually killing people, as well as wasting resources.

The two ways to go are to remove inefficient regs so the free market can impose some efficiency on the sector, or centrally plan health care in a more orderly fashion like all other advanced nations. US regs now seem to be enacted in almost a random manner, with half of them helping, and the other half harming.

[reason]

OTB US regs now seem to be enacted in almost a random manner, with half of them helping, and the other half harming.

I think your political is badly in need of reform. Having the legislature separate from the the administration is a bad idea - power without responsibility (only France, the US - both founded in 18th Century revolutions and tinpot ex-dictatorships) have that sort of system.

That's why you have piecemeal, lobbyist written law.

[real person from the real world]

Not only does limiting access to medical education keep physcian salaries high, but the costs of procedures are determined regionally, by the medical establishment, based on incomes/salaries. That also helps explain why physcians choose to live in urban areas where incomes are high, rather than rural areas that lack medical facilities and physicians. Engineered costs in pharamceuticals also keeps costs high, as well as insurance middlemen who bleedoff their cuts.

[johnchx]

The poor relative performance of the U.S. is no surprise, but I was surprised to see Canada's poor showing. Of course, this is a ranking, not an absolute scoring, so somebody had to be "second-worst."

I'd be interested in seeing some sense of how large the differences between these countries is (which rankings can't tell us).

[maria]

Too bad France was not included. It seems better in some things at least than the UK. I understand many UK patients who need care without long delays go to France for treatment.

[maria]

Sorry I forgot the link:

http://news.bbc.co.uk/2/hi/health/6660665.stm

[Lafayette]

MM: The area where the U.S. health care system performs best is preventive care, an area that has been monitored closely for over a decade by managed care plans.

Oh? Really?

With obesity a declared pandemic in the US, what preventive care is being taken?

The pattern of obesity is the same the worldwide:
1) People have become couch potatoes watching food TV commercials, which should be forbidden as much as cigarette commercials,
2) They don't know how to eat, confusing quantity with quality,
3) They are moving into sedentary vocations and out of the fields (where they expend energy physically) and they don't exercise.

As regards America, with 60% of the population overweight and nearly a third obese, I should think some preventive care was imperative. (Quick, someone announce that al Qaida has poisoned the entire supply of potato chips!)

[me]

what rana said.

As an example of market stupidity I want to hear the defense of this. I have eye glasses insurance. Included is an annual exam. I am diabetic so for a decade that has included flashing a light on my retina looking for damage. This time I had to see a different doctor who said he wouldn't do it because that is a medical procedure (30 seconds mind you) and I would have to make a medical appointment to get checked. So, there is another $75 visit to pay. What bullsh*t. That makes people not do things and then when conditions get worse it is really expensive.

But that is the US system. Milk every nickel out for the "market". Don't' invent new drugs, just change the patent so there are no generics. Or just pay the generics not to make it.

More money with worse outcomes, it is indefensible.

[Isabel]

"The area where the U.S. health care system performs best is preventive care, an area that has been monitored closely for over a decade by managed care plans."

I was surprised, too. It seems counterintuitive, if you consider the high numbers of uninsured.

[Noni Mausa]

johnchx: The poor relative performance of the U.S. is no surprise, but I was surprised to see Canada's poor showing. Of course, this is a ranking, not an absolute scoring, so somebody had to be "second-worst."

I'd be interested in seeing some sense of how large the differences between these countries is (which rankings can't tell us).

I was also surprised and disappointed to see Canada so close to US scores (51 versus 55.5), although the halving of the price was a sop to my national pride.

I will say that the difference in Canada goes beyond health care and outcomes, and even beyond the price. Two sets of people benefit greatly from Canada's system, despite the score.

One group are all the people who tie visceral financial fear to their health care. In the US one sick child, one job loss, one Alzheimer's parent, can plunge the whole extended family into poverty. To say nothing of the loss to the next generation of the money and property they might otherwise have inherited.

The other group are businesses. American businesses spend God knows how much effort and money dealing with the health care problem, directly tied to the number, age and family connections of their staff. How many more jobs would be created if the businesses didn't have to take any of that into account? I don't hear that factor discussed much, but it should be.

Noni

[caroleen]

No surprise to me. I have nearly been killed twice by the doctors here.

Having learned my lesson, I am in total charge of my health. I do NOT buy health insurance, I have a credit card with a high limit I hardly use for emergencies, I go get holistic, complimentary help BEFORE I get too sick and I eat only the purest healthy food I can get. Absolutly no high frutose corn syrup in anything I eat.

I have successfully reversed Ebstine Barr syndrom, and cervical cancer with natural methods, and NO DOCTORS!

We have the Insurace companies who are the Third party directors, (with no medical background) telling Doctors what their patients can and cannot have, we have greedy doctors just going through the motions..diagnosing major illnesses in a 15 minute visit, then drugging clients with experimental, new, untested drugs, and we have stupid people abusing their bodies through very bad diets, fads, lack of excersise and recreational alchohol and drug abuse, stress, sleep deprivation.....

So with that mix ... it was lucky the United States is even on the chart!

Doctors make money if people are sick....and if people do not know anything about their body... they will be sick because the bulldroppings of bad information is what the media rants and raves about.

So you want real health, YOU have to work for it & read books and learn about you own body and take care of it, as it will last you much longer than any doctor will tell you! LOL

[Lafayette]

c: Doctors make money if people are sick....

This is a good point. Go to a Doctor or a Lawyer, the world over, and what you can expect is to leave their offices with a billable service.

Does anyone really, truly expect a Doctor to prescribe just an aspirin or a Lawyer to tell you it's not worth pursuing a case. Almost never ...

Your other proposition, reasonable portions of health foods, is also the recipe for better health. When Americans understand that the mountains of food that they gobble down is doing them harm, then they might just be ready to understand that it is quality and not quantity that matter to health and long-life.

But, we are not there yet. Big AgriBusiness interests are leading us about the food landscape by the nose. Like cows. Just look at the media advertising spent to convince us that life is impossible without trying some new food.

[real person from the real world]

just some comments, while I think Caroleen is OTT, I have noticed that switching to more veggies and salads, and less meat (cannot really afford it, and fruit can be expensive), seems to have improved my health quite a bit, altho I seem to be at an age where it is harder and harder to take off pounds w/o exercise, no matter how you try to cut back. Also, so many processed foods have sugars of various sorts. Hard to avoid, and I think sugar and animal fats are some of the worse things.

[Lafayette]

Obesity is largely due to market factors.

All foods can be classified by three components: Protiens, carbohydrates and lipids. Proteins (meats/fish) are far more expensive to produce than carbohydrates (sugars, starches). So, people who want to eat more for less, inevitably chose carbohydrates. These are your typical "couch potatoes" - and they are, more often than not, the poor.

Atkins had a point, but he took it to an exaggeration. He proposed that fats were "naturally eliminated" by the body. The body stocks fats just as it takes carbohydrates and changes them into fats, which it stocks (for future usage, of which, in a sedentary world, there is no need).

The best diet is the simplest, don't eat. Or, eat as little as possible to maintain your health, which means a varied meal but SMALL portions and plenty of liquids that help the body evacuate the lipids.