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US and Developed Countries: Comparing Health Care Systems - 2015
Steven Miles, MD
University of Minnesota
Efficiency: Outcomes for $
How does the US stack up?
$/person-yr (adjusted for purchasing power parity) Jap
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OECD 2014
The Organization for Economic Cooperation and Development
was founded in 1961 to compile statistics and policy reports to
promote economic growth.
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OECD 2014
Efficiency as $/person-yr & Infant Mortality /1000
Efficiency as $/person-yr & Life Expectancy at BirthJa
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OECD 2014
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$/person F Life exp M Life expOECD 2015
$/person-yr & Life Expectancy at 65
Mortality Rates Amenable to Provision of Health Care 1997-2003
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Health Aff 2008;58-71. (See also
Health Aff 2012;31:2114-22.
<75 yo. Amen Mort is deaths preventable by HC system, e.g. CA,
CVD, DM, inf, etc. Rates are /100,000
USA has highest ratesof preventable death
and smallest decreasesin preventable deaths
We are falling further behind!
How do other countries succeed? Is rationing their secret?
If rationing Improves outcomes, is health care toxic?
Do they ration Doctors? No.PS: There is no rationing of nurses either.
OECD 2015
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$/person Total MDs/10,000 Series3
Do they do it by rationing doctor visits? No.( per person-yr)
OECD 2015
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OECD 2014
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$/person Acute admits beds/1000 Acute LOS
Do they ration hospital admission or stays? No.
Do they ration length of hospital stays for heart attacks? No.
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MI LOS in Days
OECD 2014
Do they ration coronary bypasses and angioplasty and accept more heart attack deaths? No.
Can Sp ItFin UK
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Percut AngioPl Cor Bypass IHD Mort/100,000
OECD 2011 We do more but we do not have lower heart attack mortality.
Age adjusted
High tech rationing vs. preventing end stage organ failure.
Less dialysis and transplantation looks like rationing
US v Norway have same incidence of early kidney disease but disease going to kidney failure reflects better routine health care.
Kid Failure0
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NorwayUS WhiteUS MeanUS Black
J Am Soc Nephrol 2006;17:2275-84.
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$/person Dial or trnsplantPer 100,000OECD 2011
US has Shorter Wait Times for Elective Surgery …
OECD Health at a Glance: 2011
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… but this does not mean more service is provided: Hip Replacements.
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Hip Rep/ 100,000 $ Person
OECD 2015
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Hip Replacement and Health Spending
OECD 2015
Myth: So if other nations do not have lower costs by rationing, the American Consumer must be a Health System Wrecker.
Old ObeseSmoking DrinkingOver financed Armed with Lawyers
The American Consumer is too:
Myth: The US Health System is handicapped relative to other developed countries because Americans drink & smoke more.
OECD 2014
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$/person %>15yo tobac Lit/cap >15yo
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%>65 $ Person
Myth: US Health Care Costs so Much Because Americans are Really Old! We are young!
World Bank 2014
Per Capita Health Spending and % >65:A young US uniquely out of position to deal with an aging population.
10 12 14 16 18 20 22 240
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!
Myth: Health Care Costs are High Because of ICU Care of Very Old.
Last year of life
11% USA health $,
27% Medicare costs (flat x20y) Health Aff 2001;20:188-95.’
Age-specific disability is falling.
Hospital costs drop 50% from 65 to 85
years old.
Nursing home, home care, drugs) rise
from 65-85 years old, more than offset
fall in hospital costs.
Overall no trend in costs vs age at death. Milbank Q 2007;85:213-57
65-74 75-74 85+0
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M'care $1000/yr % using ICU
JAMA 2001;2861349-55.
Americans are HeavyObese % Adults BMI > 30 e.g. 5’9” 200+ pounds
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% Obese $ Person
OECD 2014
Most obesity health costs accrue late in life (US is a young country). Obesity accounts for 6% of US health costs or about 2-4% of our excess costs relative
to other developed countries. J Health Econ 2012;31:219.
Myth: US Health Care Costs so Much Because Americans don’t Personally Pay for Health Care
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Out PocketPriv SpendGov Spend
Note: Our gov expenditures are comparable to other nations!
OECD 2013 Pre ACA
Myth: Malpractice Costs are why US Health Care Costs so Much.
Malpractice costs
(insurance, awards, court
costs) is .5% of health
spending. (A third higher than
other developed countries.)
Defensive medicine) is
1.9% of health spending. Health Affairs,
2009;29:1569-77.
National tort reform to
reduce suits and awards
would reduce direct and
indirect (e.g., defensive
medicine) costs,
reducing health
spending 0.5%. Congressional Budget
Office, 2009
How do they do it?
(or, How can we do better?)
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$/person F Life Exp
OECD 2012
Income Inequality, Health Spending, and Life Expectancy
Lower Inequality associated with:
Education, Obesity, Heart disease, Stroke, Unhealthy behaviors
High Inequality
Med Inequality
Low InequalitySoc Sci & Med 2008;66:1719-32.
Primary Care Orientation
10 Care Oriented (2 high) Longitudinal Comprehensive Coordinated with
secondary/tertiary care Community located
Health Policy 2002;60:201-18.
Low 10 care orient
USA
High Primary Care Associated with Lower Health Care Costs
Per person costs/yr Note: data is not updated
Primary Care Orientation Improves Health Outcomes
Many fewer low birth weight babies. Less bronchitis, emphysema, heart disease
asthma, and death from pneumonia mortality. Fewer productive years lost 0-69. Higher life expectancy at 40 and 65 years of
age. Milbank Quarterly 2005;83:457-502. Health Policy 2002;60:201-18.
$/person-yr & Asthma Admissions /100,000 (adults age-standardized)
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OECD 2012
% with Unmet Medical Care due to Costs
UK Swz Neth Swe NZ Fr Can Nor Auslia Ger US0
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> Av Inc< Av Inc
OECD 2011
Primary Care Barriers
Austral Can Ger Neth NZ Uk USA05
10152025303540
Not see MD when sick Skipped Rec Test/treatNot fill Rx one of above
Health Aff 2007;10. w7171-34.
Out-of-Pocket Medical Costs/Year(% of adults with chronic disease)
2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
Lessons from Developed Nations
A universal primary care orientation controls costs and improve public outcomes.
Low point of service charges are essential for timely/cost effective primary health care.
Universal enrollment is forced price discipline!
Many Models for Universal Health Care National Health Service-UK Single tax-based financing to regulated private
managed care plans with mandatory enrollment, specified benefits, portability etc- Germany
Multiple, progressive tax based financing for regulated, competing public and private insurers-France.
Single insurer-Canada.
