the us health care system in international perspective steven miles, md university of minnesota
TRANSCRIPT
The US Health Care System in International Perspective
Steven Miles, MD
University of Minnesota
Efficiency: Outcomes for $
How does the US stack up?
$/person-yr & Life Expectancy at Birth
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
70
72
74
76
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84
$/person Life expOECD 2008
$0
$1,000
$2,000
$3,000$4,000
$5,000
$6,000
$7,000
$8,000
15
20
25
$/person Life expOECD 2008
$/person-yr & F Life Expectancy at 65
$/person-yr & Healthy Years Lost
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
0
2
4
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$/person Healthy yrs lostOECD 2005
Death rates/10,000 of 15 year old women by age 60
0102030405060708090
Int J Health Serv 2005;35:291-311
Overall: US is 38th in chance of 15 year old women reaching age 60, below
Costa Rica 78 and Slovakia 80/10,000.
Amenable Mortality and Decline in Amenable Mortality 1997-2003
-20
0
20
40
60
80
100
120
FrJa
p
Austral It
Can Nor SweG
reG
er Fin UKPor
tUSA
Amen Mortality Decl Amen Mort
Health Aff 2008;58-71
<75 yo. Amen Mort is deaths preventable by HC sys, e.g. CA, CVD, DM, inf, etc.
Rates are /100,000
WHO: Health System Rating Good health 50%
Average age cohort survival, disability 25% (24) Disparities 25% (32)
Responsiveness (cleanliness, promptness, confidentiality, respect) 25% Average 12.5% (1) Disparities 12.5% (21)
Fairness in financing 25% (54) (37)
who.int/whr/2000/en/report.htm () US rank
Primary Care Orientation and Health Care Costs
10 Care Oriented (2 high) Longitudinal Comprehensive Coordinated with
secondary/tertiary care Community located
0
0.5
1
1.5
2
0 1000 2000 3000 4000
Health Policy 2002;60:201-18. Per person costs/yr
USA
Low 10 care orient
Higher Primary Care Orientation:
Many fewer low birth weight babies. Less bronchitis, emphysema, heart disease
asthma, and death from pneumonia mortality.
Higher life expectancy at 40 and 65 years of age. HSR 2003;38: 831-64. Health Policy 2002;60:201-18.
Primary Care Barriers
05
10152025303540
A ustral C an G er N eth N Z U k U SA
N ot see M D w hen sick Skipped R ec Test/treatN ot fill R x one of above
Health Aff 2007;10. w7171-34.
European Dental Plans
Norway: Free dental care to 18 y. Some states provide 75% of costs for 19-20 y which does not affect demand for care. Health Econ 1996; 5:119-28.
Denmark: Use and cost increased inflation due to diagnostic /preventive services rather than restorative / extraction care. Acta Odont Scand 1996;54:29-35.
Germany: 89% of services are paid by federal plan to private DDS on fee for service basis. As caries rates, DDS #s , dentists incomes . J Pub Health Pol 1992;13:491-500.
Dentists / 1000 WHO Data-2000
For Want of a Dentist Prince George's Boy Dies After Bacteria From Tooth Spread to Brain
Deamonte Driver next to his mother. (scars from brain surgery).
By the time 12 year old Deamonte's aching tooth got attention, bacteria from the abscess had spread to his brain. After two operations and more than six weeks of hospital care, the Prince George's County boy died.The cost of his care could total more than $250,000. Washington Post: February 28, 2007; Page B01
MD Access by Lowest 35% Income
05
1015
2025
3035
40
Australi
a
UK
Can NZ US
No personal MD
No MD visit in pastyear
Health Policy 2000;51L67-85
Class, 5 yr Cancer Survival: Access matters.
0.7
0.8
0.9
1
1.1
1stdecile
2nd 3rd 4th 5th 6th 7th 8th 9th 10th
Honolulu-Breast Toronto BreastHonolulu Prostate Toronto Prostate
Low Income
AJPH 2000;90:1866-72
17.3
8
16
29
0
20
40
60
80
100
0 50 100 150
OOP Drug Spending $
% P
eopl
e w
ith
OO
P D
rug
cost Ausli
CanFraGerItaJapSpaUKUS
Bubble Size = % non compliant with meds Health Aff 2008;27:89-102
Out Of Pocket drug costs: compliance.
Is Rationing the Secret of their Success?
Rationing of Health Workers?
OECD 2008
Rationing of Hospital Care?
OECD 2008
Length of Hospital Stay after an Uncomplicated Heart Attack
54,000 persons, 9 countries, GUSTO 1,2 & Assent
Eligible for early discharge Lancet 2004;363:511-17
Same trend for normal delivery (e.g. US 1.9, France 4.4) OECD 2005
0
5
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30
Ger Pol
Spa
Fr
Bel
Can
Au
stra
lU
SA
LOS
Rationing: CABG, Angioplasty, MI Deaths?
0
100
200
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400
500
UK Neth Can Swe Nor Ger USA
0
20
40
60
80
100
Cor Bypass Percut AngioPl MI Mort
OECD 2008
Acute Myocardial Infarction
Minneapolis,US Goteberg,Sweden
Angiography 62 33
PTCA/CABG 58 34
Exercise test 51 59B blockers 62 87Short Nitrates 54 661,36 m’nth survl Identical
American Heart Journal 2003;146:1023-9.
Rationing Transplants?
0
1
2
3
4
5
6
Austral
ia
Canad
a
Germ
any
NZUK
Neth
Fra
OECD MEDIA
NUSA
HeartLiverKidney
OECD in Health Affairs 2006;25:819-31
Per 100,000 persons
Big ticket therapies benefit individuals & do not raise public health measures./// 10% of health care resources go to least costly 70% of the population.
Health Affairs 2001;20:9-15
Canadian Waiting Times Wait for elective surgery is 31 days and does not
differ by economic status CMAJ 2003;168:413-6.
Waiting for elective cholecystectomy has no adverse effect before 19 weeks.
CMAJ 2003;169:662-5
Waiting for elective hip has no adverse effect before 6 months at which time QoL and mobility decrease.
CMAJ 2002;167:661115-21.
0
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140
Hip Replacement /105 persons
Ann Rhemu Dis 2003;62:222-6
0
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7000
FranceNorSweFinDenAliaUKUSA
Hip Replacement /105 persons
Data from Ann Rhemu Dis 2003;62:222-6 and OECD
Mammograms US/UK: More aggressive bx,
more false +, no improved dx.
JAMA 2003;290:2129-2137. F 50+, 3.9 million UK mammograms UK, 1.5 in US, 1996-9.
0%
2%
4%
6%
8%
10%
12%
14%
Abn
Surg B
x
Perc b
xCa+
USUK
50-54 yo
Is the American Consumer a Health System Wrecker?
Old ObeseSmoking DrinkingOver financed Armed with Lawyers
Myth: The US Health System Costs so Much Because Americans Drink and Smoke so Much
OECD 2008
0
5
10
15
20
25
30
35
% Daily Smoker Alc Lit/pers
Myth: US Health Care Costs so Much Because Americans are Really Old!
0
5
10
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20
25
30% Over 60
UN Dept of Economic and Social Affairs 2007
0
1000
2000
3000
4000
5000
6000
7000
8000
16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
% over 60
$
JapUSAItGerSweSwzUKSpNorNethAtlia
Per Capita Health Spending and % Elderly
OECD 2008, UN Dept of Economic and Social Affairs 2007
Myth: Health Care Costs are High Because of Last Year Medical Care for Very Old.
Last year of life 11% USA health $
27% M’care costs (flat x20y)
Health Aff 2001;20:188-95.
Universal use of Advance directives Hospice care Futility guidelines
would save US 3.5% med $. NEJM 1993:1092
0
5
10
15
20
25
30
65-74 75-74 85+
M'care $1000/yr % using ICU
JAMA 2001;2861349-55.
Americans are Heavy
OECD 2007-8
0
10
20
30
% Adults BMI > 30 Kg/M2 e.g. 5’9” 200+ pounds
Obesity does raise health costs, esp in elderly.
0
50
100
150
200
18.5-25 25-30 30-35 >35
BMIJAMA 2004;292:2743-9.
2-4% of our excess costs relative to other developed countries.
11% of Medicare $ Health Affairs 2003;(May).
HC costs in $1000s
from 65 to death or 83
yo
Myth: US Health Care Costs so Much Because Americans don’t Personally Pay for Health Care
OECD 2005
Dental Malpractice: One-half of claims resulted in no payment to the plaintiff. Verdicts were in 7% of cases; 93% favored defendant. Median award to plaintiffs $750; 95% of awards were under $5,000. Pub Hlth Rep 1984:87-93.
02468
1012141618
$ M
alp
Aw
ards
/ per
s-yr
$/person% of US Health Spending Insurance, awards,
settlements, legal fees .46% Health Affairs 2005,
24:903-914
Defensive medicine ? 2-6%
Myth: Malpractice Costs are Why US Health Care Costs so Much
Lessons from Developed Nations
Non-universal access Allows prices to rise. High administrative costs. Incents inequitable and
“dodge the sick” health sector strategies.
Promotes over capacity and over use.
Universal access Enables price discipline. Low administrative costs Increases equitable
access to health care.
Rationalizes capacity & empowers broad political pressure against harmful clinical rationing.
N Eng J Med 1995;332:742-6.
Lessons from Developed Nations Low point of service charges are essential for
timely/cost effective primary health care. Drug coverage not essential if system controls
drug prices. Private opt-out insurance is politically necessary
but will be only used for amenities by ~10% and for basic care by ~3%.
Progressive financing & broad benefits are essential. AJPH 93;2003:1(issue)
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.
