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U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
U.S. health system performance from international perspective
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U.S. health system performance from international perspective

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Presentation on U.S. health system performance from international perspective, Elizabeth Docteur, World Bank, October 2009

Presentation on U.S. health system performance from international perspective, Elizabeth Docteur, World Bank, October 2009

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  • 1. U.S. Health System Performance   Viewed Through the Lens of InternaBonal  Comparisons  Elizabeth Docteur  Independent health policy consultant  World Bank  Washington, DC  October 13, 2009 
  • 2. Overview of presentaBon  •  IdenBfy key performance challenges  –  Access  –  Cost   –  Quality of care and populaBon health status  •  Point to (hypotheBcal) factors explaining U.S.  relaBve performance  •  Suggest lessons from OECD experience 
  • 3. Access to care  •  U.S. access to care for those with insurance is  mixed, relaBve to other countries  –  RelaBvely short waiBng Bmes  –  New medicines reach U.S. market quickly; no “4th  hurdle”  –  Care is foregone due to affordability problems  relaBvely oUen 
  • 4. Main U.S. access challenge is coverage:  As in Mexico and Turkey, a significant share of US popula?on is  uninsured   Unlike Turkey and Mexico,  Total public coverage Primary private health coverage U.S. rate of uninsured has  Mexico Turkey 50.4 67.2 not improved over last 15  United States Poland 27.3 97.3 59.2 years.   Slovak Republic Netherlands 97.6 62.1 35.8 Austria 98.0 Belgium 99.0 Being uninsured in the  Spain 99.5 Luxembourg 99.7 Germany 89.6 10.2 United States is associated  France United Kingdom 99.9 100 with ge_ng less care, being  Switzerland Sweden 100 100 less healthy and increased  Portugal Norway 100 100 mortality (U.S. InsBtute of  New Zealand Korea 100 100 Medicine)  Japan 100 Italy 100 Ireland 100 Iceland 100 Hungary 100 Greece 100 Finland 100 Denmark 100 Czech Republic 100 Canada 100 Australia 100 0 20 40 60 80 100 Source: OECD Health at a Glance, 2007 
  • 5. Why do coverage shoraalls persist?  •  Coverage is voluntary  –  not automaBc and no mandate to purchase coverage  (except in Mass.)  •  Problems with availability of insurance   –  declining share of employers offer health benefits  –  individual market limits coverage for pre‐exisBng  condiBons and insurers can reject applicants based on  health risks  •  Problems with affordability of insurance   –  risk raBng, adverse selecBon in voluntary risk pools 
  • 6. Some lessons from OECD experience  •  Regulate insurance market to set the playing  ground for compeBBon on basis of value in a  mulB‐payer system – Dutch and Swiss examples  –  Risk adjustment  •  Make coverage compulsory (or automaBc) –  Swiss example  •  Subsidize coverage for those who cannot afford it  – Dutch and French examples 
  • 7. 0 1 000 2 000 3 000 4 000 5 000 6 000 7 000 United States Norway 4 763 Switzerland 4 417 Luxembourg 4 162 (2006)1 Canada 3 895 Netherlands 3 837 Austria 3 763 France 3 601 Belgium 3 595 Germany 3 588 Source: OECD Health Data, 2009.  Denmark 3 512 Ireland 3 424 Sweden 3 323 Iceland 3 319 Australia (2006/07) 3 137 United Kingdom 2 992 OECD 2 984 Finland 2 840 Greece 2 727 Private expenditure on health Italy 2 686 Spain 2 671 Per capita spending, 2007  Japan (2006) 2 581 New Zealand2 2 510 Portugal (2006) 2 150 exceeds other countries’    Korea 1 688 Czech Republic 1 626 Slovak Republic 1 555 Hungary 1 388 Poland 1 035 Public expenditure on health Mexico 823 Cost outlier: U.S. Health spending greatly  Turkey (2005) 618
  • 8. ,- ./0 1 36 23/ ! " # $% $& [2C2<FB ./7 4/0 08 5 94 !"#$ - :8 1 <0 ; 4- !!#$ 8= 0 (2)  2005 ?0 4-> !!#! 9@ BC .A= !%#& (1)  2005/2006 8/ 2 A !%#' DA @49 5/ !%#( E4 8.4 F0 -41 !%#! H -= 4 0/ H I08 48G !%#% 06 94 2J -1 )#" 04 5 Source: OECD Health Data 2008  9 )#$ 36 4-1 01 )#$ <8 0- 00 )#( K; ;0 09 4- )#! 1 K/4 )#! '()*+, '-+./01 DA L 9> 5/ ME 84 F )#% 9.4 H 2N!O *#) C8 ,- 6 *#* ./0 4 12 3P > Q. 4. *#+ -@ - 1 *#' RA C= -@ :. 48> *#' - S4 94- *#$ P4 1 -2 *#( T K80 N(O 39 AU0 94 *#( CW = -1 4 V E7 G2X CA +#" 0; 0P 8@ I2 AV X0 9. +#$ PA ; V +#! Y 9.; 0U .; &#* QC C 8 &#& BC 04 ZA 94 &#' Health expenditure as a share of GDP, 2006  8G -1 0> 2N( &#( O "#+
  • 9. •  Health expenditure is high share  United States 19.8 Current health  United Kingdom1 14.9 consumpBon  of final U.S. household  Turkey (2005) 16.9 expenditure represents a  Switzerland1 Sweden 14.9 14.8 relaBvely high share in  Spain Slovak Republic 14.3 U.S. final household  15.0 Portugal (2006) 12.6 Poland consumpBon, 2007  14.7 OECD Norway 13.9 New Zealand2 11.9 Netherlands3 12.4 Mexico 13.3 Luxembourg 13.2 (2006)4 15.4 Korea 12.9 Japan (2006) 11.8 Italy 12.4 Ireland 12.0 Iceland1 10.4 Hungary Greece 11.9 Germany 11.8 France 11.6 Finland 12.8 Denmark 11.0 Czech Republic 16.8 Canada 10.5 Belgium3 11.2 Austria 8.6 Australia 8.1 (2006/07) 7.1 Source: OECD Health Data, 2009  0 5 10 15 20
  • 10. What problems are associated with  high U.S. health costs?  •  Insurance is increasingly unaffordable   –  Especially for those who must buy on the individual market, where as  likle as half of the premium intake goes to pay medical claims  –  Wage increases for employed are dampened by rising insurance cost  •  Problems in affordability of health care for the uninsured and  underinsured  –  62% of bankruptcies in 2007 related to health care costs  •  Opportunity cost  •  QuesBon of future sustainability 
  • 11. Why is U.S. health care so  expensive? 
  • 12. Richer countries spend more on health, although U.S.  costs exceed those of countries with comparable  income  Health expenditure and GDP per capita, 2007  8 000 USA 7 000 6 000 5 000 CHE NOR DNK BEL CAN LUX 4 000 AUT NLD DEU FRA ISL SWE IRL 3 000 GBR AUS GRC ESP FIN NZL ITA JPN PRT 2 000 SVK KOR HUN CZE 1 000MEX POL TUR 0 10 000 15 000 20 000 25 000 30 000 35 000 40 000 45 000 50 000 55 000 60 000 Source: OECD Health Data, 2009. 
  • 13. RelaBvely high administraBve costs in (1) a mulB‐payer system that is (2)  characterized by minimal standardizaBon compared to elsewhere (benefits,  payment levels, payment methods)  Share of total health expenditures allocated to administraBve expenses, 2004   % 12 10.7 10.2 10 8 7.5 7.6 6.2 6 4.8 4.3 4.4 4.1 4 3.5 3.5 3.7 2.7 2.8 2.3 2.4 1.7 1.8 1.9 2 1 0 itz D ga ) l nd ) g ea s ey lia ) ) he a y s n ce o ) nd ga (2 (1 (1 (2 (2 te EC an nd ur ad Be pai Lu exic la tra rk or an la rtu ta k bo m n lic ry m an rla Po O S ar Tu K er pa S us Fr iu M Po er ub m C m lg d Ja A G xe un ep en te et w ni D H N R S U ch ze C (1) 2003 (2) 2002 OECD Health Data October 2006 AdministraBve costs and profits account for half of  premium for policies purchased in the individual market. 
  • 14. U.S. physicians earn more than counterparts in most countries  Physician remunera?on, ra?o to GDP per capita    Specialists General practitioners (GPs) Salaried Australia (2004) 5.3 2.1 Salaried Self-employed Austria (2003) 5.6 3.4 Self-employed Belgium (2004) 1 7.8 2.3 Canada (2004) 4.9 3.3 1.6 Czech Republic 2.3 1.8 2.8 Denmark 2.5 Finland 1.9 France (2004) 4.5 2.8 2.7 Germany (2004) 3.7 2.3 Greece 2 2.4 1.7 Hungary 1.7 2.9 Iceland 3.0 4.6 Ireland 3 4.0 2.8 Luxembourg (2003) 3 1.6 4.2 2.0 2.4 Mexico 2.1 4.0 Netherlands 8.4 3.5 3.7 New Zealand 4.0 1.6 Norway 3.3 Portugal 2.5 Sweden (2002) 2.2 Switzerland (2003) 3.7 3.2 4.8 United Kingdom (2004) 3.8 4.8 United States (2001) 3.8 6.5 4.4 10 8 6 4 2 0 0 2 4 6 8 10 Ratio to GDP per capita Ratio to GDP per capita
  • 15. Other factors explaining high cost of  U.S. health care  •  More intensive service mix  –  Higher share of docs are specialists and U.S. uses  more specialist‐intensive care, including elecBve  surgery, even though physician consultaBon and  hospital discharge rates are relaBvely low  •  Physician incenBves to provide excess care to  the insured  –  FFS, defensive medicine to avert malpracBce  judgments, ownership of scanners 
  • 16. Some lessons from U.S. experience  •  Greater reliance on salary and capitaBon payments  helps with cost control, but may come at cost in terms  of producBvity  •  AcBvity‐based payments appear to encourage  efficiency (more service for money), but may not have  a posiBve impact on overall health‐system efficiency  (less health improvement for money)  •  Price controls, budgets and all‐payer rate se_ng can  help control rate of growth, but may be an impact on  Bmely availability of medicines and services 
  • 17. Quality of care  •  U.S. quality of care good in some areas (e.g.,  cancer care), below average in others (e.g.,  renal care, asthma care); no parBcular area in  which quality of care is excepBonal, relaBve to  other countries (Docteur and Berenson, 2009)  •  Some evidence that medical errors may be  relaBvely more common in the United States 
  • 18. 90.5 United States 88.6 88.3 Iceland 87.1 Canada Breast cancer 5‐year  85.6 86.1 Sweden 83.8 survival rates, 1997 –  Japan Finland 86.1 86.0 2002 and 2002 –  82.0 85.2 Netherlands 80.0 2007 or nearest  France Denmark 82.6 82.4 available year  76.2 82.1 New Zealand 77.0 81.9 Norway 80.5 81.1 OECD (14) 77.9 United Kingdom 76.2 Ireland 72.2 75.5 Korea 76.9 75.4 Czech Republic 70.8 61.6 Poland 2002-2007 1997-2002 0 20 40 60 80 100 Age-standardised rates (%) Source: OECD Health at a Glance 2009 
  • 19. Mammography, percentage of women aged 50 - 69 screened, 2005 *Norw ay1 98.0 *Netherlands 81.9 **Canada 70.4 *United Kingdom 69.5 *New Zealand2 63.0 **United States1 60.8 *Australia1 55.6 23-country average3 54.7 0 25 50 75 100 Percentage Notes: * stands for program data whereas ** stands for survey data. 1.2003 2.2002 3. Includes Japan, Poland, the Slovak Republic, Mexico, the Czech Republic, Switzerland, Korea, Hungary, Australia, Belgium, Italy, Portugal, the United States, Iceland, New Zealand, the United Kingdom, Canada, France, Ireland, the Netherlands, Sweden, Finland and Norway. Source: OECD Health Data 2007
  • 20. Breast cancer mortality, female, 1995  to 2005  Age-standardised rates per 100 000 females 1995 2000 2005 40 30 20 29.5 28.4 27.0 25.8 25.1 24.9 24.2 23.9 23.1 22.4 22.4 21.5 21.3 21.1 20.8 20.7 20.5 20.3 20.0 19.9 19.5 19.5 19.3 19.3 19.2 10 16.7 11.0 10.4 5.8 0 Source: OECD Health at a Glance 2009 
  • 21. Amenable mortality  •  As of 2002‐2003, the US has the highest rate of  mortality due to preventable and treatable condiBons  (amenable mortality) among 19 countries studied  (Nolte and McKee, Health Affairs, 2008)  •  This represents a decline in U.S. performance since  1997‐1998, when the U.S. was 15th among 19  countries studied. All countries experienced a decline  in rate of mortality amenable to health care, but U.S.  achieved a relaBvely small decline.   
  • 22. US health status below OECD average by some measures     Life expectancy and infant mortality, 2006 USA to OECD avg. Life expectancy at birth (yrs): Total population 80.7 < 81.8 Females 75.4 < 76.1 Males 78.1 < 78.9 Life expectancy at age 65 (yrs): Females 20.3 > 20.2 Males 17.4 > 16.8 Infant mortality rate (per 1000 live births) 6.7 > 5.1 Source: OECD Health Data 2009.
  • 23. Life expectancy, Total population at birth, Years Life expectancy at birth:  1995 Total 2006 Total Increase population at population at 1995-2006 US improvement since  Countries birth Years birth Years 1995 falls well short of  Australia Austria 77.9 76.6 81.1 79.9 3.2 3.3 Belgium 77.0 79.5 2.5 avg improvement and  Canada Czech Republic 78.1 73.3 80.7 76.7 2.6 3.4 even improvement  Denmark Finland 75.3 76.6 78.4 79.5 3.1 2.9 among those with  France Germany 77.9 76.6 80.7 79.8 2.8 3.2 greatest longevity  Greece 77.7 79.6 1.9 Hungary 69.9 73.2 3.3 Iceland 78.0 81.2 3.2 Ireland 75.6 79.7 4.1 Italy 78.4 81.2 2.8 Japan 79.6 82.4 2.8 Korea 73.5 79.1 5.6 Luxembourg 76.8 79.4 2.6 Mexico 72.5 74.8 2.3 Netherlands 77.5 79.8 2.3 New Zealand 76.8 80.1 3.3 Norway 77.9 80.6 2.7 Poland 72.0 75.3 3.3 Portugal 75.4 78.9 3.5 Slovak Republic 72.4 74.3 1.9 Spain 78.1 81.1 3.0 Sweden 78.8 80.8 2.0 Switzerland 78.7 81.7 3.0 Turkey 67.9 71.6 3.7 United Kingdom 76.7 79.1 2.4 United States 75.7 78.1 2.4 OECD Average 76.0 78.9 3.0 OECD Health Data 2009 - Version: June 09
  • 24. Factors explaining U.S. performance in  terms of health and quality  •  IncenBves for overuse faced by health care providers (FFS payment,  malpracBce encouraged defensive medicine)  •  Lack of incenBves for prevenBon (insurers, providers): limited use of P4P,  frequent change of coverage over lifeBme  •  The uninsured (example: adult asthma admission rates)  •  Limited use of health ICT applicaBons (e.g., EHR) that could promote  evidence‐based care and help to avert errors  •  Lack of integraBon/coordinaBon in the delivery system  •  Health status shoraalls also explained by factors not directly in health  system purview: violence, teen birth rate, segments of populaBon who are  at a great disadvantage in terms of income, educaBon 
  • 25. Some lessons from OECD experience  •  SBll at an early stage of research into what structural  characterisBcs and policies contribute to top  performance in quality of care  •  Quality measurement and benchmarking is essenBal  •  Improved health data and informaBon systems needed  both to track and to improve quality of care  –  Unique paBent idenBfiers allowing for data linkage 
  • 26. Conclusions  •  Every reason to believe that U.S. gets poor value  for money, relaBve to other developed countries  •  This is the case irrespecBve of whether increased  spending over Bme has yielded benefits valued  more than they cost   •  Lessons from internaBonal experience may be  useful to build upon strengths and address  weaknesses, although naBonal context (i.e.,  insBtuBonal factors) and values very important  
  • 27. For more informaBon  •  “OECD Health Systems: Lessons from the  Reform Experience,” by E. Docteur and H.  Oxley, OECD Economics Department Working  Paper, 2003.  •  “The U.S. Health System: Assessment and  ProspecBve DirecBons for Reform,” by E.  Docteur, H. Suppanz and J. Woo, OECD  Economics Department Working Paper, 2002.  •  OECD Health at a Glance, 2009 (forthcoming). 

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