How Does U.S. Health Care Quality Compare Internationally?

How Does the Quality of U.S. Health Care Compare
Internationally?
Timely Analysis of Immediate Health Policy Issues
August 2009
Elizabeth Docteur and Robert A. Berenson

Introduction aspects of health care signify its individuals and populations
quality and which ones are most increase the likelihood of desired
There is a perception among many important. health outcomes and are consistent
Americans that despite coverage, with current professional
cost and other problems in the This brief brings together available knowledge.”4 A similar definition
health care system, the quality of evidence on how quality of care in is used by the U.S. Agency for
health care in the United States is the United States compares to that Healthcare Research and Quality:
better than it is anywhere else in of other countries and comments “Quality health care means doing
the world and might be threatened on the implications of the evidence the right thing at the right time in
by health reform. In fact, 55 for the health reform debate. By the right way for the right person
percent of Americans surveyed last exploring how the quality of our and having the best results
year said U.S. patients receive care compares internationally, we possible.”5 Both definitions refer to
better quality of care than do those can address the underlying characteristics of health care that
in other nations, even though only attitudes and concerns that people are increasingly referred to as
45percent said they thought the have about health reform. For “technical” or “clinical" quality or
United States had the world’s best example, if claims that the United “effectiveness.”6
health care system.1 And while States has the best quality of care
Americans overwhelmingly in the world — overall or in In the context of efforts to assess
support government action to particular respects — were well health system performance, the
increase coverage and reduce the supported by the evidence, it term “quality” is often used to
costs of health care, a recent poll would caution us against adopting encompass a range of desirable or
found that 63 percent worry that forms of health reform that positive attributes of health care
the quality of their own care would threaten those attributes of our and the overall performance of
get worse if the government health system responsible for this health-care systems. A review of
ensured health care for all.2 standing. But if quality of care is eight country-specific and
Another poll found that as many as not remarkable — or may be even internationally developed
81percent of Americans have such lagging — there should be less frameworks for evaluating health
concerns.3 reluctance to change. In addition, a systems found a great deal of
more explicit need for health commonality in how performance
Participants in the current reform has been conceptualized.7 In
debate refer to the relative quality reform to address quality
improvement would appear addition to effectiveness, the
of U.S. health care as providing researchers identified 14 other
support for their views, and warranted.
dimensions of the performance of
perceptions of health-care quality What constitutes high- health care systems: acceptability,
—!what it is and where it can be accessibility, appropriateness, care
quality health care?
found — are often at the heart of environment and amenities,
disagreements over what form of A number of definitions of health competence or capability,
health reform the country should care quality have been put forward continuity, expenditure or cost,
adopt. But hard facts to support over the years. The U.S. Institute efficiency, equity, governance,
claims are often missing, and it is of Medicine’s definition, which patient-centeredness (-focus) or
clear that quality of care experts, has grounded expert work in the responsiveness, safety,
policy makers, health care United States and elsewhere, sustainability, and timeliness.
providers and the general public all describes quality as “the degree to
have different ideas as to which which health services for
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Many of these performance superiority, including a belief that many holes in our knowledge of
dimensions might reasonably be Americans with good insurance the relative quality in many areas,
considered to be attributes of high- coverage uniquely benefit from it is impossible to use a single
quality care (e.g., appropriateness, prompt availability and measure as a meaningful proxy.
competence, timeliness). Those in accessibility of cutting-edge Measures that reflect multiple
a second group (e.g., cost, medical procedures, medicines, dimensions of quality have a
governance, sustainability) are and devices, as well as highly certain appeal as performance
readily observed as separate educated and well-trained health indicators for policy-makers,
performance concerns. Reasonable care professionals, who know and although more specific or narrow
people might have different views consistently do what is best for measures have the advantage of
on whether others (e.g., their patients. On the other hand, being more actionable for
accessibility, acceptability, those who assert that we have administrators and clinicians. And
responsiveness) are dimensions of inferior quality of care point to our even with a broad set of
quality or closely related concepts, relatively poor population health comparative measures, people may
and indeed these are treated in status,8 and factors such as barriers differ on which measures are most
different ways in the frameworks to access for those without important, for example, those
reviewed. Accessibility is adequate insurance coverage or focusing on the level of typical or
particularly difficult to disentangle limited health plan provider average care for common
from considerations of health care networks and insufficient conditions versus the care
quality in that it is a prerequisite to coordination among providers in available for unusual, life-
receipt of quality health care. the fragmented health care delivery threatening conditions.
Availability of providers and system.
services, coverage, benefits and The evidentiary basis for cross-
affordability all come into play as All of these aspects of quality and country comparisons of quality
potential explanations for different broader health system performance could be strengthened by
user experiences with the health are important and legitimate additional studies and
care system and the outcomes considerations; therefore, we cast a improvements in methods and
attained. Finally, (technical) relatively wide net in this brief. data. Nonetheless, a number of
efficiency is a function of the Specifically, we focus on comparative studies on the quality
quality and quantity of services effectiveness (or “technical” or of care have been published.
produced at a given cost. “clinical” quality) and consider Below we review some of the key
Efficiency, or value for money, is a additional dimensions of quality or findings from recent research that
performance consideration of great health system performance that are provide insight on how the quality
interest to public authorities and most closely related: of care in the United States
purchasers, although only modest appropriateness, safety, compares to the quality of care
headway in measuring efficiency accessibility, acceptability, and in other nations. We explore
in health care has been made to responsiveness. quality as assessed by measures
date, reflecting limitations in the based upon population health
What is the evidence on status, measures of processes
capacity to measure the quality of
health care. how quality of care in and outcomes of care for particular
the United States conditions, measures of patient
It is evident from the U.S. reform compares to other safety, and indicators based
debates that popular conceptions of on patients’ experience with
what constitutes good quality
countries? health services. In each area,
health care encompass a range of To make an informed assessment we put forward the evidence
dimensions. Although obviously about the quality of care in one we could find on how the
high quality implies superior health system versus another, it is attribute in question stacks up
health outcomes, other attributes important to look at a wide range (or fails to do so).
considered indicative of quality of indicators. Because health care
appear to underlie popular involves a complex array of
expressions of U.S. health care activities, and because there are

Timely Analysis of Immediate Health Policy Issues 2

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How strong is the evidence base for comparing health care quality across countries?
There is modest research literature comparing the quality of care in the United States with the quality of care furnished
elsewhere. Most studies of technical quality or effectiveness draw on data compiled from disease registries, medical
records or administrative data. Such studies generally focus on a particular condition, such as coronary heart disease
or specific forms of cancer, and they differ in the extent to which they endeavor to account for factors outside the
control of the health care provider and system that could affect the results.
Efforts to identify a set of indicators for use in making international comparisons across a range of conditions as part
of regular monitoring activities include an ongoing Organisation for Economic Co-operation and Development
(OECD) initiative, which builds on initial work by the Commonwealth Fund and a coalition of Nordic countries. To
date, the OECD has formulated, tested and validated a relatively small number of quality measures for use in
international comparisons, with other measures in development.55 Initial results have been published showing cross-
country differences based on data obtained from national sources, but with caveats as to factors making comparisons
indicative, rather than absolute. Limitations include differences in data sources used in measurement, different
reporting periods, and limited ability to adjust for age and other factors (not reflecting quality of care differences) that
can explain apparent cross-national differences.
Beyond this, surveys of citizens, patients and health care providers in five or more countries have been produced
annually since 1998 by the Commonwealth Fund.56 These provide information on how health care is perceived as well
as how the experience of health care differs internationally in relation to public expectations. Surveys can explore
aspects of health care and quality dimensions for which other forms of data do not exist in comparable form. Their
limitations include cross-country differences in the interpretation of questions and concepts, which could affect how
countries’ health systems fare relative to one another, as well as standard survey research problems like recall bias.
An important issue in health care quality measurement, as in other types of research that attempt to ascertain causality,
is that it is very difficult to adjust for factors outside the health care system which contribute to particular health
outcomes, such as socioeconomic status, lifestyle, and disease incidence or prevalence. Similarly, quality of care
measures could be affected by differential access to care across a population, reflecting coverage gaps in the United
States as well as shortfalls in supply or financial barriers presented by cost-sharing requirements here and in other
countries. Thus, the quality of care obtained by those with unfettered access might differ considerably from that of
those who face obstacles to getting needed care.

Are cross-country mortality) show the United States both men and women at age 65 is
to be among the worst performers. above the Organisation for
differences in life Economic Co-operation and
expectancy and The United States is not among top Development (OECD) average, but
mortality indicative of performers in terms of life below what the top countries have
expectancy, an indicator achieved, particularly for women.9
differences in health influenced by factors outside the
care quality? health system in addition to health Among 19 countries included in a
While U.S. life expectancy is at or care. We rank among the lower recent study of amenable
below the average in comparison third of developed countries in life mortality,10 the United States had
with that of other developed expectancy at birth. Life the highest rate of deaths from
countries, findings from research expectancy at age 65 may be a conditions that could have been
that has adjusted mortality to better indicator of U.S. health care prevented or treated successfully.
account for deaths not related to performance because all older The extent to which differences
health care (so-called amenable Americans have reasonably good across countries in the prevalence
insurance coverage through of particular conditions may
Medicare. U.S. life expectancy for explain the poor U.S. showing in


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What do life expectancy and mortality data tell us about the quality and effectiveness of
health care?
Health status measures based on mortality and life expectancy data have been used to assess the overall effectiveness
of the health system, reflecting the quality and accessibility of services, as well as environmental factors. Examples of
such measures include crude mortality rates for defined populations; disability-adjusted life years (DALY), an
indicator developed by the World Health Organization to assess the burden of disease; health-adjusted life expectancy
(HALE), which can be used to assess whether increases in longevity are accompanied by compression of morbidity;
and potential years of life lost (PYLL), a summary measures of premature mortality that assigns greater weight to
deaths that are further away from a defined benchmark (such as age 70).
Although very interesting as indicators of health status, all fall short as measures of health care quality because they
tend to be significantly influenced by factors other than health care. For example, of the 30 OECD countries, only
Hungary does worse than the United States in female premature mortality, as measured by PYLL, and only three
countries exceed the U.S. rate of male premature mortality. However, accidents, suicides and homicides play a large
role in explaining this finding, as the U.S. homicide rate is more than five times the OECD average.57
More sophisticated mortality measures set aside those deaths that cannot be attributed to the effectiveness of health
care. So-called amenable mortality is an indicator that aims to cast light on the relative effectiveness of health systems
by calculating the rate of deaths prior to a certain age which are considered by experts to be avoidable through
appropriate health care. As with other measures of mortality, amenable mortality is affected by differences in the
prevalence of particular conditions across populations being compared. Thus, two health care systems could have
identical rates of failing to provide adequate care for a condition that should not be fatal; however, if one of the two
countries has a higher rate of prevalence of the condition among its population, its amenable mortality rate will also
be higher. Nevertheless, amenable mortality does a better job than crude mortality data in assessing the effectiveness
of health care delivery in improving health.

the recent study is unknown, health system ranked somewhat survival rates for individuals with
although studies in which it was better (16 of 19) among its peers in particular conditions. Such
possible to adjust for such minimizing amenable mortality. In measures are less sensitive to
differences found that the greatest the years between the two studies, differences across countries in
part of regional differences in there was an average reduction in disease prevalence.
mortality for certain conditions amenable mortality for men of 17
were explained by differences in percent across all countries Below we review available
disease prevalence.11 A recent included in the study, compared evidence on U.S. quality of care in
study comparing the United States with only a 4 percent reduction in a variety of clinical areas, in
and 10 European countries found the rate of amenable mortality for comparison with other countries.
that the United States had a much men in the United States. The overall evidence is mixed,
higher prevalence of nine of 10 indicating that the United States
conditions, including cancer, heart Studies of processes has neither the best nor the worst
disease, and stroke, in its and outcomes of care for quality of health care for particular
population over age 50.12 conditions among developed
particular conditions countries. In certain cases where
However, it is unlikely that relative reveal differences in
differences across countries in the U.S. quality appears low relative to
prevalence of disease changed
health-care quality that of other countries — in the
during the five years that had areas of prevention and care for
Measures specifically designed to
passed since an earlier study13 by chronic conditions, for example —
assess technical/clinical quality of
the same authors using the same care focus on health services and access barriers experienced by the
methodology, in which the U.S. health outcomes, such as five-year uninsured and the underinsured
may contribute to the results seen.


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States came in below average in a
Measuring the technical quality or effectiveness of health care: field where one-third of OECD
A brief primer countries have rates above 95
percent.
The science of health care quality measurement has been developed over
the course of several decades. Quality measures include those to assess Quality of care for chronic
health care processes (what was done), outcomes (what was achieved) and conditions
structural measures that evaluate the capacity to do what needs to be done. Findings on the quality of U.S.
Process measures can be further categorized as measures of overuse (when care for several chronic conditions
patients get services that are inappropriate for their medical condition, also provide a mixed picture.
subjecting them to unwarranted risk and/or expense), underuse (when
patients do not receive care that is indicated based on their medical Among 30 OECD countries, the
condition) and misuse (when a service is provided in a technically United States ranked below
incorrect manner), although the bulk of the measures used regularly for average in adult asthma care. Adult
comparison relate to underuse of services considered medically necessary hospital admission rates for
in defined circumstances. asthma, an indicator of inadequate
care for the condition, were second
Quality can be assessed objectively (against standards defined by evidence highest among 17 countries
or professional agreement) or subjectively (against patients’ expectations reporting (12 per 10,000 U.S.
or experiences, or reviewer judgment, for examples). Assessment draws versus 5.8 OECD average) and
upon empirical data, such as administrative and medical records or patient U.S. asthma mortality, double the
registries and the perceptions of those involved in health care (surveys, OECD average rate, was fifth
testimonials). Quality is evaluated for populations and sub-groups within highest among 25 countries
the population, as there is a particular interest in evaluating whether and reporting.17
how differences in health care contribute to observed disparities in health
status. A handful of studies undertaken in
the 1990s18 have compared
outcomes for U.S. and Canadian
Quality of preventive care average mammography rates (61
patients with end-stage renal
percent U.S. versus 55 percent
The evidence on how the United disease and found that Canadians
OECD), although was far below
States compares to other developed have longer survival times while in
the best performers (82-98 percent
countries in terms of the quality of hemodialysis or peritoneal dialysis
in four countries). However, the
its preventive care is quite mixed. programs, and after receipt of
United States had the highest
kidney transplant, even when
In a report that summarized survey cervical cancer screening rate (83
extensive adjustment for
research comparing quality of care percent) among 22 countries
comorbidity is done.
in five countries, Davis et al.14 reporting data to OECD.
concluded that the United States A survey of patients in six
Among 30 OECD countries, the
had relatively high-quality countries19 found that more than
United States had above-average
preventive care. 85 percent of half of U.S. diabetics had received
rates of flu vaccination for senior
American women reported having four recommended services, a rate
citizens (65 percent U.S. versus 55
had a Pap smear within the last comparable to the UK and
percent OECD average and 80
two years and 84 percent of Germany, and higher than the rate
percent in top-performing
American women age 50 to 64 seen in Australia, Canada and New
Australia). However, childhood
reported having received a Zealand. The same survey found
vaccination rates were below the
mammogram within the last two that 85 percent of U.S.
OECD average.16 The U.S.
years, the highest shares among the hypertension patients reported
pertussis vaccination rate stood at
countries included in the survey. having received two recommended
86 percent in 2005; only Austria
Perhaps reflecting differences in tests, a rate identical to Canada and
and Canada reported lower rates.
data sources, the OECD15 found Even with a 92 percent childhood
exceeded only by Germany (91
that the United States had above- percent).
measles vaccination, the United


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Quality of care for certain early postoperative events. The United States for patients age 65 or
acute conditions United States and Manitoba older at diagnosis. In the case of
used a more advanced surgical stomach cancer, the U.S. survival
Studies of diverse conditions method for cataract removal as rate for patients under age 45 was
ranging from heart disease, hip compared with Barcelona or below those of many European
fracture and vision impairment Denmark.24 nations, but similar among the
also are mixed in terms of their older patients. Other studies (e.g.,
findings as to how U.S. quality Quality of cancer care Coleman, et al. 2008)26 have also
compares to that of other countries. found that U.S. survival rates for
While interpreting the available
! 20
Yusuf et al. studied patients evidence is challenging in the light certain cancers, particularly
undergoing invasive cardiac of different screening protocols prostate cancer, are among the
procedures in six countries and across countries, it does suggest best. Among 30 OECD countries,
found that higher rates of that the United States as one of the United States had one of the
invasive and revascularization several world leaders in providing best five-year survival rates for
procedures in United States high-quality cancer care. patients with breast or colorectal
and Brazil were associated cancer.27
with lower rates of refractory A study by Gatta and colleagues,25
looked at five-year cancer survival There is an important link between
angina or readmission for survival rates and screening rates
unstable angina, no apparent rates for the United States and 17
European countries. The United for many cancers (e.g., melanoma,
reduction in cardiovascular prostate cancer, breast cancer,
death or myocardial infarction, States had the highest survival
rates for cancer of the colon, colorectal cancer). Many cancers
but higher rates of stroke. Tu are more amenable to treatment
et al.21 found that short-term, rectum, lung, breast, and prostate.
U.S. survival rates were also when caught early. But it is also
but not long-term, cardiac true that in countries with higher
outcomes were better in the among the highest for melanoma
(fourth), uterine (second) and screening, more cancers will be
United States than Ontario. diagnosed early, and survival rates
ovarian (fifth) cancer, cervical
! Ho et al.22 found that inpatient cancer (sixth), Hodgkins disease in those countries will be higher
hip fracture mortality was (third) and non-Hodgkins simply because there are more
higher in Canada (Manitoba lymphoma (fourth). The United patients in the denominator with
and Quebec) than in the United States was ninth in survival of less advanced disease. Thus, Gatta
States (California and stomach cancer. Although average et al.28 found that those countries
Massachusetts). Canadians had survival differences between the with the highest breast cancer
longer waits for surgery, United States and Europe as a incidence rate (share of population
although this was found not to whole were in some cases large, newly diagnosed with the disease
explain the difference in the difference between the United in a given year) also had the
mortality observed. States and the other countries with highest survival rates.
relatively high five-year survival Differing national commitments to
! Norregaard et al.23 found rates were generally small screening becomes an issue,
similar postoperative visual (approximately 3 to 4 percent for particularly, in the case of prostate
acuity for cataract patients many cancers) and (due to small cancer, where U.S. incidence rates
across four countries studied, sample sizes) usually not are double those of Europe
including the United States, statistically significant. The study because aggressive screening
despite considerable also looked at cross-country uncovers cancers at a very early
differences in the organization differences by population group, stage. The implications for quality
of care and patterns of clinical finding that survival rates for are complicated, in that cancer
practice. The United States had colon, breast and uterine cancer detection has instigated more
fewer adverse intra-operative were similar in the United States treatments with serious risk of
events than the other three and Europe for patients under 45 quality of life deterioration for a
sites studied but, along with years, but were much better in the condition that is very slow to
Manitoba, had higher rates of


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develop. In 2008, the U.S. U.S.-Canada does not vary across countries with
Preventive Services Task Force comparisons more often different service rates.
updated its screening advice,
recommending that known risks of
find Canadian quality is The degree of variation in the
screening outweigh potential better share of populations receiving
benefits for older men, and that particular services is greater than
A significant share of the academic what would be expected based on
informed patient preferences research studies comparing the
should serve as a determinant of population health status
outcomes and effectiveness of differences, raising a question as to
appropriate care in younger men. health care across countries
Other countries, such as Denmark, whether there is underuse of the
consists of U.S./Canada procedure in countries with
had recommended against comparisons, perhaps reflecting
widespread use of the test as early relatively low rates or overuse in
policy interest, data availability or the countries with relatively high
as 1990 (cited in Coleman et al. other factors. Although studies
2008).29 rates. For example, OECD
findings go in both directions, the countries’ rates of caesarean
Differences across countries in bulk of the research finds higher sections per 100 live births range
access to diagnostic and treatment quality of care in Canada. from 13.6 to 37.9, with U.S. rates
services explain most of the A review of the evidence on among the highest in the OECD.
observed differences in cancer quality differences between the Although determining the extent to
survival rates.30 Better survival United States and Canada found which the procedure is overused
rates are associated with higher that each of the two countries requires investigation of patient
national income levels, higher performed better in different characteristics, including age and
levels of expenditure on health, studies. Guyatt et al.32 identified 38 comorbidities, the World Health
and higher investment in health studies comparing populations of Organization has stated that rates
technology, as proxied by patients in Canada and the United above 15 percent offer no benefits
indicators such as the rate of CT States. Studies addressed diverse in terms of population health.33
scanners per person. The problems, including cancer, The United States also has the
relationship between cancer coronary artery disease, chronic highest rates of coronary
survival and level of expenditure illnesses and surgical procedures. revascularization procedures, with
on diagnosis and treatment has yet Of 10 studies that included more than double the rates of other
to be fully explored, due to data extensive statistical adjustment and countries with similar mortality
limitations, although some cross- enrolled broad populations, five rates from heart disease.34
country differences in expenditure favored Canada, two favored the
have been documented. Using an However, relying on assessment of
United States, and three showed performance against evidence-
approach to assess relative equivalent or mixed results.
spending across nations with based criteria, McGlynn et al.35
found comparable rates of
different income levels, OECD Overuse of health inappropriate use of coronary
found that the United States spent services not linked with
between 41 and 62 percent of its angiography and CABG, when
per capita GDP on the first six
service volume comparing New York State and
months of breast cancer treatment Canada, despite different rates of
Although there have been
following diagnosis for each use of service in the areas studied.
relatively few studies comparing
patient, while Canada and France Findings from studies by Bernstein
the rates of overuse of health
spent about one-third of their et al.36 and Gandjour et al.37 also
services, the limited available
respective per capita GDPs for suggest that rates of inappropriate
evidence suggests that higher rates
treatment during the initial phase.31 services are not dependent on the
of certain surgeries and procedures
frequency of the procedure.
in the United States put more
Despite performing relatively few
Americans at risk, in comparison
cardiovascular procedures, in
with their counterparts, even if it is
comparison with the United States,
the case that the share of
the rates of inappropriate surgeries
procedures that are inappropriate


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in the UK and Germany were more likely than patients in other Australia, Canada, New Zealand
comparable. countries to report mistakes or and the United Kingdom,
adverse events and gaps in expert- American doctors were less likely
Higher rates of surgery may have recommended safe medication to agree that their health care
both positive and negative impact management practices.39 A survey system works well and more likely
of health outcomes. On the one of chronically ill or intensively ill to consider that the system needs
hand, when performed on patients in eight countries40 found complete rebuilding. A 2003
appropriate candidates, surgery that the United States had the survey of hospital executives
will tend to have positive benefits highest reported rates of problems yielded a similar finding; half of
in terms of life expectancy and such as being given the wrong American hospital executives said
morbidity associated with the medication or dosage, they were not satisfied with the
underlying condition. On the other, experiencing a medical error, performance of their country’s
greater per capita rates of heart receiving incorrect test results, or health care system, compared with
surgery may contribute to the facing delays in hearing about between 4 and 12 percent of
higher rates of mortality due to abnormal test results. Patient hospital executives in four other
surgical and medical errors in the reports of these types of problems countries.42
United States. were lowest in the Netherlands (17
percent), France (18 percent), and Davis43 reviewed findings from
Patient safety problems multi-country surveys conducted
Germany (19 percent) and highest
appear more prevalent in in the United States (34 percent). in 2004 and 2005 that examined
the United States patients’ satisfaction and
Physician and patient experience with their health care.
Few studies have compared patient Patients assigned the U.S. health
safety at an international level, as
perceptions of health
system mixed marks in terms of
data and indicators for use within care quality suggest whether their health care providers
countries are still in development. strengths and communicated needed
Notwithstanding such limitations, weaknesses of U.S. care information. U.S. patients were
available evidence suggests that less satisfied than patients in other
patients may be at greater risk of As with most of the indicators
countries with the quality of
safety problems in the United described above, physician and
communication relating to doctor’s
States than they are elsewhere. patient reports suggest some areas
office visits, but more satisfied
of strength, but as a general matter
than other patients with the quality
Data are available for cross- do not distinguish American health
of communication relating to
national comparisons on mortality care as providing especially high
hospitalization. On the other hand,
due to surgical and medical quality compared to the health care
U.S. patients were less satisfied
errors.38 These data show that the provided in other countries.
than patients in other countries
United States has relatively high
A survey of physicians in five with how much their physicians
rates, in comparison with other
countries41 found that U.S. engaged them in making health
OECD countries, but the rates may
physicians were more likely than care decisions. In terms of
be problematic as quality
physicians in other countries to satisfaction with the level of
indicators due to differences in
report that interventions in patient choice of doctor, Americans were
reporting accuracy across countries
care geared towards cost control less satisfied than patients from
and the relative infrequency of this
were threatening the quality of New Zealand and more satisfied
outcome.
care they could provide to their that Canadian patients. Finally, in
Surveys provide another source of patients. U.S. physicians were less terms of timeliness, American and
information on relative safety. A likely to report that community German patients reported
six-country survey of patients with resources were inadequate, but relatively short waiting times for
a high incidence of chronic illness more likely to say that limitations seeing a specialist or obtaining
and recent intensive use of the on the medicines they could elective surgery. But Americans
health care system found that prescribe posed a problem. were less likely to say they could
patients in the United States were Compared with doctors in get medical attention when needed


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and could readily obtain care on with other countries studied, uninsured receive fewer preventive
nights and weekends. Considering resulting in the United States and diagnostic services, tend to be
timeliness measures as a whole, dropping from 16th to 19th place more severely ill when diagnosed,
German patients were more over five years. Furthermore, the and receive less therapeutic care.
satisfied than American patients, findings showing that the United He concluded that insurance
and British and Canadian patients States does better than Europe in coverage could reduce mortality by
were least satisfied. cancer survival for the over-65 an estimated 4 to 25 percent,
population suggests a possible role depending on the condition.
Is the average quality of for insurance status as an
care in the United States explanatory factor, especially since But all of this does not necessarily
mean that the uninsured have
negatively affected by working age and retirees have the
worse quality of care, as measured
access barriers faced by same coverage in most European
countries. by provision of evidence-based,
the uninsured? recommended processes of care
In addition, there is evidence to that are likely to improve patient
When comparing the quality of
suggest that access barriers are an outcomes. In fact, a study by Asch
care in the United States to that of
issue affecting U.S. performance, et al.51 found that health insurance
other countries it is impossible to
in particular. As compared with the status was largely unrelated to the
ignore one stark difference — the residents of other countries, many quality of care as measured by
fact that close to one-fifth of the more Americans — and adherence to professionally
U.S. population under age 65 is recommended standards of care,
chronically ill Americans — say
uninsured. The United States is among those with at least one
they skip medicines or medical
one of only three countries in the contact with the health care system
appointments due to cost.45 46 Such
OECD, together with Mexico and within a two-year period. This
behavior, which may reflect
Turkey, which has a sizeable share somewhat surprising finding
problems of underinsurance as
of its population lacking coverage. suggests that the access barriers
well as uninsurance, may result in
It stands to reason that some of the impaired health outcomes. By experienced by the uninsured may
gap between United States and contrast, the types of access not result in differential treatment
other countries in average quality problems reported in other once an uninsured person succeeds
may well be related, in at least countries — mainly longer waits in engaging with the health care
some part, to the insurance for elective surgeries — are likely delivery system.
coverage problem in this country. to affect perceptions of service
Most of today’s measures capture quality and reduced quality of life
Summary and
problems of “underuse,” or the during the waiting period without conclusions
share of a population that receives impact on clinical outcomes.47 Taken collectively, the findings
the screening or treatment from international studies of health
indicated, based on agreed medical Based on a comprehensive review
of the relevant research literature, care quality do not in and of
practice standards. For many such themselves provide a definitive
measures, quality and access are the Institute of Medicine48
concluded that the uninsured have answer to the question of how the
intrinsically linked. United States compares in terms of
worse health and higher mortality
There is, in fact, some suggestive than the insured population in the the quality of its health care. While
evidence of a quality-coverage United States. Population based the evidence base is incomplete
relationship. In their updated study studies have shown that uninsured and suffers from other limitations,
of amenable mortality, Nolte and Americans have shorter survival it does not provide support for the
McKee44 suggest that an increase times for conditions such as cancer oft-repeated claim that the “U.S.
in the share of Americans of the breast, colorectum and health care is the best in the
uninsured between the two study prostate than those with world.” In fact, there is no hard
periods may be responsible for the insurance.49 A review of the evidence that identifies particular
failure of the United States to research literature over the past 25 areas in which U.S. health care
improve its performance apace years by Hadley50 found that the quality is truly exceptional.


!

Instead, the picture that emerges information technology, other developed countries achieve
from the information available on differences in the coordination of comparable quality of care while
technical quality and related care and the fragmentation of devoting at most two-thirds the
aspects of health system health care delivery, variations in share of their national income.
performance is a mixed bag, with reliance of incentives for providers
the United States doing relatively and consumers to provide and Faced with the evidence, one
well in some areas — such as select care based on consideration might well ask why it is that
of quality). We do know, however, assertions of the superiority of
cancer care — and less well in
from a five-country survey of U.S. health care are so common.
others — such as mortality from
primary care physicians52 that U.S. Technical definitions and popular
conditions amenable to prevention
physicians’ practices are more conceptions of quality include
and treatment. Many Americans
limited in information capacity, many different dimensions and
would be surprised by the findings
provide less patient access outside there may not be agreement about
from studies showing that U.S.
of traditional work hours, and are which dimensions are most
health care is not clearly superior
among the least likely to work in important. For example, people
to that received by Canadians, and
teams or to receive financial who make the claims that the
that in some respects Canadian
rewards for quality, all factors that United States has the “best quality
care has been shown to be of
could bear on the quality of of care” in the world may be
higher quality.
primary care furnished. prioritizing a degree of access to
To be sure, there are limitations to medical technology and innovation
the current evidence base. In Taken together, these studies do which they believe to be unique to
particular, there is no data or provide a strong basis for the United States. Perhaps media
evidence by which to answer the determining whether proposed attention paid to outcomes for a
question of whether the United health reform initiatives might select few (e.g., multiple organ
States is a place where one finds threaten or, alternatively, transplant recipients, high-risk
health care that exceeds the quality strengthen the current level of U.S. delivery of multiple births) has
of the best care available quality. While evidence is not cast into shadow the average
elsewhere in the world — in other conclusive, it is clear that the outcomes of the majority of
words, whether the “best U.S. argument that reform of the U.S. Americans with more routine, yet
health care is the best in the health system stands to endanger serious, conditions and other
world.” Although it is often held “the best health care quality in the health care needs.
that the U.S. strength lies in state- world” lacks foundation. Like
other countries, the United States But a less-than-fully informed
of-the-art, technically oriented public comes at a cost in that
care, especially focused on has been found to have both
strengths and weaknesses in terms assertions of excellence divert
“rescue” care, rather than care for attention from the need to inspire
more routine acute and chronic of the quality of care available, and
the quality of care the population and foster systematic quality
conditions, studies typically do not improvement activities.
compare the “best” care offered in receives. The main ways in which
the United States differs from Furthermore, there seems to be a
different countries. Further, there routine genuflection to the
remain other aspects of health care other developed countries are in
the very high costs of its health widespread belief of U.S. quality
for which we have no quality excellence, even among experts. In
measures or inadequate data for care and the share of its population
that is uninsured. an environment where even
comparisons. insured Americans receive only
Existing studies also fail to tell us In the light of the fact that the about half of the services that
much at all about the reasons for United States spends twice as experts consider necessary, there is
the apparent differences in quality much per person on health care as a strong argument for placing
observed across countries, its peers, those who question the quality firmly on the health reform
although numerous hypotheses value for money obtained in U.S. agenda.53 In short, health reform
have been put forward (e.g., health expenditures are on a firm can be seen as an opportunity to
differences in the use of health footing. The evidence suggests that systematically improve quality of


!

care, rather than as a threat to has the “best” quality of care in the health system on quality. If reform
existing levels of quality. world are sometimes put forward accomplishes no more than
to support views that reforms are extending insurance coverage to
Health reform provides an unwarranted on quality grounds the more than 45 million
opportunity to build on strengths and even risky —!particularly Americans without insurance, it
and correct weaknesses, work those reforms that would modify will be an important step forward,
towards aims for improvement, U.S. health financing, coverage or but more is needed to ensure health
such as those defined by IOM in delivery arrangements in ways care quality improvement. To the
Crossing the Quality Chasm,54 that similar to those used in other extent it is possible to improve
care be safe, effective, patient- countries. health care delivery through
centered, timely, efficient and reforms that strengthen incentives
equitable. The IOM continues to On the basis of this review it is to apply knowledge and meet
push for quality improvement safe to say that U.S. health care is quality standards, employ
based on the evident gap between not pre-eminent on quality; technology to reduce errors and
what is done and what should be furthermore, one can surely argue ensure appropriate care, and help
done, what can be achieved and that U.S. health care quality is not consumers and patients demand
what is achieved, but international at risk from the kinds of health better quality, even more might be
comparisons have not played a reform proposals receiving achieved.
major role in pushing forward that attention. On the contrary, our
message. On the contrary, findings strengthen arguments that
unsubstantiated claims that, despite reform is needed to improve the
any shortfalls, the United States relative performance of the U.S.


!
14 26
Notes! Davis, K, C Schoen, S C Schoenbaum, AJ
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The views expressed are those of the authors and should not be attributed to any campaign or to the Robert Wood Johnson
Foundation, or the Urban Institute, its trustees, or its funders.

About the Authors and Acknowledgements
Elizabeth Docteur is an independent health policy analyst and researcher. She was formerly the deputy head of the health
division at the Organization for Economic Cooperation and Development from 2005 to 2009. Robert A. Berenson is an Institute
Fellow at the Urban Institute.
The authors thank Stan Dorn, Kelly Devers, Elizabeth McGlynn, Sheila Leatherman, and Michael Millenson for their comments
and suggestions. This research was funded by the Robert Wood Johnson Foundation.

About the Urban Institute
The Urban Institute is a nonprofit, nonpartisan policy research and educational organization that examines the social, economic,
and governance problems facing the nation.

About the Robert Wood Johnson Foundation
The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation’s
largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a
diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful, and timely change.
For more than 35 years, the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems
that affect the health and health care of those it serves. When it comes to helping Americans lead healthier lives and get the care
they need, the Foundation expects to make a difference in your lifetime. For more information, visit www.rwjf.org.
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