U.S. Health: First in Spending but Last in Results…Why?

America’s top clinical talent and mega-investments in “health services” do not correlate to better overall health compared to other countries. Learn why.

Let’s get the good news out of the way first.

If you are going to get sick and have great insurance or lots of money, there is no better place to do so than in the United States. We excel at taking care of really sick people.

Medical miracles are performed daily through an amazing pool of talented clinicians who have access to the best technology, facilities and pharmaceuticals.

In this regard, we are the envy of the rest of the world. But there remains a most vexing question: Why do we invest more in healthcare than any country on the planet to have the “best of the best”, only to come in last compared to other countries in success measures like outcomes, longevity, quality and access?

Simply put, America’s mega-investment in “health services” does not correlate to better overall health.

The Commonwealth Fund is a private foundation started in 1918 by one of America’s first female philanthropists Anna Harkness. Its mission is to research, study and promote high performing health care systems to achieve better access, improved quality, and greater efficiency, particularly for society’s most vulnerable citizens.
 
Paying More for Less
In its most recent report, Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care, the authors note that despite having the most expensive health care, the United States ranks last overall among the 11 countries on measures of health system equity, access, administrative efficiency, care delivery, and health care outcomes.

While there is room for improvement in every country, the U.S. has the highest costs and lowest overall performance of the nations in the study, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The U.S. spent $10,739 per person on health care in 2017, compared to $4,094 in the U.K., which ranked first on performance overall.

Among the 11 high-income countries surveyed, the U.S. is the only one without universal health insurance coverage. The U.S. offers its citizens the least financial protection among these wealthy countries.

Since 2004, the U.S. has ranked last in every one of six similar reports.

In a recent issue of the New England Journal of Medicine, lead author and Commonwealth Fund senior vice president for policy and research Eric Schneider, M.D. reflected on lessons from top performing countries and actions the U.S. could take to move from last to first among wealthy countries. They include:

  • Expand health insurance coverage. The highest-performing countries have universal coverage that allows people to get the health care they need at little or no cost.
  • Invest more in primary care. Spending up front to make primary care accessible, available on nights and weekends, and affordable keeps people healthier and reduces costs in the long run.
  • Cut down on paperwork. The U.S. leads the world when it comes to time spent dealing with the requirements of our cumbersome health insurance system. Reducing the administrative burden would give countless hours back to patients, caregivers, and physicians while also making the system easier for people to navigate.
  • Invest more in social services to reduce disparities. Factors beyond traditional health care, such as housing, education, nutrition, and transportation, have a substantial effect on people’s health. Investing in services that provide support in these areas can make our population healthier as a whole and reduce health care costs.

Additional report findings related to improving the U.S. health system include:

  • Access to Care: Other studies show that access to care and ability to afford care have improved markedly in the U.S. following the Affordable Care Act. Nevertheless, compared to other countries, Americans of all incomes have the hardest time affording the health care they need. The U.S. ranks last on most measures of financial barriers to care, with one-third (33%) of adults reporting they did not take a prescription drug, visit a doctor when sick, or receive recommended care in the past year because of the expense. This is four times the rates for patients in Germany (7%), the U.K. (7%), Sweden (8%), and the Netherlands (8%).
  • Health Care Outcomes: The U.S. ranks last overall on health care outcomes. Compared to other countries, the U.S. comes in last on infant mortality, life expectancy at age 60, and deaths that were potentially preventable with timely access to effective health care. However, there are some bright spots: the U.S. performs relatively well on certain clinical outcomes, such as lower in-hospital mortality rates for a heart attack or stroke and is a top performer in breast cancer survival.
  • Care Process: The U.S. ranks in the middle for care process, which is a combination of four separate measures: delivery of preventive services, safety of care, coordinated care, and patient engagement. On three of the four measures, the U.S. ranks near the top, coming in third on safety and fourth on prevention and engagement. The U.S. tends to excel on measures that involve the doctor–patient relationship, wellness counseling, and preventive care, such as mammograms and adult flu shot rates.
  • Administrative Efficiency: The U.S ranks near the bottom on this measure because of the amount of time providers and patients must spend dealing with administrative issues, duplicative medical testing, and insurance disputes. More than half (54%) of U.S. doctors reported problems trying to get their patients needed treatment because of insurance coverage restrictions. In Norway and Sweden, which rank first on this measure, only 6 percent of doctors reported this problem.

Special thanks to the Commonwealth Fund for their research as well as the outstanding materials they provide.  


For Consideration:

  • What do you see as the key reasons for the U.S. to have such low performance ratings compared to the investments made in the health system?
  • What might we learn from other countries that invest less but have health measures that are significantly better than the U.S.?
  • Do you believe this data provides a valid comparison of the performance of health systems and also reflect the “performance measures” that are important in assessing value?

Resources:

Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care:

Additional resources my be found by clicking on the “Resources” in the Navigation bar

 

2019: The Ten Greatest Threats to Health Worldwide

How should the planet’s ten biggest health threats affect our approach to health reform in the United States?

The world we live in is facing multiple health challenges. The World Health Organization (WHO) recently released a report detailing the top ten major threats to global health.  From outbreaks of vaccine-preventable diseases like measles, growing rates of obesity, to the health impacts of environmental pollution and climate change, these issues are relevant in our approach to health reform and health policy in the United States.

Here are the planet’s ten biggest health threats according to WHO:

1.    Air pollution and climate change

According to WHO, nine out of ten people breathe polluted air every day. In 2019, air pollution is considered by WHO as the greatest environmental risk to health. Microscopic pollutants in the air can penetrate respiratory and circulatory systems, damaging the lungs, heart and brain, killing 7 million people prematurely every year from diseases such as cancer, stroke, heart and lung disease.

2. Noncommunicable diseases

Seventy percent of deaths worldwide are due to noncommunicable diseases, such as diabetes, cancer, and heart disease.

According to WHO, the five risk factors driving increases in noncommunicable diseases are tobacco use, alcohol use, physical inactivity, unhealthy diets, and air pollution. 

3. Influenza

The world will face another influenza pandemic – the only thing not known is when it will hit and how severe it will be. Global defenses are only as effective as the weakest link in any country’s health emergency preparedness and response system WHO says. 

4. Fragile and vulnerable settings

Over 22% of the world’s population lives in fragile settings, which are defined as places where access to basic health care is minimal, often due to being in a state of crisis and having poor health services.

Fragile settings exist in almost all regions of the world, and these are where half of the key targets in the sustainable development goals, including on child and maternal health, remain unmet. 

5. Antimicrobial resistance

The development of antibiotics, antivirals and antimalarials are some of modern medicine’s greatest successes. Now, time with these drugs is running out. Antimicrobial resistance – the ability of bacteria, parasites, viruses and fungi to resist these medicines – threatens to send us back to a time when we were unable to easily treat infections such as pneumonia, tuberculosis, gonorrhea, and salmonellosis. The inability to prevent infections could seriously compromise surgery and procedures such as chemotherapy. 

Drug resistance is driven by the overuse of antimicrobials in people, but also in animals, especially those used for food production, as well as in the environment, according to WHO.

6. Ebola and high-threat pathogens

When it comes to responding to a high-threat pathogen such as Ebola, context is “critical,” according to WHO. The way a high-threat pathogen spreads and impacts a rural area might look very different from the way it would look in urban areas or active conflict zones—making it difficult for health systems and governments to prepare an effective emergency response.

WHO’s current watchlist of high-treat pathogens includes Ebola, Zika, SARS, and disease X—a placeholder for any unknown pathogen that could cause an epidemic.

7. Weak primary care

Primary care is supposed to be the most consistent and accessible form of health care a patient has over their lifetime, WHO explains. But when a country lacks adequate primary care facilities, patients lack affordable and comprehensive care for their needs, which can cause everyday health problems to evolve into health emergencies.

8. Vaccine hesitancy

Vaccine hesitancy – the reluctance or refusal to vaccinate despite the availability of vaccines – threatens to reverse progress made in tackling vaccine-preventable diseases. Vaccination is one of the most cost-effective ways of avoiding disease – it currently prevents 2-3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccinations improved. 

Measles, for example, has seen a 30% increase in cases globally. The reasons for this rise are complex, and not all of these cases are due to vaccine hesitancy. However, some countries that were close to eliminating the disease have seen a resurgence (including the United States). 

9. Dengue

About 40% of the world is at risk of becoming infected with dengue, a mosquito-borne illness that infects 390 million people each year and kills up to 20% of people with a severe form of the disease, according to WHO.

10. HIV

The progress made against HIV has been enormous in terms of getting people tested, providing them with antiretrovirals (22 million are on treatment), and providing access to preventive measures such as a pre-exposure prophylaxis (PrEP, which is when people at risk of HIV take antiretrovirals to prevent infection). 

However, the epidemic continues to rage with nearly a million people every year dying of HIV/AIDS. Since the beginning of the epidemic, more than 70 million people have acquired the infection, and about 35 million people have died.

The list provides an overview of the top 10 health threats WHO and the organization’s partners will target under a five-year strategic plan that kicks off this year. According to WHO, the goal is to ensure one billion more people benefit from access to universal health coverage, one billion more people are protected from health emergencies, and one billion more people enjoy better health and well-being.


For Consideration:

  • Does the WHO list of the top Global Health Risks fit with what you consider to be the top health risks facing the United States?
  • Which risks as noted by WHO should be included in the top health risks faced by Americans?  
  • What other issues do you consider to be the Top Health Risks facing the United States?
  • Many of the top risks defined by WHO are “Social and Environmental Determinants of Health.” What is your view on whether these should be considered part of health reform?

Additional Resources:

Visit the World Health Organization’s web page to learn more about the Top Global Health Threats of 2019.

Review this primer on Social Determinants of Health from NEJM Catalyst.

Go deeper on Social Determinants of Health by visiting the Centers for Disease Control and Prevention’s website: Social Determinants of Health: Know What Affects Health

Has Healthcare Value Improved in the Last 25 Years?

Measuring the value we receive from the U.S. Health system is a tricky but important part of the health reform conversation.

Measuring the value we receive from the U.S. Health system is a tricky but important part of the health reform conversation. If we strip down the complexities there are two questions worth considering:

  • Is the U.S. health system generating better value than in the past?
  • How do factors other than the healthcare system affect health outcomes (compared to other countries)?


As noted in other articles on this site, the United States spends more per citizen than any other country but ranks lower than most on almost all comparative value measures including quality, costs and outcomes.

To examine the issue of “value” the Kaiser Family Foundation developed an approach to measure the level of improvement in health outcomes over time, and the incremental costs incurred by the health system.

This work is part of the Peterson-Kaiser Health System Tracker which includes a “Dashboard” of indicators that can be used to describe, evaluate and compare changes in the value of U.S. healthcare over time. With many measures spanning 25 years, or approximately a generation, the Dashboard paints a picture of how the value of the system has changed over time.

The assessment looks at whether the value of the U.S. health system has improved or worsened from 1991 – 2016 by measuring the level of improvement in health outcomes, and the incremental costs the healthcare system incurred at the same time.

Here is a summary of results:

  • Between 1991 and 2016, life expectancy increased by 3.1 years to 78.6, representing a 4% improvement. In the same time, disease burden (as measured by  something known as the total number of disability adjusted life years, or DALYs) improved by 12%.
  • At the same time, there was a worsening of years living in disability which is largely due to  an increase in substance use disorders. Substance use is actually one of the primary contributors to the decline in life expectancy in 2015 and 2016, the first time life expectancy has dropped two years in a row in several decades. This trend clearly points to the importance of social and environmental determinants being included in the broader debate of health reform.
  • In looking at this data there is a very troubling trend in Women’s Health where outcomes have actually gotten worse.  In the United States maternal mortality has gone up significantly from 14 deaths per 100,000 live births in 1991 to nearly 31 in 2016.  

The good news is that the study shows that health outcomes have generally improved in the U.S. over the past 25 years as measured by life expectancy and disease burden. However, since value is a function of outcomes and costs, one must also take into account the increase in health spending

In 1991, the Gross Domestic Product (GDP) attributable to healthcare was 12.8% or $788 billion. By 2016, healthcare consumed 17.9% of GDP or $3.3 Trillion. This brings us to a key question in how we evaluate value:

  • Is the 4% improvement in life expectancy and 12% reduction in disease burden enough to warrant a 40% increase in GDP consumption over the past 25 years?
  • What does this portend for future access and affordability? This is an especially important issue to address as part of health reform in the United States as we consider a shift in demographics such as increase in elderly population, as well as the impact of other key health challenges such as the Opioid epidemic.

As a comparison to America’s performance as noted above, similar nations during the same period generated an average increase in life expectancy of 5.2 years, or 7%, compared to the U.S.’s 3.1 years, or 4% improvement. In these countries, disease burden improved by 22%, compared to the U.S.’s 12%.

By these indicators, comparable countries spent under two thirds (60%) of what the U.S. spent on healthcare relative to GDP.

Relative to the health reform debate, another interesting finding is that the United States spends less on social services and more on healthcare,  but has worse health outcomes than similar countries.

And so, to summarize the question of whether value from the healthcare system has improved:

  • The outcomes generated by U.S. healthcare as measured by life expectancy, mortality amenable to healthcare, and years lost to premature death have improved over the past quarter century.
  • Total years living in disability have increased with mental health and substance use issues being the leading contributors to the increase.
  • If total spending for health had remained constant at 12.8% of GDP, one could easily conclude that the value proposition had improved dramatically. Unfortunately, healthcare spending in 2016 consumed 17.9% of the nation’s wealth, which is a 40% increase from 1991.  

This assessment points to a significant opportunity to be more efficient and effective in improving life expectancy and reducing the burden of disease while shedding light on socioeconomic factors and the potential impact lower investment in social services is having on outcomes.


For Consideration:

  • Did improvements seen over the past quarter century need to cost this much as they did?
  • Had the level of investment in the U.S. health system been at a similar level (percentage of GDP) from 1991, or mirrored other countries, what else might we have invested in to improve the health and wellbeing of citizens?
  • Do you believe that higher levels of investment in public and social services (as happens in other countries) correlates to higher levels of health outcomes?

Additional Resources:


Americans Remain Dissatisfied With Healthcare Costs

This report from Gallup summarizes results of a recent poll showing that most Americans consider healthcare costs and access to be a major issue. Provides a breakdown of the issues along with useful charts to explain details surrounding the issues.

Peterson-Kaiser Health System Dashboard

This site includes a rich set of data from credible sources that allow users to explore a variety of indicators of health spending, quality of care, access, and health outcomes. Provides great visuals and infographics that can be downloaded and used (with attribution). While easy to use, the site also includes a brief tutorial.

The Kaiser Family Foundation (KFF)

The Kaiser Family Foundation (KFF) is a non-profit, private operating foundation focusing on the major health care issues facing the U.S., as well as the U.S. role in global health policy. KFF’s website focuses on policy research, basic health care facts and numbers, and health reform implementation information. The Kaiser Family Foundation is not associated with Kaiser Permanente or Kaiser Industries.