The US Health Care System in International Perspective

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 OECD 2008

$/person-yr & F Life Expectancy at 65 OECD 2008

$/person-yr & Healthy Years Lost OECD 2005

Death rates/10, 000 of 15 year old women by age 60 Overall: US is 38 th in chance of 15 year old women reaching age 60, below Costa Rica 78 and Slovakia 80/10, 000. Int J Health Serv 2005; 35: 291 -311

Amenable Mortality and Decline in Amenable Mortality 1997 -2003 <75 yo. Amen Mort is deaths preventable by HC sys, e. g. CA, CVD, DM, inf, etc. Rates are /100, 000 Health Aff 2008; 58 -71

WHO: Health System Rating n Good health 50% n n n Responsiveness (cleanliness, promptness, confidentiality, respect) 25% n n n Average cohort survival, disability 25% (24) Disparities 25% (32) 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 n 10 Care Oriented (2 high) n n Longitudinal Comprehensive Coordinated with secondary/tertiary care Community located USA Low 10 care orient Health Policy 2002; 60: 201 -18. Per person costs/yr

Higher Primary Care Orientation: n n n 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. n n HSR 2003; 38: 831 -64. Health Policy 2002; 60: 201 -18.

Primary Care Barriers Health Aff 2007; 10. w 7171 -34.

European Dental Plans n Norway: Free dental care to 18 y. Some states provide 75% of costs for 19 -20 y which does not affect demand for care. n n Denmark: Use and cost increased inflation due to diagnostic /preventive services rather than restorative / extraction care. n n Health Econ 1996; 5: 119 -28. 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 . n 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 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 B 01 Deamonte Driver next to his mother. (scars from brain surgery).

MD Access by Lowest 35% Income Health Policy 2000; 51 L 67 -85

Class, 5 yr Cancer Survival: Access matters. Low Income AJPH 2000; 90: 1866 -72

Out Of Pocket drug costs: compliance. Bubble Size = % non compliant with meds Health Aff 2008; 27: 89 -102

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 n 54, 000 persons, 9 countries, GUSTO 1, 2 & Assent n Eligible for early discharge n n Lancet 2004; 363: 511 -17 Same trend for normal delivery (e. g. US 1. 9, France 4. 4) n OECD 2005

Rationing: CABG, Angioplasty, MI Deaths? OECD 2008

Acute Myocardial Infarction Minneapolis, US Goteberg, Sweden Angiography 33 PTCA/CABG 62 58 Exercise test 51 B blockers 62 Short Nitrates 54 59 87 66 1, 36 m’nth survl 34 Identical American Heart Journal 2003; 146: 1023 -9.

Per 100, 000 persons Rationing Transplants? 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 OECD in Health Affairs 2006; 25: 819 -31

Canadian Waiting Times n Wait for elective surgery is 31 days and does not differ by economic status n n Waiting for elective cholecystectomy has no adverse effect before 19 weeks. n n CMAJ 2003; 168: 413 -6. CMAJ 2003; 169: 662 -5 Waiting for elective hip has no adverse effect before 6 months at which time Qo. L and mobility decrease. n CMAJ 2002; 167: 661115 -21.

Hip Replacement 5 /10 persons Ann Rhemu Dis 2003; 62: 222 -6

Hip Replacement 5 /10 persons Data from Ann Rhemu Dis 2003; 62: 222 -6 and OECD

Mammograms US/UK: More aggressive bx, more false +, no improved dx. n JAMA 2003; 290: 2129 -2137. F 50+, 3. 9 million UK mammograms UK, 1. 5 in US, 1996 -9. 50 -54 yo

Is the American Consumer a Health System Wrecker? Old Smoking Over financed Obese Drinking Armed with Lawyers

Myth: The US Health System Costs so Much Because Americans Drink and Smoke so Much OECD 2008

Myth: US Health Care Costs so Much Because Americans are Really Old! UN Dept of Economic and Social Affairs 2007

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. n Last year of life n n 27% M’care costs (flat x 20 y) n n 11% USA health $ Health Aff 2001; 20: 188 -95. Universal use of n n n Advance directives Hospice care Futility guidelines would save US 3. 5% med $. n NEJM 1993: 1092 JAMA 2001; 2861349 -55.

Americans are Heavy % Adults BMI > 30 Kg/M 2 OECD 2007 -8 e. g. 5’ 9” 200+ pounds

Obesity does raise health costs, esp in elderly. HC costs in $1000 s from 65 to death or 83 yo JAMA 2004; 292: 2743 -9. n n 2 -4% of our excess costs relative to other developed countries. 11% of Medicare $ Health Affairs 2003; (May).

Myth: US Health Care Costs so Much Because Americans don’t Personally Pay for Health Care OECD 2005

Myth: Malpractice Costs are Why US Health Care Costs so Much % of US Health Spending n Insurance, awards, settlements, legal fees. 46% n Health Affairs 2005, 24: 903 -914 Defensive medicine ? 2 -6% 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.

Lessons from Developed Nations n n 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. n n n N Eng J Med 1995; 332: 742 -6. Universal access Enables price discipline. Low administrative costs Increases equitable access to health care. Rationalizes capacity & empowers broad political pressure against harmful clinical rationing.

Lessons from Developed Nations n n 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 n n 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.

Steve Miles, MD Slides available Miles 001@umn. edu