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US and Developed Countries: Comparing Health Care Systems - 2014
Steven Miles, MD
University of Minnesota
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Efficiency: Outcomes for $
How does the US stack up?
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$/person-yr (adjusted for purchasing power parity)
OECD 2013
The Organization for Economic Cooperation and Development
was founded in 1961 to compile statistics and policy reports to
promote economic growth.
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OECD 2014
Efficiency as $/person-yr & Infant Mortality /1000
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Efficiency as $/person-yr & Life Expectancy at Birth
OECD 2014
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OECD 2014
Efficiency as $/person-yr & Life Expectancy at 60
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Mortality Rates Amenable to Provision of Health Care 1997-2003
Health Aff 2008;58-71. (See also
Health Aff 2012;31:2114-22.
<75 yo. Amen Mort is deaths preventable by HC system, e.g. CA,
CVD, DM, inf, etc. Rates are /100,000
USA has highest ratesof preventable death
and smallest decreasesin preventable deaths
We are falling further behind!
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How do other countries succeed? Is rationing their secret?
If rationing Improves outcomes, is health care toxic?
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Do they ration Doctors? No.PS: There is no rationing of nurses either.
OECD 2014
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Do they do it by rationing doctor visits? No.( per person-yr)
OECD 2014
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OECD 2014
Do they ration hospital admission or stays? No.
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Do they ration length of hospital stays for heart attacks? No.
OECD 2014
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Do they ration coronary bypasses and angioplasty and accept more heart attack deaths? No.
OECD 2011 We do more but we do not have lower heart attack mortality.
Age adjusted
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High tech rationing vs. preventing end stage organ failure.
Less dialysis and transplantation looks like rationing
US v Norway have same incidence of early kidney disease but disease going to kidney failure reflects better routine health care.
J Am Soc Nephrol 2006;17:2275-84.Per 100,000OECD 2011
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US has Shorter Wait Times for Elective Surgery …
OECD Health at a Glance: 2011
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OECD 2012 Compiled by Commonwealth
… but this does not mean more service is provided: Hip Replacements.
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Hip Replacement and Health Spending
OECD 2011: Compiled by Commonwealth
Hip Replacement /100,000
Per pers $
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Myth: So if other nations do not have lower costs by rationing, the American Consumer must be a Health System Wrecker.
Old ObeseSmoking DrinkingOver financed Armed with Lawyers
The American Consumer is too:
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Myth: The US Health System is handicapped relative to other developed countries because Americans drink & smoke more.
OECD 2014
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Myth: US Health Care Costs so Much Because Americans are Really Old! We are young!
United Nations: 2011data
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Per Capita Health Spending and % Elderly:A young US uniquely out of position to deal with an aging population.
OECD 2012, US Census Dept
% of population over 65
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Myth: Health Care Costs are High Because of ICU Care of Very Old.
Last year of life
11% USA health $,
27% Medicare costs (flat x20y) Health Aff 2001;20:188-95.’
Age-specific disability is falling.
Hospital costs drop 50% from 65 to 85
years old.
Nursing home, home care, drugs) rise
from 65-85 years old, more than offset
fall in hospital costs.
Overall no trend in costs vs age at death. Milbank Q 2007;85:213-57 JAMA 2001;2861349-55.
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Americans are Heavy (but there is missing data)
OECD 2014
Obese % Adults BMI > 30 Kg/M2 e.g. 5’9” 200+ pounds
Health care costs increase for people with BMI > 35 (237 lbs). Most of this occurs late in life (US is a young country). Obesity accounts for 2-4% of our
excess costs relative to other developed countries. Health Affairs 2003;(May).
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Myth: US Health Care Costs so Much Because Americans don’t Personally Pay for Health Care
Note: Our gov expenditures are comparable to other nations!
OECD 2013 Pre ACA
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Myth: Malpractice Costs are why US Health Care Costs so Much.
Malpractice costs (insurance, awards, court costs) is .5% of health spending. (A third higher than
other developed countries.) Defensive medicine) is
1.9% of health spending. Health Affairs,
2009;29:1569-77.
National tort reform to reduce suits and awards would reduce direct and indirect (e.g., defensive medicine) costs, reducing health spending 0.5%. Congressional Budget
Office, 2009
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How do they do it?
(or, How can we do better?)
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OECD 2012
Income Inequality, Health Spending, and Life Expectancy
Lower Inequality associated with:
Education, Obesity, Heart disease, Stroke, Unhealthy behaviors
High Inequality
Med Inequality
Low InequalitySoc Sci & Med 2008;66:1719-32.
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Primary Care Orientation
10 Care Oriented (2 high) Longitudinal Comprehensive Coordinated with
secondary/tertiary care Community located
Health Policy 2002;60:201-18.
Low 10 care orient
USA
High Primary Care Associated with Lower Health Care Costs
Per person costs/yr Note: data is not updated
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Primary Care Orientation Improves Health Outcomes
Many fewer low birth weight babies. Less bronchitis, emphysema, heart disease
asthma, and death from pneumonia mortality. Fewer productive years lost 0-69. Higher life expectancy at 40 and 65 years of
age. Milbank Quarterly 2005;83:457-502. Health Policy 2002;60:201-18.
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$/person-yr & Asthma Admissions /100,000 (adults age-standardized)
OECD 2012
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% with Unmet Medical Care due to Costs
OECD 2011
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Primary Care Barriers
Health Aff 2007;10. w7171-34.
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Out-of-Pocket Medical Costs/Year(% of adults with chronic disease)
2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.
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Lessons from Developed Nations
A universal primary care orientation controls costs and improve public outcomes.
Low point of service charges are essential for timely/cost effective primary health care.
Universal enrollment is forced price discipline!
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Many Models for Universal Health Care National Health Service-UK Single tax-based financing to regulated private
managed care plans with mandatory enrollment, specified benefits, portability etc- Germany
Multiple, progressive tax based financing for regulated, competing public and private insurers-France.
Single insurer-Canada.