Phusit Prakongsai International Health Policy Program (IHPP) Ministry of Public Health, Thailand

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Mirror, Mirror on the Wall:How the Performance of the US Health Care System Compares Internationally

Phusit PrakongsaiInternational Health Policy Program (IHPP)

Ministry of Public Health, Thailand

29 July 2010

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ndBackground

• The US health system is the most expensive in the world.

• Comparative analyses consistently show the US underperforms relative to other countries on most dimensions of performance.

• The Commonwealth Fund Commission on a High Performance Health System employed the National Scorecard to measure and monitoring health care outcomes, quality, access, efficiency, and quality in the US in 2006 and 2008.

• This 2010 report includes information on: – health care outcomes in the 2008 US health system

scorecard,– Most recent three Commonwealth Fund surveys of patients

and primary care physicians in 2007-2009.

Healthcare spending as % of GDPOECD countries, 2008

Growth in personal health care expenditures in the US

from 1990 to 2007

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Core dimensions of Commonwealth National Scorecard

Measuring and monitoring health system performance

Efficiency

Equity Access

Quality care

Long, healthy,

and productive lives

Commonwealth

National

Scorecard

• Effective care

• Safe care

• Coordinated care

• Patient-centered care

• Cost-related access problems

• Timeliness care

1. Quality care1.1 Effective care

Source AUS CAN

GER NETH NZ UK US

PreventionPhysicians reporting it is easy to print out a list of patients who are due or overdue for tests or preventive care

2009 63(3)

18(7)

37(5)

65(2)

57(4)

90(1)

24(6)

Patients sent computerized reminder notices for preventive or follow-up care

2009 82(2)

10(7)

17(6)

48(4)

92(1)

76(3)

18(5)

Receive reminders for preventive/ follow-up care

2007 44(6)

40(7)

57(4)

58(2.5)

48(5)

58(2.5)

70(1)

Doctor asked if emotional issues were affecting health

2007 37(2)

36(3)

25(6.5)

27(5)

31(4)

25(6.5)

46(1)

Received advice from doctors on weight, nutrition, and exercise

2007 41(3)

46(2)

37(4)

24(7)

36(5)

29(6)

56(1)

Overall benchmark ranking

2 7 6 3 5 1 4

1. Quality care1.1 Effective care

Source AUS CAN

GER NETH NZ UK US

Chronic careDiabetics receiving all four recommended services*

2008 36(7)

39(6)

40(5)

59(2)

55(3)

67(1)

43(4)

Practice routinely uses written guidelines to treat diabetes

2009 87(4)

82(5.5)

77(7)

98(1)

93(3)

96(2)

82(5.5)

Patients with HT who have had cholesterol checked in past year

2008 82(4)

83(3)

88(1)

78(6)

75(7)

81(5)

85(2)

Practice routinely uses written guidelines to treat HT

2009 83(3)

81(4)

75(6.5)

90(2)

75(6.5)

96(1)

78(5)

Practice routinely uses written guidelines to treat depression

2009 71(2)

45(5)

26(7)

31(6)

65(3)

80(1)

49(4)

Has chronic condition and did not follow recommended care because of cost

2007 11(6)

7(3)

0(1)

1(2)

9(4)

10(5)

24(7)

Primary care practices that routinely provide chronic dis patients written instructions

2007 24(3)

16(6)

23(4)

22(5)

15(7)

33(1)

30(2)

* Four recommended services include HbA1C checked in the past six months, feet examined, eye exam, and cholesterol checked in the past year.

1. Quality care1.2 Safe care

Source AUS CAN

GER NETH NZ UK US

Believed a medical mistake was made in your treatment or care in past 2 years

2008 17(7)

16(5.5

)

12(3)

9(2)

15(4)

8(1)

16(5.5)

Given the wrong medication or wrong dose by a doctor, nurse, hospital, or pharmacist in past 2 years

2008 13(5.5)

10(4)

7(2)

6(1)

13(5.5

)

9(3)

14(7)

Given incorrect results for a diagnostic or lab test in past 2 years

2008 7(6.5)

5(4.5

)

5(4.5

)

1(1)

3(2.5

)

3(2.5)

7(6.5)

Experienced delays in being notified about abnormal test results in past 2 years

2008 13(6)

12(5)

5(1.5

)

5(1.5)

10(4)

8(3)

16(7)

Hospitalized patients reporting infection in hospital

2008 7(4.5)

6(2.5

)

6(2.5

)

5(1)

11(7)

10(6)

7(4.5)

Doctors routinely receives a computerized alert or prompt about potential problem with drug dose or interaction

2009 92(3)

20(7)

24(6)

95(1)

90(4)

93(2)

37(5)

2. Access to care

Source AUS CAN

GER NETH NZ UK US

Cost-related access problems

Did not fill the prescription: skipped recommended medical test, RX or follow-up in the past 2 years due to cost

2008 36(6)

25(3)

26(4)

7(1)

31(5)

13(2)

54(7)

Patient had serious problems paying or was unable to pay medical bills

2007 8(5.5)

4(2.5

)

4(2.5

)

5(4)

8(5.5

)

1(1)

19(7)

Physicians think their patients often have difficulty paying for medications or OOP costs

2009 23(2)

27(4)

28(5)

33(6)

25(3)

14(1)

58(7)

OOP expenses for medical bills more than 1000 USD in the past year

2008 25(6)

20(5)

13(3)

8(2)

14(4)

4(1)

41(7)

Overall benchmark ranking

6 3.5 3.5 2 5 1 7

3. Efficiency measuresSource AUS CA

NGER NETH NZ UK US

Total exp on health as percent of GDP

2007 8.9(2)

10.1(5)

10.4(6)

9.8(4)

9.0(3)

8.4(1)

16.0(7)

% of national health expenditure spent on health administration and insurance

2007 2.6(1)

3.6(3)

5.3(5)

5.2(4)

7.4(7)

3.4(2)

7.1(6)

Medical records/test results did not reach MD office in time for appointment

2008 16(4)

19(6)

12(2)

11(1)

17(5)

15(3)

24(7)

Sent for duplicate tests by different health care professionals in past 2 years

2008 12(5)

11(4)

18(6)

4(1)

10(3)

7(2)

20(7)

Visited ED for a condition that could have been treated by a regular doctor

2008 17(5)

23(7)

6(1.5

)

6(1.5)

8(3.5

)

8(3.5)

19(6)

Hospitalized patients went to ER or re-hospitalized for complications from discharge

2008 11(3.5)

17(5.5

)

9(1)

17(5.5)

11(3.5

)

10(2)

18(7)

Overall benchmark ranking

2 6 5 3 4 1 7

4. Health equity

Source AUS CAN

GER NETH NZ UK US

Rated doctor fair/poor 2007 5(5)

5(5)

3(2.5

)

5(5)

0(1)

3(2.5)

9(7)

Had medical problem but did not visit doctor because of costs in the past year

2008 0(3)

8(5)

-2(1.5

)

1(4)

20(6)

-2(1.5)

24(7)

Did not get recommended test or treatment or follow-up because of cost in the past year

2008 15(6)

6(3.5

)

3(1.5

)

3(1.5)

10(5)

6(3.5)

19(7)

Did not fill prescription or skipped doses because of cost in the past year

2008 6(2)

9(5)

7(3.5

)

0(1)

16(6)

7(3.5)

18(7)

Need dental care but did not see dentist because of cost in past year

2008 13(5)

20(6)

6(3)

2(2)

7(4)

-5(1)

28(7)

Last time needed medical attention had to wait 6 or more days for appointment

2009 3(4)

11(6)

6(5)

-1(1.5)

1(3)

-1(1.5)

13(7)

Overall ranking 4 5 3 1 6 2 7

5. Long, healthy, and productive lives measures

Source AUS CAN

GER NETH NZ UK US

Mortality amenable to health care (deaths per 100,000)

2003 71(1)

77(2)

90(4)

82(3)

96(5)

103(6)

110(7)

Infant mortality 2006 4.7(3)

5.0(4.5

)

3.8(1)

4.4(2)

5.2(6)

5.0(4.5)

6.7(7)

Healthy life expectancy at age 60 (average of women and men)

2006 24.6(1)

23.8(2)

23.0(4)

22.8(5)

23.7(3)

22.5(7)

22.6(6)

Overall ranking 1 2 3 4 5 6 7

Overall ranking of health systems among seven countries

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Summary key findings• Quality

– The US was best on provision and receipt of preventive and patient-centered care,

– However, its low scores on chronic care management, and safe and coordinated care which pull its overall quality score down,

• Access– Without universal coverage, costs related access problems

in the US were higher than other countries,• Efficiency

– The US ranks last among the seven countries, while the UK and Australia ranking first and second, respectively.

• Equity– The US ranks a clear last on nearly all measures of equity.

• Long, healthy and productive lives– The US ranks last overall with poor scores on all three

indicators of long, healthy, and productive lives.

Efficiency analysisPer capita THE at inter dollar with Life

expectancy

USA

Monitoring & Evaluation of health systems reform /strengtheningA general framework for HSPA

Data sources

Indicatordomains

Analysis & synthesis

Communication & use

Administrative sourcesFinancial tracking system; NHADatabases and records: HR, infrastructure, medicines etc.Policy data

Facility assessments Population-based surveysCoverage, health status, equity, risk protection, responsiveness

Clinical reporting systemsService readiness, quality, coverage, health status

Vital registration

Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems

Targeted and comprehensive reporting; Regular country review processes; Global reporting

Improved health outcomes

& equity

Social and financial risk protection

Responsiveness

Fina

ncin

gInfrastructure

/ ICT

Health workforce

Supply chain

Information

Interventionaccess & services

readiness

Interventionquality, safety and efficiency

Coverage of interventions

Prevalence risk behaviours &

factors

Gov

erna

nce

Inputs & processes Outputs Outcomes Impact

Health Systems

Assessment Approach of

HS 20/20

Sub-national HSPAImmunization coverage <1 year by district in SA

2007-2008

Source: District Health Barometer 2007-08

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20

Thank you

for your

attentio

n