US and Developed Countries Comparing Health Care Systems

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US and Developed Countries: Comparing Health Care Systems - 2014 Steven Miles, MD University

US and Developed Countries: Comparing Health Care Systems - 2014 Steven Miles, MD University of Minnesota

Efficiency: Outcomes for $ How does the US stack up?

Efficiency: Outcomes for $ How does the US stack up?

$/person-yr (adjusted for purchasing power parity) OECD 2013 The Organization for Economic Cooperation and

$/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.

Efficiency as $/person-yr & Infant Mortality /1000 OECD 2014

Efficiency as $/person-yr & Infant Mortality /1000 OECD 2014

Efficiency as $/person-yr & Life Expectancy at Birth OECD 2014

Efficiency as $/person-yr & Life Expectancy at Birth OECD 2014

Efficiency as $/person-yr & Life Expectancy at 60 OECD 2014

Efficiency as $/person-yr & Life Expectancy at 60 OECD 2014

Mortality Rates Amenable to Provision of Health Care 1997 -2003 USA has highest rates

Mortality Rates Amenable to Provision of Health Care 1997 -2003 USA has highest rates of preventable death and smallest decreases in preventable deaths <75 yo. Amen Mort is deaths preventable by HC system, e. g. CA, CVD, DM, inf, etc. Rates are /100, 000 We are falling further behind! Health Aff 2008; 58 -71. (See also Health Aff 2012; 31: 2114 -22.

How do other countries succeed? Is rationing their secret? If rationing Improves outcomes, is

How do other countries succeed? Is rationing their secret? If rationing Improves outcomes, is health care toxic?

Do they ration Doctors? No. PS: There is no rationing of nurses either. OECD

Do they ration Doctors? No. PS: There is no rationing of nurses either. OECD 2014

Do they do it by rationing doctor visits? No. ( person-yr) OECD 2014

Do they do it by rationing doctor visits? No. ( person-yr) OECD 2014

Do they ration hospital admission or stays? No. OECD 2014

Do they ration hospital admission or stays? No. OECD 2014

Do they ration length of hospital stays for heart attacks? No. OECD 2014

Do they ration length of hospital stays for heart attacks? No. OECD 2014

Do they ration coronary bypasses and angioplasty and accept more heart attack deaths? No.

Do they ration coronary bypasses and angioplasty and accept more heart attack deaths? No. Age adjusted OECD 2011 We do more but we do not have lower heart attack mortality.

High tech rationing vs. preventing end stage US v Norway have same incidence of

High tech rationing vs. preventing end stage US v Norway have same incidence of early organ failure. kidney disease but disease going to kidney failure reflects better routine health care. Less dialysis and transplantation looks like rationing OECD 2011 Per 100, 000 J Am Soc Nephrol 2006; 17: 2275 -84.

US has Shorter Wait Times for Elective Surgery … OECD Health at a Glance:

US has Shorter Wait Times for Elective Surgery … OECD Health at a Glance: 2011

… but this does not mean more service is provided: Hip Replacements. OECD 2012

… but this does not mean more service is provided: Hip Replacements. OECD 2012 Compiled by Commonwealth

Hip Replacement and Health Spending Per pers $ Hip Replacement /100, 000 OECD 2011:

Hip Replacement and Health Spending Per pers $ Hip Replacement /100, 000 OECD 2011: Compiled by Commonwealth

Myth: So if other nations do not have lower costs by rationing, the American

Myth: So if other nations do not have lower costs by rationing, the American Consumer must be a Health System Wrecker. The American Consumer is too: Old Smoking Over financed Obese Drinking Armed with Lawyers

Myth: The US Health System is handicapped relative to other developed countries because Americans

Myth: The US Health System is handicapped relative to other developed countries because Americans drink & smoke more. OECD 2014

Myth: US Health Care Costs so Much Because Americans are Really Old! We are

Myth: US Health Care Costs so Much Because Americans are Really Old! We are young! United Nations: 2011 data

Per Capita Health Spending and % Elderly: A young US uniquely out of position

Per Capita Health Spending and % Elderly: A young US uniquely out of position to deal with an aging population. % of population over 65 OECD 2012, US Census Dept

Myth: Health Care Costs are High Because of ICU Care of Very Old. n

Myth: Health Care Costs are High Because of ICU Care of Very Old. n Last year of life n 11% USA health $, n 27% Medicare costs (flat x 20 y) n Health Aff 2001; 20: 188 -95. ’ n Age-specific disability is falling. n Hospital costs drop 50% from 65 to 85 years old. n Nursing home, home care, drugs) rise from 65 -85 years old, more than offset fall in hospital costs. n Overall no trend in costs vs age at death. n Milbank Q 2007; 85: 213 -57 JAMA 2001; 2861349 -55.

Americans are Heavy (but there is missing data) Obese % Adults BMI > 30

Americans are Heavy (but there is missing data) Obese % Adults BMI > 30 Kg/M 2 e. g. 5’ 9” 200+ pounds OECD 2014 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).

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

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

Myth: Malpractice Costs are why US Health Care Costs so Much. n Malpractice costs

Myth: Malpractice Costs are why US Health Care Costs so Much. n Malpractice costs (insurance, awards, court costs) is. 5% of health spending. (A third higher than other developed countries. ) n Defensive medicine) is 1. 9% of health spending. n Health Affairs, 2009; 29: 1569 -77. n National tort reform to reduce suits and awards would reduce direct and indirect (e. g. , defensive medicine) costs, reducing health spending 0. 5%. n Congressional Budget Office, 2009

How do they do it? (or, How can we do better? )

How do they do it? (or, How can we do better? )

Income Inequality, Health Spending, and Life Expectancy OECD 2012 Lower Inequality associated with: High

Income Inequality, Health Spending, and Life Expectancy OECD 2012 Lower Inequality associated with: High Inequality Med Inequality Low Inequality Soc Sci & Med 2008; 66: 1719 -32. Education, Obesity, Heart disease, Stroke, Unhealthy behaviors

Primary Care Orientation High Primary Care Associated with Lower Health Care Costs n 10

Primary Care Orientation High Primary Care Associated with Lower 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 Note: data is not updated

Primary Care Orientation Improves Health Outcomes n n Many fewer low birth weight babies.

Primary Care Orientation Improves Health Outcomes n n 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. n n Milbank Quarterly 2005; 83: 457 -502. Health Policy 2002; 60: 201 -18.

$/person-yr & Asthma Admissions /100, 000 (adults age-standardized) OECD 2012

$/person-yr & Asthma Admissions /100, 000 (adults age-standardized) OECD 2012

% with Unmet Medical Care due to Costs OECD 2011

% with Unmet Medical Care due to Costs OECD 2011

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

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

Out-of-Pocket Medical Costs/Year (% of adults with chronic disease) 2008 Commonwealth Fund International Health

Out-of-Pocket Medical Costs/Year (% of adults with chronic disease) 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.

Lessons from Developed Nations n A universal primary care orientation controls costs and improve

Lessons from Developed Nations n A universal primary care orientation controls costs and improve public outcomes. n Low point of service charges are essential for timely/cost effective primary health care. n Universal enrollment is forced price discipline!

Many Models for Universal Health Care n n National Health Service-UK Single tax-based financing

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

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