US lags in health system performance

Affordable Care Act holds promise for US performance; focus on information technology and primary care vital to achieving high performance

Despite having the most expensive health care system, the United States ranks last overall compared to six other industrialized countries-Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom-on measures of health system performance in five areas: quality, efficiency, access to care, equity and the ability to lead long, healthy, productive lives, according to a new Commonwealth Fund report. While there is room for improvement in every country, the U.S. stands out for not getting good value for its health care dollars, ranking last despite spending $7,290 per capita on health care in 2007 compared to the $3,837 spent per capita in the Netherlands, which ranked first overall.

Provisions in the Affordable Care Act that could extend health insurance coverage to 32 million uninsured Americans have the potential to promote improvements to the United States' standing when it comes to access to care and equity, according to Mirror Mirror On The Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, by Commonwealth Fund researchers Karen Davis, Cathy Schoen, and Kristof Stremikis. The United States' low marks in the quality and efficiency dimensions demonstrate the need to quickly implement provisions in the new health reform law and stimulus legislation that focus on realigning incentives to reward higher quality and greater value, investment in preventive care, and expanding the use of health information technology.

"It is disappointing, but not surprising that, despite our significant investment in health care, the U.S. continues to lag behind other countries," said Commonwealth Fund President and lead author Karen Davis. "With enactment of the Affordable Care Act, however, we have entered a new era in American health care. We will begin strengthening primary care and investing in health information technology and quality improvement, ensuring that all Americans can obtain access to high quality, efficient health care."

Earlier editions of the report, produced in 2004, 2006, and 2007, showed similar results. This year's version incorporates data from patient and physician surveys conducted in seven countries in 2007, 2008, and 2009.

Key findings include:

On measures of quality the United States ranked 6th out of 7 countries. On two of four measures of quality-effective care and patient-centered care-the U.S. ranks in the middle (4th out of 7 countries). However, the U.S. ranks last when it comes to providing safe care, and next to last on coordinated care. U.S. patients with chronic conditions are the most likely to report being given the wrong medication or the wrong dose of their medication, and experiencing delays in being notified about an abnormal test result.

On measures of efficiency, the U.S ranked last due to low marks when it comes to spending on administrative costs, use of information technology, re-hospitalization, and duplicative medical testing. Nineteen percent of U.S. adults with chronic conditions reported they visited an emergency department for a condition that could have been treated by a regular doctor, had one been available, more than three times the rate of patients in Germany or the Netherlands (6%).

On measures of access to care, people in the U.S. have the hardest time affording the health care they need-with the U.S. ranking last on every measure of cost-related access problems. For example, 54 percent of adults with chronic conditions reported problems getting a recommended test, treatment or follow-up care because of cost. In the Netherlands, which ranked first on this measure, only 7 percent of adults with chronic conditions reported this problem.

On measures of healthy lives, the U.S. does poorly, ranking last when it comes to infant mortality and deaths before age 75 that were potentially preventable with timely access to effective health care, and second to last on healthy life expectancy at age 60.

On measures of equity, the U.S. ranks last. Among adults with chronic conditions almost half (45%) with below average incomes in the U.S. reported they went without needed care in the past year because of costs, compared with just 4 percent in the Netherlands. Lower-income U.S. adults with chronic conditions were significantly more likely than those in the six other countries surveyed to report not going to the doctor when they're sick, not filling a prescription, or not getting recommended follow-up care because of costs.