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

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

$/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.

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

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

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

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

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 2014

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

Do they ration hospital admission or stays? No.

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. OECD 2011 We do more but we do not have lower heart attack mortality. Age adjusted

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: Per 100,000 OECD 2011

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

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

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

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

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 young! United Nations: 2011data

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

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: ’ Age-specific disability is falling. Hospital costs drop 50% from 65 to 85 years old. Nursing home, home care, drugs) rise from years old, more than offset fall in hospital costs. Overall no trend in costs vs age at death. Milbank Q 2007;85: JAMA 2001;

Americans are Heavy (but there is missing data) OECD 2014 Obese % Adults BMI > 30 Kg/M 2 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).

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. 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: 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

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

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 Inequality Soc Sci & Med 2008;66:

Primary Care Orientation 1 0 Care Oriented (2 high) Longitudinal Comprehensive Coordinated with secondary/tertiary care Community located Health Policy 2002;60: Low 1 0 care orient USA High Primary Care Associated with Lower Health Care Costs Per person costs/yr Note: data is not updated

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 Higher life expectancy at 40 and 65 years of age. Milbank Quarterly 2005;83: Health Policy 2002;60:

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

% with Unmet Medical Care due to Costs OECD 2011

Primary Care Barriers Health Aff 2007;10. w

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 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!

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.

Steve Miles, MD Slides available