1. Mirror, Mirror on the Wall: How the Performance of the US Health Care System Compares Internationally
Phusit Prakongsai
International Health Policy Program (IHPP)
Ministry of Public Health, Thailand
29 July 2010

2. Background 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

3. Healthcare spending as % of GDP OECD countries, 2008

5. Growth in personal health care expenditures in the US from 1990 to 2007

6. Core dimensions of Commonwealth National Scorecard Measuring and monitoring health system performance

7. 1. Quality care 1.1 Effective care
Source
AUS
CAN
GER
NETH NZ UK US
Prevention
Physicians 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 82 10 17 48 92 76
Receive reminders for preventive/ follow-up care
2007 44 40 58
(2.5) 70
Doctor asked if emotional issues were affecting health 36 25
(6.5) 27 31 46
Received advice from doctors on weight, nutrition, and exercise 41 29 56
Overall benchmark ranking 2 7 6 3 5 1 4

8. 1. Quality care 1.1 Effective care
Source
AUS
CAN
GER
NETH NZ UK US
Chronic care
Diabetics 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 82
(5.5) 77 98 93 96
Patients with HT who have had cholesterol checked in past year 83 88 78 75 81 85
Practice routinely uses written guidelines to treat HT
(6.5) 90
Practice routinely uses written guidelines to treat depression 71 45 26 31 65 80 49
Has chronic condition and did not follow recommended care because of cost
2007 11 7 1 9 10 24
Primary care practices that routinely provide chronic dis patients written instructions 16 23 22 15 33 30
* Four recommended services include HbA1C checked in the past six months, feet examined, eye exam, and cholesterol checked in the past year.

9. 1. Quality care 1.2 Safe care AUS CAN GER NETH NZ UK US 17 (7) 16
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)
Given the wrong medication or wrong dose by a doctor, nurse, hospital, or pharmacist in past 2 years 13 10 7 6 14
Given incorrect results for a diagnostic or lab test in past 2 years
(6.5) 5
(4.5) 1 3
(2.5)
Experienced delays in being notified about abnormal test results in past 2 years
(6)
(5)
(1.5)
Hospitalized patients reporting infection in hospital 11
Doctors routinely receives a computerized alert or prompt about potential problem with drug dose or interaction
2009 92 20 24 95 90 93 37

10. 2. Access to care AUS CAN GER NETH NZ UK US 36 (6) 25 (3) 26 (4) 7 (1)
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) 5 1 19
Physicians think their patients often have difficulty paying for medications or OOP costs
2009 23 27 28 33 14 58
OOP expenses for medical bills more than 1000 USD in the past year 20 41
Overall benchmark ranking 6
3.5 2

11. 3. Efficiency measures AUS CAN GER NETH NZ UK US 8.9 (2) 10.1 (5) 10.4
Source
AUS
CAN
GER
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
2.6
3.6
5.3
5.2
7.4
3.4
7.1
Medical records/test results did not reach MD office in time for appointment
2008 16 19 12 11 17 15 24
Sent for duplicate tests by different health care professionals in past 2 years 18 4 10 7 20
Visited ED for a condition that could have been treated by a regular doctor 23 6
(1.5) 8
(3.5)
Hospitalized patients went to ER or re-hospitalized for complications from discharge
(5.5) 9
Overall benchmark ranking 2 5 3 1

12. 4. Health equity AUS CAN GER NETH NZ UK US 5 (5) 3 (2.5) (1) 9 (7) (3)
Source
AUS
CAN
GER
NETH NZ UK US
Rated doctor fair/poor
2007 5
(5) 3
(2.5)
(1) 9
(7)
Had medical problem but did not visit doctor because of costs in the past year
2008
(3) 8 -2
(1.5) 1
(4) 20
(6) 24
Did not get recommended test or treatment or follow-up because of cost in the past year 15 6
(3.5) 10 19
Did not fill prescription or skipped doses because of cost in the past year
(2) 7 16 18
Need dental care but did not see dentist because of cost in past year 13 2 -5 28
Last time needed medical attention had to wait 6 or more days for appointment
2009 11 -1
Overall ranking 4

13. 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
5.0
(4.5)
3.8
4.4
5.2
6.7
Healthy life expectancy at age 60 (average of women and men)
24.6
23.8
23.0
22.8
23.7
22.5
22.6
Overall ranking 1 2 3 4 5 6 7

14. Overall ranking of health systems among seven countries

15. Summary key findings Quality Access Efficiency Equity
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.

16. Efficiency analysis Per capita THE at inter dollar with Life expectancy
USA

17. Monitoring & Evaluation of health systems reform /strengthening
A general framework for HSPA
Inputs & processes
Outputs
Outcomes
Impact
Improved
health outcomes
& equity
Social and financial risk protection
Responsiveness
Financing
Infrastructure / ICT
Health workforce
Supply chain
Information
Intervention
access & services readiness
quality, safety and efficiency
Coverage of interventions
Prevalence risk behaviours & factors
Governance
Indicator
domains
Data
sources
Administrative sources
Financial tracking system; NHA
Databases and records: HR, infrastructure, medicines etc.
Policy data
Facility assessments
Population-based surveys
Coverage, health status, equity, risk protection, responsiveness
Clinical reporting systems
Service readiness, quality, coverage, health status
Vital registration
Analysis &
synthesis
Data quality assessment; Estimates and projections; In-depth studies; Use of research results; Assessment of progress and performance of health systems
Communication & use
Targeted and comprehensive reporting; Regular country review processes; Global reporting 17 17

18. Health Systems Assessment Approach of HS 20/20

19. Sub-national HSPA Immunization coverage <1 year by district in SA 2007-2008
Source: District Health Barometer

20. Thank you for your attention20