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US and Developed Countries: Comparing Health Care Systems - 2012 . Steven Miles, MD University of Minnesota. Efficiency: Outcomes for $. How does the US stack up?. $/person-yr (adjusted for purchasing power parity).

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Us and developed countries comparing health care systems 2012 l.jpg

US and Developed Countries: Comparing Health Care Systems - 2012

Steven Miles, MD

University of Minnesota


Efficiency outcomes for l.jpg

Efficiency: Outcomes for $

How does the US stack up?


Person yr adjusted for purchasing power parity l.jpg
$/person-yr (adjusted for purchasing power parity)

The Organization for Economic Cooperation and Development was founded in 1961 to compile statistics and policy reports to promote economic growth.

OECD 2012 (2009 data)


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

OECD 2012


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

OECD 2012


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Efficiency as $/person-yr & Life Expectancy at 65

OECD 2012


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Mortality Rates Amenable to Provision of Health Care 1997-2003

USA has highest rates

of preventable death

and smallest decreases

in preventable deaths

We are falling further behind!

<75 yo. Amen Mort is deaths preventable by HC system, e.g. CA, CVD, DM, inf, etc. Rates are /100,000

Health Aff 2008;58-71. (See also Health Aff 2012;31:2114-22.


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How do other countries succeed? 1997-2003Is rationing their secret?

If rationing Improves outcomes, is health care toxic?


Do they ration doctors no ps there is no rationing of nurses either l.jpg
Do they ration Doctors? No. 1997-2003PS: There is no rationing of nurses either.

OECD 2012


Do they do it by rationing doctor visits no per person yr l.jpg
Do they do it by rationing doctor visits? 1997-2003No.( per person-yr)

OECD 2012




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

Age adjusted

We do more but we do not have lower heart attack mortality.

OECD 2011


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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.

OECD 2011

Per 100,000

J Am Soc Nephrol 2006;17:2275-84.



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

OECD 2012 Compiled by Commonwealth


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Hip Replacement and Health Spending Replacements.

Per pers $

Hip Replacement /100,000

OECD 2011: Compiled by Commonwealth


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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 Obese

Smoking Drinking

Over financed Armed with Lawyers


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

OECD 2012


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

United Nations: 2011data


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Per Capita Health Spending and % Elderly: Really Old!

A young US uniquely out of position to deal with an aging population.

% of population over 65

OECD 2012, US Census Dept


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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;20:188-95.’

  • Age-specific disability is falling.

  • Hospital costs drop 50% from 65 to 85 years old.

  • Nursing home, home care, drugs) rise from 65-85 years old, more than offset fall in hospital costs.

  • Overall no trend in costs vs age at death.

    • Milbank Q 2007;85:213-57

JAMA 2001;2861349-55.


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Americans are Heavy Old.

Obese % Adults BMI > 30 Kg/M2 e.g. 5’9” 200+ pounds

OECD 2011

Health care costs increase for people with BMI > 35 (237 lbs) and 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).


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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 2011


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Myth: Malpractice Costs are why Personally Pay for Health Care 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;29:1569-77.

  • 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


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How do they do it? Personally Pay for Health Care

(or, How can we do better?)


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Income Inequality, Health Spending, and Life Expectancy Personally Pay for Health Care

OECD 2012

Lower Inequality associated with:

Education,

 Obesity,

 Heart disease,

 Stroke,

 Unhealthy behaviors

High Inequality

Med Inequality

Low Inequality

Soc Sci & Med 2008;66:1719-32.


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High Primary Care Associated with Lower Personally Pay for Health CareHealth Care Costs

USA

Primary Care Orientation

  • 10 Care Oriented (2 high)

    • Longitudinal

    • Comprehensive

    • Coordinated with secondary/tertiary care

    • Community located

Low 10 care orient

Per person costs/yr

Note: data is not updated

Health Policy 2002;60:201-18.


Primary care orientation improves health outcomes l.jpg
Primary Care Orientation Improves Health Outcomes Personally Pay for Health Care

  • 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.

    • HSR 2003;38: 831-64.

    • Health Policy 2002;60:201-18.


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$/person-yr & Asthma Admissions Personally Pay for Health Care/100,000 (adults age-standardized)

OECD 2012


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% with Unmet Medical Care due to Costs Personally Pay for Health Care

OECD 2011


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Primary Care Barriers Personally Pay for Health Care

Health Aff 2007;10. w7171-34.


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Out-of-Pocket Medical Costs/Year Personally Pay for Health Care(% of adults with chronic disease)

2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.


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Lessons from Developed Nations Personally Pay for Health Care

  • 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!


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Many Personally Pay for Health Care 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.


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Steve Miles, MD Personally Pay for Health Care

Slides available

[email protected]


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