In a new, detailed international comparison, the United States looks a lot more like its peers than researchers expected.
Maybe the United States health care system isn’t that bizarre after all.
Compared
with peer nations, the United States sends people to the hospital less
often, it has a smaller share of specialist physicians, and it gives
people about the same number of hospitalizations and doctors’ visits,
according to a new study.
The quality of health care looks pretty good, it finds, while its
spending on social services outside of health care, like housing and
education, looked fairly typical.
If
you’ve been listening to many of the common narratives that seek to
explain the high costs of America’s health system and the nation’s
relatively low life expectancy, those results might surprise you.
Analysts are fond of describing the system as wasteful, with too many
patients getting too many services, driven by too many specialist
doctors and too few social supports.
But
a large and comprehensive review in The Journal of the American Medical
Association punctures a lot of those pat explanations. The paper,
conducted by a research team led by Ashish Jha, compiled detailed data
from the health care systems of the United States and 10 other rich
developed nations, and tried to test those hypotheses. The group
included nations with single-payer health care systems, like Britain and
Canada, and countries with competitive private insurance markets, like
Switzerland and the Netherlands.
Dr.
Jha, the director of the Harvard Global Health Institute, said he came
to the project with a sense of the conventional wisdom about how the
United States differed from its peers. But, after assembling the data
from the countries’ health ministries, he changed his mind about a
number of key assumptions.
“We
know we spend a lot more than everyone else, and we have looked for
easy explanations — things like greed in the system, fee-for-service
medicine, overutilization,” he said. But the research, he said, didn’t
match his expectations. “I’ve been looking at other countries and seeing
there’s a lot of fee-for-service in other countries, and other
countries are struggling with overutilization.”
When
it came to many of the measures of health system function, the United
States was in the middle of the pack, not an outlier, as Dr. Jha had
expected. Many analysts have called for the country to shift its
physician training away from specialty care and toward more primary care
medicine, for example. But the study found that 43 percent of U.S.
doctors practice primary care medicine, about typical for the group.
It’s
often argued that patients in the United States use too much medical
care. But the country was below average on measures of how often
patients went to the doctor or hospital. The nation did rank near the
top in its use of certain medical services, including expensive imaging
tests and specific surgical procedures, like knee replacements and
C-sections.
The data are consistent with other evidence that health care systems are beginning to converge, as information and technologies spread around the world among doctors and administrators.
Bruce
Landon, a professor of policy and medicine at Harvard Medical School,
said that the complaints about rising health care costs are a worldwide
issue. Even though other countries spend less than the United States,
few believe they have found a way to tame spending forever.
“I don’t think there’s any of these countries where if you went and
talked to them individually, they wouldn’t say they’re having a health
care cost crisis,” he said. “They’re all struggling with paying for new
technology and the cost of the system.”
The
data did not suggest that any country had a plug-and-play policy
template for devising a lower-cost, high-performing system. The systems
tended to perform better than the United States on some measures and
worse on others, with lots of idiosyncrasies.
Some
experts who reviewed the results wondered about the accuracy of all the
paper’s data points, which were numerous and drawn from an array of
international sources. Dr. Jha acknowledged that the numbers may not be
perfect but described the effort as careful and more comprehensive than
previous comparisons.
There were two areas where the United States really was quite different: We pay substantially higher prices
for medical services, including hospitalization, doctors’ visits and
prescription drugs. And our complex payment system causes us to spend
far more on administrative costs. The United States also has a higher
rate of poverty and more obesity than any of the other countries,
possible contributors to lower life expectancy that may not be explained
by differences in health care delivery systems.
Just
because other countries use the hospital more doesn’t mean that every
hospitalization in the United States is appropriate. Jonathan Skinner, a
professor at Dartmouth, who has studied patterns in health care use in
the United States, noted that there probably is money to be saved by
eliminating some of the extra scans and operations that are much more
common in the United States than elsewhere.
“It’s
not that we’re buying more pizzas, we’re just paying more for each
pie,” Dr. Jha said. “But that doesn’t mean that you can’t still buy
fewer pizzas.”
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