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Health Care Spending in the United States and Other High-Income Countries

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Importance: Health care spending in the United States is a major concern and is higher than in other high-income countries, but there is little evidence that efforts to reform US health care delivery have had a meaningful influence on controlling health care spending and costs. Objective: To compare potential drivers of spending, such as structural capacity and utilization, in the United States with those of 10 of the highest-income countries (United Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland, and Denmark) to gain insight into what the United States can learn from these nations. Evidence: Analysis of data primarily from 2013-2016 from key international organizations including the Organisation for Economic Co-operation and Development (OECD), comparing underlying differences in structural features, types of health care and social spending, and performance between the United States and 10 high-income countries. When data were not available for a given country or more accurate country-level estimates were available from sources other than the OECD, country-specific data sources were used. Findings: In 2016, the US spent 17.8% of its gross domestic product on health care, and spending in the other countries ranged from 9.6% (Australia) to 12.4% (Switzerland). The proportion of the population with health insurance was 90% in the US, lower than the other countries (range, 99%-100%), and the US had the highest proportion of private health insurance (55.3%). For some determinants of health such as smoking, the US ranked second lowest of the countries (11.4% of the US population ≥15 years smokes daily; mean of all 11 countries, 16.6%), but the US had the highest percentage of adults who were overweight or obese at 70.1% (range for other countries, 23.8%-63.4%; mean of all 11 countries, 55.6%). Life expectancy in the US was the lowest of the 11 countries at 78.8 years (range for other countries, 80.7-83.9 years; mean of all 11 countries, 81.7 years), and infant mortality was the highest (5.8 deaths per 1000 live births in the US; 3.6 per 1000 for all 11 countries). The US did not differ substantially from the other countries in physician workforce (2.6 physicians per 1000; 43% primary care physicians), or nursing workforce (11.1 nurses per 1000). The US had comparable numbers of hospital beds (2.8 per 1000) but higher utilization of magnetic resonance imaging (118 per 1000) and computed tomography (245 per 1000) vs other countries. The US had similar rates of utilization (US discharges per 100 000 were 192 for acute myocardial infarction, 365 for pneumonia, 230 for chronic obstructive pulmonary disease; procedures per 100 000 were 204 for hip replacement, 226 for knee replacement, and 79 for coronary artery bypass graft surgery). Administrative costs of care (activities relating to planning, regulating, and managing health systems and services) accounted for 8% in the US vs a range of 1% to 3% in the other countries. For pharmaceutical costs, spending per capita was $1443 in the US vs a range of $466 to $939 in other countries. Salaries of physicians and nurses were higher in the US; for example, generalist physicians salaries were $218 173 in the US compared with a range of $86 607 to $154 126 in the other countries. Conclusions and Relevance: The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries. As patients, physicians, policy makers, and legislators actively debate the future of the US health system, data such as these are needed to inform policy decisions.
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Health Care Spending in the United States
and Other High-Income Countries
Irene Papanicolas, PhD; Liana R. Woskie, MSc; Ashish K. Jha, MD, MPH
IMPORTANCE Health care spending in the United States is a major concern and is higher than
in other high-income countries, but there is little evidence that efforts to reform US health
care delivery have had a meaningful influence on controlling health care spending and costs.
OBJECTIVE To compare potential drivers of spending, such as structural capacity and
utilization, in the United States with those of 10 of the highest-income countries (United
Kingdom, Canada, Germany, Australia, Japan, Sweden, France, the Netherlands, Switzerland,
and Denmark) to gain insight into what the United States can learn from these nations.
EVIDENCE Analysis of data primarily from 2013-2016 from key international organizations
including the Organisation for Economic Co-operation and Development (OECD), comparing
underlying differences in structural features, types of health care and social spending, and
performance between the United States and 10 high-income countries. When data were not
available for a given country or more accurate country-level estimates were available from
sources other than the OECD, country-specific data sources were used.
FINDINGS In 2016, the US spent 17.8% of its gross domestic product on health care, and
spending in the other countries ranged from 9.6% (Australia) to 12.4% (Switzerland). The
proportion of the population with health insurance was 90% in the US, lower than the other
countries (range, 99%-100%), and the US had the highest proportion of private health
insurance (55.3%). For some determinants of health such as smoking, the US ranked second
lowest of the countries (11.4% of the US population !15 years smokes daily; mean of all 11
countries, 16.6%), but the US had the highest percentage of adults who were overweight or
obese at 70.1% (range for other countries, 23.8%-63.4%; mean of all 11 countries, 55.6%).
Life expectancy in the US was the lowest of the 11 countries at 78.8 years (range for other
countries, 80.7-83.9 years; mean of all 11 countries, 81.7 years), and infant mortality was the
highest (5.8 deaths per 1000 live births in the US; 3.6 per 1000 for all 11 countries). The US
did not differ substantially from the other countries in physician workforce (2.6 physicians per
1000; 43% primary care physicians), or nursing workforce (11.1 nurses per 1000). The US had
comparable numbers of hospital beds (2.8 per 1000) but higher utilization of magnetic
resonance imaging (118 per 1000) and computed tomography (245 per 1000) vs other
countries. The US had similar rates of utilization (US discharges per 100 000 were 192 for
acute myocardial infarction, 365 for pneumonia, 230 for chronic obstructive pulmonary
disease; procedures per 100 000 were 204 for hip replacement, 226 for knee replacement,
and 79 for coronary artery bypass graft surgery). Administrative costs of care (activities
relating to planning, regulating, and managing health systems and services) accounted for 8%
in the US vs a range of 1% to 3% in the other countries. For pharmaceutical costs, spending
per capita was $1443 in the US vs a range of $466 to $939 in other countries. Salaries of
physicians and nurses were higher in the US; for example, generalist physicians salaries were
$218 173 in the US compared with a range of $86 607 to $154 126 in the other countries.
CONCLUSIONS AND RELEVANCE The United States spent approximately twice as much as
other high-income countries on medical care, yet utilization rates in the United States were
largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals,
and administrative costs appeared to be the major drivers of the difference in overall cost
between the United States and other high-income countries. As patients, physicians, policy
makers, and legislators actively debate the future of the US health system, data such as these
are needed to inform policy decisions.
JAMA. 2018;319(10):1024-1039.doi:10.1001/jama.2018.1150
Viewpoint page 977 and
Editorials pages 983,986,
988, and 990
Animated Summary Video
Supplemental content and
Audio
CME Quiz at
jamanetwork.com/learning
Author Affiliations: Department of
Health Policy and Management,
Harvard T.H. Chan School of Public
Health, Boston, Massachusetts
(Papanicolas, Woskie, Jha); Harvard
Global Health Institute, Cambridge,
Massachusetts (Papanicolas, Woskie,
Jha); Department of Health Policy,
London School of Economics and
Political Science, London, England
(Papanicolas, Woskie).
Corresponding Author: Irene
Papanicolas, PhD, Department of
Health Policy, LondonSchool of
Economics and Political Science,
Houghton Street, London WC2A
2AE, England (i.n.papanicolas
@lse.ac.uk).
Clinical Review & Education
JAMA | Special Communication
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© 2018 American Medical Association. All rights reserved.
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The United States spends more per capita on health care
than any other nation, substantially outpacing even other
very high-income countries.
1,2
However, despite its
higher spending, the United States performs poorly in areas such
as health care coverage and health outcomes.
3-5
Higher spending
without commensurate improved health outcomes at the popula-
tion level has been a strong impetus for health care reform in the
United States.
6
Although it is well known that the United States spends
more on health care than other countries, less is known about
what explains these differences. The consensus has been that
the US fee-for-service system is a primary factor,
7
leading to
fragmentation, overuse, and
an underinvestment in social
determinants of health,
8-10
driving high utilization of
health care services and poor
outcomes. Older studies have
found that the United States
may underinvest in social
services,
11
although other data
suggest that higher prices
in the United States, especially
for pharmaceuticals, may be
a contributor to spending dif-
ferences.
12,13
One study sug-
gested that increasing rates of outpatient spending and remu-
neration of clinicians is a major contributor to the cost difference
between the United States and other countries.
14
Given that
other high-income countries are able to spend less and achieve
better health outcomes, a more nuanced, data-driven under-
standing of all aspects of health care cost are needed to assist in
reform of the US health care system.
The Organisation for Economic Co-operation and Develop-
ment (OECD) and the Commonwealth Fund have recently col-
lected and made available increasingly comparable data on inputs
and performance of the health care systems across high-income
countries. Using these and related data, we compared perfor-
mance of the United States with 10 other high-income countries on
key metrics that underpin health care spending. By examining
granular data, we sought to understand why US health care costs
are so much higher and where policy makers might target their
efforts to encourage a more efficient system.
Methods
Selection of Comparison Countries
Ten high-income countries were selected for comparison. These
countries were chosen because they were among the highest-
income countries in the world, had relatively high health care
spending, and had populations with similar demographic character-
istics that have similar burdens of illness.
3,15
Based on these criteria,
the United Kingdom (consisting of England, Scotland, Wales, and
Northern Ireland), Canada, Germany, Australia, Japan, Sweden,
France, Denmark, the Netherlands, and Switzerland were chosen
for comparison. These 10 selected countries represent different
geographic areas and diverse health system structures.
Conceptual Framework and Indicator Selection
To better understand the higher US health care costs relative to
other high-income countries, a range of outcomes were explored.
We first analyzed comparative data on general health system
spending, including spending by function. Next, comparative
inputs, including labor costs and structural capacity (which,
aside from contributing to direct costs, may also influence mainte-
nance costs or influence the price to use equipment) were ex-
amined. Because many of the leading explanations relating to
higher health care costs involve the transformation of health care
dollars to health care outcomes,
16
we extended the analysis to
examine a range of intermediate outputs—namely, access, utiliza-
tion (inpatient, outpatient, major procedures), pharmaceutical
spending and utilization, patient experience, and quality of care—as
well as valued health system outcomes, such as population health.
To pr ovide a bro ad er cont ex t of over all fac to rs that can c on tribu te
to differences in health care spending, we also examined social
spending, as well as demographic differences, risk factors, and
prevalence of disease. In line with previous international compari-
sons, the health care system included all groups whose primary
intent is to improve health.
5,17
This approach resulted in the presentation of a total of 98 indi-
cators across 7 domains: (1) general spending; (2) population
health; (3) structural capacity; (4) utilization; (5) pharmaceuticals;
(6) access and quality; and (7) equity. In each domain, measures
were selected that were available across the majority of the coun-
tries in the analysis. We were unable to find comparable pricing
data for most areas, such as for diagnostic procedures and treat-
ments, except for workforce remuneration and pharmaceuticals.
In the area of quality, the focus was on indicators that captured
quality of prevention, primary care, and inpatient care across the
areas of appropriateness, effectiveness, experience, and safety. In
the area of access to care, variations related to financial costs as
well as waiting times were explored. In addition, reflecting equity,
variations related to service availability, quality of care, and cost
were assessed.
Data Sources
Data were extracted from a range of databases compiled by inter-
national organizations, with the majority coming from the OECD.
JAMA.COM +
Animated Summary Video
Health Care Spending in the
United States and Other
High-Income Countries
Key Points
Question Why is health care spending in the United States so
much greater than in other high-income countries?
Findings In 2016, the United States spent nearly twice as much as
10 high-income countries on medical care and performed less well
on many population health outcomes. Contrary to some
explanations for high spending, social spending and health care
utilization in the United States did not differ substantially from
other high-income nations. Prices of labor and goods, including
pharmaceuticals and devices, and administrative costs appeared
to be the main drivers of the differences in spending.
Meaning Efforts targeting utilization alone are unlikely to reduce
the growth in health care spending in the United States; a more
concerted effort to reduce prices and administrative costs
is likely needed.
Health Care Spending in the United States and Other High-Income Countries Special Communication Clinical Review & Education
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Data on structural equipment, workforce, utilization, pharmaceuti-
cal spending, access, and quality were accessed from OECD.stat
and the OECD 2015 Health Care at a Glance report. Additional
data on health spending, health system, and country characteris-
tics were obtained from the World Bank International Bank for
Reconstruction and Development–International Development
Association database and the 2016 OECD Health Systems Charac-
teristics Survey.
Data on retail pharmaceutical spending per capita were
obtained from the OECD for all countries. Data on total pharmaceu-
tical spending per capita were obtained from Intercontinental
Marketing Services or the International Federation of Pharmaceuti-
cal Manufacturers and Associations. Pharmaceutical data on
country-level output of new chemical entities was taken from
Daemmrich.
18
Population perceptions of the health system and
select access measures were obtained from the 2016 Common-
wealth Fund Survey of Consumers.
15
All data on per capita spending, gross domestic product (GDP),
and remuneration were translated into US dollar equivalents, with
exchange rates based on purchasing power parities of national cur-
rencies. Remuneration data were then converted to 2017 dollars
using the US Consumer Price Index in line with Laugesen and
Glied.
19
Data on health spending are presented by function of care
as a percentage of the country’s total spending on health consis-
tent with System of Health Accounts categorization, with adapta-
tions for outpatient spending to address issues of comparability
with the United States’ National Health Expenditure Accounts
(eTable 2 in Supplement 1). When OECD data were not available
for a given country or more accurate country-level estimates were
available, country-specific data sources were used. The focus was
on indicators from 2013 onward with an occasional exception. For
example, for the United States, data for the horizontal index, neo-
natal mortality by low birth weight, and antibiotic prescribing were
from 2009, 2004, and 2004, respectively.
Figure 1. Spending
General
Overall population (in millions)
Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11
Denmark
6
CHE
8
Sweden
10
NLD
17
Australia
24
Canada
36
France
64
UK
66
Germany
83
Japan
127
US
323
69
Mean
Population 65 y, % US
14.5
Australia
14.7
Canada
15.7
NLD
17.3
UK
17.3
CHE
17.5
Denmark
18.1
France
18.2
Sweden
19.9
Germany
21.4
Japan
25.1
18.2
GDP per capita, US $
(in thousands)
Japan
37.50
UK
38.50
France
41.00
Canada
42.40
Germany
42.90
Australia
45.10
NLD
46.30
Sweden
51.60
US
52.10
Denmark
53.40
CHE
54.00
45.90
Land area (× 1000 sq km) CHE
42
NLD
42
Denmark
43
UK
244
Germany
357
Japan
378
Sweden
450
France
549
Australia
7741
US
9834
Canada
9985
2697
Poverty rate, % below poverty
line of 60%
Denmark
12
NLD
15
France
15
Germany
16
CHE
17
Sweden
17
UK
18
Australia
20
Canada
21
Japan
22
US
24
18
Total spending on health,
% of total national GDP
Australia
9.6
UK
9.7
Canada
10.3
NLD
10.5
Denmark
10.8
Japan
10.9
France
11
Germany
11.3
Sweden
11.9
CHE
12.4
US
17.8
11.5
Health spending
Public spending on health,
% of total national GDP
Australia
6.3
Canada
7.4
UK
7.6
CHE
7.7
US
8.3
Japan
8.6
France
8.7
Germany
8.7
Denmark
9.2
NLD
9.5
Sweden
10
8.4
Inpatient care Canada
17
US
19
Sweden
21
UK
24
Japan
27
Germany
27
Denmark
28
CHE
28
France
30
Australia
31
NLD
32
26
Outpatient care NLD
22
France
23
Germany
23
Japan
27
UK
30
Sweden
31
CHE
33
Denmark
34
Canada
36
Australia
39
US
42
31
Mean spending on health
per capita, US $
UK
3377
France
3661
Japan
3727
Australia
4357
Canada
4641
Germany
5182
NLD
5202
Denmark
6463
CHE
6787
Sweden
6808
US
9403
5419
Long-term care Australia
2
US
5
France
11
Canada
14
Germany
16
UK
18
Japan
19
CHE
19
Denmark
24
NLD
26
Sweden
26
16
Medical goods Denmark
10
NLD
12
Sweden
12
CHE
13
US
14
UK
15
Australia
17
Japan
20
Canada
20
France
20
Germany
20
16
Governance and
administration
Japan
1
France
1
Denmark
2
Sweden
2
UK
2
Australia
3
Canada
3
CHE
4
NLD
4
Germany
5
US
8
3
Home-based care Denmark
NA
CHE
NA
Australia
0
Canada
0
NLD
0
Sweden
0
Germany
1
Japan
3
UK
3
US
3
France
4
2
Preventive care Australia
2
CHE
2
France
2
Japan
3
Denmark
3
Sweden
3
Germany
3
US
3
NLD
4
UK
5
Canada
6
3
Other Denmark
0
NLD
0
Japan
1
CHE
1
UK
3
Canada
4
Sweden
5
Germany
5
Australia
6
US
6
France
9
4
Health expenditure by function of care as a % of total national health expenditure
Population with health care
coverage, %
Australia
100
Japan
100
Canada
100
Denmark
100
CHE
100
NLD
99.9
France
99.9
Sweden
100
Germany
99.8
UK
100
US
90
99
GDP indicatesgross domestic product;NA, not applicable. CHE indicates Switzerland; NLD,the Netherlands. SeeeTable 1 in Supplement 2 for data ordered by country.
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Supplement 1 includes tables that provide a breakdown of
sources and methods for the data reported herein. In these tables,
we note issues of comparability and timeliness for each indicator,
such as workforce. In figures describing data for each of the 7 do-
mains, a simple mean of the data for each indicator across all 11 coun-
tries is presented in the final column. Throughout the Results sec-
tion in the text, all comparative findings are presented descriptively.
Results
Demographic Characteristics and Health Care Spending
In 2016, the US population was significantly larger than all
comparison countries at 323 million (Figure 1 and eTable 1 in
Supplement 2). Japan had the next largest population with 127 mil-
lion. The US system also covered the second largest geographical
area (9 834 000 sq km), following Canada (9 985000 sq km). The
other countries other than Australia had much smaller land mass.
In 2016, the United States spent 17.8% of its GDP on health care
(range of the other countries, 9.6%-12.4%; mean of all 11 countries,
11.5%) (Figure 1 and Figure 2) and had almost double the health
spending per capita (mean, $9403) compared with the other coun-
tries (range, $3377-$6808; mean of all 11 countries, $5419).
Although the United States spent more, the percentage of the
population with health insurance in the United States was 90%,
lower than in all of the other countries (range, 99%-100%).
All systems had relatively similar levels of public spending as a
percentage of GDP (defined as spending from government and/or
social or compulsory insurance funds), with the United States spend-
ing at about the mean level (8.3%)of all the countrie s, although, un-
like the other countries, this spending covered only about 37% of
the population. By expenditure as a function of care, the United
States spent only 19% of its health spending on inpatient care, which
excludes same -day hospital care. This p roportion was less th an that
of all other countries, with Australia (31%) and the Netherlands (32%)
spending the most (Figure 1). The United States spent a greater pro-
portion than the other countries on outpatient care (44% com-
pared with a mean of 31%) and governance and administration,which
includes activities relating to planning, regulating, and managing
health systems and services (8% compared with a mean of 3%).
Across the 11 countries, the United States had the lowest per-
centage of the population older than 65 years (14.5%compared with
ameanof18.2%)andalsohadthehighestrateofpoverty,with24%
of the population living below the poverty line, followed by Japan
(22%) and Canada(21%). The United States rankedbelow the mean
but was not an outlier with regard to total social spending (spend-
ing on old age, incapacity, labor market, education, family, and hous-
ing [Figure 3]) at 16.7% of GDP (compared with a mean of 19.4% of
GDP in all 11 countries). This reflected public social spending, which
was, at 11.3% of GDP, below the mean of all 11 countries (15.3% of
GDP). The United States ranked fourth with regard to private social
spending at 5.4% of GDP (compared with a mean of 4.1%) and was
similar to the United Kingdom (5.6%) and ranked behind
the Netherlands (7.1%) and Switzerland (6.0%), reflecting mostly
private pension payments.
20
Insurance System Characteristics
The structural characteristics of the health care system are de-
tailed in the Tab le.Threecountries,theUnitedKingdom,Sweden,
and Denmark, have national health care systems, whereas
Canada and Australia have regionally administered universal insur-
ance programs. Germany, France, the Netherlands, and Switzerland
have statutory/mandatory health insurance systems. Only the
United States has a voluntary, private employer-based and
individual-based system. All of the countries except the United
States have an automatic or compulsory enrollment process.
Private insurance as the primary form of insurance is highest in the
United States at 55.3%, followed by Germany at 10.8%. The major-
ity of the countries do not have private insurance as the primary
form of insurance.
Population Health
Among important determinants of health, the United States had the
highest percentage of overweight or obese adults (70.1% com-
pared with a mean of 55.6%) but had relatively low smoking rates
(11.4%of the population compared with a mean of 16.6%) (Figure 4
and eTable 2 in Supplement 2). The drinking rate (8.8 L per capita)
and unemployment rate (4.4%) in the United States are both
close to the mean values of all 11 countries at 9.1 L per capita and
5.4%, respectively.
Figure 2. Health Spending as a Percentage of Gross Domestic Product
20
8
10
12
14
16
18
6
4
2
0
Spending on Health as a % of GDP
United
States
United
Kingdom
CanadaGermany AustraliaJapanSweden France The
Netherlands
Switzerland Denmark
Total health spending Government health spending Private health spending
Mean Mean Mean
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The United States consistently had the poorest population
health outcomes (Figure 4). The United States had the lowest life
expectancy (78.8 years compared with a mean of 81.7 years) and
the lowest health-adjusted life expectancy (69.1 years compared
with a mean of 72.0 years). The variability of life expectancy across
the United States (ranging from 81.3 years in Hawaii to 75 years in
Mississippi) (eTable 3 in Supplement 1)wassimilartothatofthelife
expectancy across all countries in the study.
The United States had the highest infant mortality (5.8 deaths
per 1000 live births compared with a mean of 3.6), neonatal mor-
tality (4.0deaths per 1000 live births compared with a mean of 2.6),
and maternal mortality (26.4 deaths per 100000 live births com-
pared with a mean of 8.4)(Figure 4). The United States also had the
second highest percentage of infants with low birth weight (8.1%
compared with a mean of 6.6%). Japan had the highest low birth
weight (9.5%). When adjusting neonatal mort ality to exclude deaths
of infants born weighing less than 1000 g, the United States ranked
fifth relative to the other countries, with 1.61 deaths per 1000 live
births, compared with a mean of 1.70 for all 11 countries.
Workforce and Structural Capacity
The physician workforce in the United States was lower than the
mean of all 11 countries at 2.6 per 1000 population compared with
3.3 per 1000 population (Figure 5 and eTable 3 in Supplement 2).
The proportion of US physicians who were primary care physicians
(43%) was the same as the mean of all 11 countries. Using a func-
tionality-based approach to identifying primary care physicians,
US general internists provided a significant amount of primary care,
whereas internists in Canada almost exclusively provided acute
hospital-based care (Figure 6). Compared with countries with
comparable data, mean remuneration of generalists, special-
ists, and nurses was higher in the United States. When adjusting
for purchasing power parity, the mean US remuneration for gener-
alists was $218 173, nearly double the mean remuneration in all 11
countries, which ranged from $86 607 in Sweden to $154126 in
Germany.The remuneration for specialists was higher in the United
States at $316 000 compared with other countries, ranging from
$98 452 in Sweden to $202291 in Australia). The remuneration of
nurses was also higher in the United States ($74 160) than in other
countries, whereit ranged from $42 492 in Franceto $65 082 in the
Netherlands. The remuneration of health care professionals as a ra-
tio to the mean national wage was highest in the United States for
specialists (5.3 compared with a mean of 3.7),generalists (3.6 com-
pared with a mean of 2.7), and nurses (1.23 compared with
a mean of 1.1).
There was notable variation between countries in the supply of
medical equipment, such as magnetic resonance imaging (MRI) units,
computed tomography (CT) machines, and mammography ma-
chines. Japan had the highest number of MRI units and CT scanners
per population (approximately 52 and 107per 1 million population, re-
spectively), and the United States had the second highest for MRI
(38 per 1 million population) and third highest for CT (41 per 1 million
population). The lowest per capita rate forboth MRI units and CT scan-
ners was in the United Kingdom, with 7.2 MRI units and 9.5 CT scan-
ners per 1 million population. The United States had fewer hospital
beds per 1000 population (2.8) than Japan (13.2) and Germany(8.2)
and fewer long-term beds per 1000 population older than 65 years
(38.8) compared with the mean of the study countries (54.2).
Utilization
The United States’ utilization of health care services was similar
to the other countries (Figure 7 and eTable 4 in Supplement 2),
Figure 3. Social Spending as a Percentage of Gross Domestic Product
30
20
25
15
10
5
0
Social Spending as a % of GDP
United
States
United
Kingdom
Germany Sweden France The
Netherlands
Switzerland Denmark Canada Japan Australia
Total social spending
Mean
Public social spending
Mean
Private social spending
Mean
Social spending is the provision by public (and private) institutions of benefits to
and financial contributions targeted at households and individuals to provide
support during circumstances that adversely affect their welfare, provided that
the provision of the benefits and financial contributions constitutes neither a
direct payment for a particular good or service nor an individual contract or
transfer. Such benefits can be cash transfers or can be direct (in-kind) provision
of goods and services. Main spending areas include old age, health, family,
incapacity,labor market, and housing (Organisation for Economic Co-operation
and Development). Private social spending is functionally the same as public
social spending but provided through a private mechanism. Social benefits
delivered through the private sector (not transfers between individuals) involve
an element of compulsion and/or interpersonal redistribution; for example,
through pooling of contributions and risk sharing. This may include old-age
pensions and support services for older adults, survivor benefits, disability and
sickness cash benefits, family support, unemployment benefits, housing
support (eg, rent subsidies), and other social policy areas excluding health
spending. Pensions constitute an important part of private social spending in
the United States and can be mandatory or voluntary. Independent,
out-of-pocket spending on social services is not included.
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Table. InsuranceSystem Characteristics
Characteristics
Country
United States
United
Kingdom
a
Germany Sweden France
The
Netherlands Switzerland Denmark Canada Japan Australia
General
Main source of
basic care
coverages
b
Private
employer-based
and individual
insurance
National health
care system
Statutory
health
insurance
system
National health
care system
Statutory
health
insurance
system
Mandatory
health
insurance
system
Mandatory
health
insurance
system
National health
care system
Regionally
administered
universal public
insurance
program
Statutory health
insurance system
Regionally
administered
universal public
insurance
program
Enrollment process
for basic care
coverage
c
Voluntary Automatic Compulsory Automatic Compulsory Compulsory;
universally
mandated
private
insurance
Compulsory;
universally
mandated
private
insurance
Automatic Automatic Compulsory Automatic
No. of insurers for
insurance-type
systems
d
880 Firms;
5379
establishments
NA 118 Sickness
funds
NA 3
Noncompeting
insurance
schemes
60 Insurance
plans
52 Insurance
plans
NA NA >3400
Noncompeting
public, quasi-public,
and employer-based
insurers
NA
Private by type, % of
total population
e
Private as primary
form of insurance
55.3 0 10.8 NA 0 0 0 0 NA NA 0
Duplicative,
supplementary, or
complimentary
insurance
7.7 10.6 23.1 10 95.5 84.1 27.9 36.5 67 NA 32.0
Abbreviation: NA, not applicable.
a
The information in this specific table refers only to England, not the entire United Kingdom.
b
United States: public (Medicare) for ages !65; state-administered public (Medicaid) for low income.
c
United States: compulsory from 2014 to 2017.
d
United States: an establishment is defined as a single physical location where business is conducted or where
services or industrial operations are performed.
e
Duplicate: private insurance that offers coverage for health services already included under public health
insurance. Duplicate health insurance can be marketed as an option to the public sector because,
while it offers access to the same medical services as the public scheme, it also offers access to different
providers or levels of service, such as (1) access to private health facilities that are not accessible through public
insurance when the full cost of the service is paid by private insurance; (2) access to fast/privileged coverageby
bypassing queues in public system; (3) access to care independent of referral and gatekeeper systems;
(4) choice of physician, hospital, or other health care provider.It does not exempt individuals from contributing
to public health insurance. Supplementary: private health insurance that provides coveragefor additional health
services not covered by the public scheme. Depending on the country,it may include services that are
uncovered by the public system such as luxury care, elective care, long-term care, dental care, pharmaceuticals,
rehabilitation, alternative or complementary medicine, etc, or superior hotel and amenity hospital services
(even when other portions of the service, such as the medical component, are covered by the public system).
Complimentary: private insurance that complements coverage of publicly insured services or services within
principal/substitute health insurance, which is intended to pay only a proportion of qualifying care costs,
by covering all or part of the residual costs not otherwise reimbursed (eg, co-payments). May be referred to
as “supplementary” in US literature.
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except for imaging. The United States performed the second high-
est number of MRI scans and the highest number of CT scans (118
MRIs per 1000 population compared with a mean in all 11 countries
of 82 per 1000 population; 245 CTs per 1000 population com-
pared with a mean of 151 per 1000 population).
Annual hospital discharges in the United States, at 125 per 1000
population, were just below the middle of the distribution (ranging
from 84 per 1000 in Canada to 255 per 1000 in Germany, with a
mean of 150 per 1000 in all 11 countries) (Figure 8). Discharges for
common conditions in the United States such as acute myocardial
infarction (192 per 100 000 population compared with a mean of
190 per 100 000 population), pneumonia (365 per 100 000 popu-
lation compared with a mean of 352 per 100 000 population), and
chronic obstructive pulmonary disease (230 per 100 000 popula-
tion compared with a mean of 206 per 100 000 population) were
similar to the means of all 11 countries. For discharges for mental and
behavioral conditions, the United States was below the mean of all
11 countries (679 per 100 000 population compared with a mean
of 736 per 100 000 population) (Figure 7). Consultation levels in the
United States were below the mean at 4 visits per person per year
compared with a mean of 6.6 (Figure 8).
The United States had somewhat higher levels of some com-
mon surgical procedures, such as revascularization procedures (for
coronary artery bypass procedures, 79 per 100 000 population com-
pared with a mean of 54 per 100 000 population), knee replace-
ments (226 per 100 000 population compared with a mean of 163
per 100 000 population), cesarean deliveries (33 per 100 live births
compared with a mean of 25 per 100 live births), coronary angio-
plasties (248 per 100 000 population compared with a mean of 217
per 100 000 population), and cataract surgeries (1110 per 100 000
population compared with a mean of 971 per 100 000 popula-
tion). For a few procedures, the United States had comparable or
lower rates vs the other 10 countries, such as for hip replacements
(204 per 100 000 population compared with a mean in all 11 coun-
tries of 207 per 100 000 population).
Length of stay had less variation across countries with the ex-
ception of Japan, which had a mean all-cause length of stay of 16.9
days, far longer than in the other countries (Figure 8). The United
States had relatively fewer days in the hospital compared with the
mean for 3 different length-of-stay measures (all-cause hospitaliza-
tion, normal neonatal delivery hospitalization, and acute myocar-
dial infarction hospitalization) (Figure 7).
The United Sta tes had high levels of adm inistrative burden; th is
was notable in particular for administrative spending, for which the
United States was an outlier (8% of GDP spent on administrationand
governance compared with a mean of 3% of GDP) (eTable 1 in
Supplement 1). Physicians in the United States also reported hav-
ing a higher level of administrative burden than the mean of all 11
countries in 3 areas; however,this burden was high in all insurance-
based systems. Fifty-four percent of surveyed physicians in the
United States identified time spent on administrative issues re-
lated to insurance or claims as a major problem, 33% reported that
Figure 4. Population Health
Smoking, % of population
aged 15 y who smoke daily
1234567891011
Sweden
11.2
US
11.4
Australia
12.4
Canada
14
UK
16.1
Denmark
17
Japan
18.2
NLD
19
CHE
20.4
Germany
20.9
France
22.4
16.6
Mean
Alcohol consumption, L per
capita in population aged 15 y
Japan
7.2
Sweden
7.2
NLD
8
Canada
8.1
US
8.8
Denmark
9.4
CHE
9.5
UK
9.5
Australia
9.7
Germany
11
France
11.9
9.1
Obese or overweight, % of
population aged 15 y
Japan
23.8
France
49
Germany
60
Canada
60.3
UK
62.9
Australia
63.4
US
70.1
CHE
41a
Denmark
47.4a
NLD
47.4a
Sweden
48.3a
55.6
Rank (highest to lowest)
Determinants of health
Life expectancy in total
population at birth, mean, y
US
78.8
Germany
80.7
Denmark
80.8
UK
81
NLD
81.6
Canada
81.7
Sweden
82.3
France
82.4
Australia
82.5
CHE
83
Japan
83.9
81.7
Health-adjusted life
expectancy, mean, y
US
69.1
Denmark
71.2
Germany
71.3
UK
71.4
Australia
71.9
Sweden
72
NLD
72.2
Canada
72.3
France
72.6
CHE
73.1
Japan
74.9
72
Life expectancy for women
aged 40 y, mean, y
US
42.6
Denmark
43.4
UK
43.7
NLD
43.9
Germany
43.9
Canada
44.8
Sweden
44.8
Australia
45.4
CHE
45.8
France
46.4
Japan
47.7
44.8
Life expectancy for men
aged 40 y, mean, y
US
38.7
Germany
39.4
Denmark
39.8
UK
40.5
France
40.6
NLD
40.8
Canada
41.1
Sweden
41.5
Australia
41.7
Japan
41.8
CHE
42
40.7
Life expectancy
Infant mortality, deaths per
1000 live births
Japan
2.1
NLD
2.5
Sweden
2.5
Australia
3.2
Germany
3.3
Denmark
3.7
France
3.8
CHE
3.9
UK
3.9
Canada
5.1
US
5.8
3.6
Neonatal mortality, deaths per
1000 live births
Japan
0.9
Sweden
1.7
Australia
2.3
Germany
2.3
NLD
2.5
France
2.6
UK
2.7
Denmark
3
CHE
3.1
Canada
3.2
US
4
2.6
Maternal mortality, deaths per
100
000 live births
Denmark
4.2
Sweden
4.4
Australia
5.5
CHE
5.8
Japan
6.4
NLD
6.7
Canada
7.3
France
7.8
Germany
9
UK
9.2
US
26.4
8.4
Neonatal mortality, deaths per
1000 live births excluding <1000 g
Australia
NA
Japan
NA
CHE
NA
France
NA
Germany
1.49
Sweden
1.56
US
1.61
Canada
1.63
UK
1.77
NLD
1.96
Denmark
2.09
1.7
Low birth weight, % of total
live births
CHE
NA
Sweden
4.4
Denmark
5
France
6.2
Canada
6.3
Australia
6.4
NLD
6.5
Germany
6.6
UK
6.9
US
8.1
Japan
9.5
6.6
Maternal and infant health
NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands. See eTable 2 in Supplement 2 for data ordered by country.
a
Patient self-reported data.
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“time spent on administrative issues related to reporting clinical or
quality data to government or other agencies is a major problem,
and 16% reported having spent “a lot of time on paperwork or dis-
putes related to medical bills.
Pharmaceuticals
Among the 11 countries, the United States had the highest pharma-
ceutical spending per capita at $1443, with Switzerland following at
$939 and a mean of $749 for all 11 countries (Figure 9 and eTable 5
in Supplement 2). Retail spending per capita was also highest in the
United States at $1026, representing about 71% of the total, which
was consistent with the group mean at 72% (Figure 9). For 4 phar-
maceuticals (Crestor, Lantus, Advair, and Humira) used for com-
mon conditions, the United States had higher prices than all other
countries; for 3 of these, the US price was more than double the
next highest price. With respect to a measure of innovation, the
United States and Switzerland had the highest number of new
chemical entities at 111 and 26, respectively. The United States
accounted for 57% of total global production of new chemical enti-
ties. No estimates were available for Canada, Australia, Sweden,
the Netherlands, and Denmark. The United States also had high
generic penetration at 84% of the total pharmaceutical market,
which was comparable with markets in the United Kingdom and
Germany. Australia and the Netherlands had low generic penetra-
tion at 30% and 17%, respectively. Despite having the highest rate
of generic penetration, the amount that the United States spent
on generic products as a percentage of totalpharmaceutical spend-
ing was similar to other countries, suggesting that brand-name
Figure 5. Workforce and Structural Capacity
Magnetic resonance
imaging units
Denmark
NA
CHE
NA
Sweden
NA
UK
7.2
Canada
8.9
France
12.6
NLD
12.9
Australia
14.7
Germany
30.5
US
38.1
Japan
51.7
22
Computed tomography
units
Sweden
NA
UK
9.5
Canada
12.7
NLD
13.3
France
16.6
Germany
35.3
CHE
36.1
Denmark
37.1
US
41
Australia
56.1
Japan
107.2
36.5
Mammography machine
units
NLD
NA
Sweden
NA
Germany
NA
France
7.5
Denmark
14.2
Canada
17.3
UK
21
Australia
23
CHE
28.3
Japan
33
US
43.3
23.5
Overall physicians per
1000 population
Rank (highest to lowest)
Practicing workforce
1234567 8 9 10 11
UK
2.1
Japan
2.4
Canada
2.6
US
2.6
France
3.1
Australia
3.5
NLD
3.5
Denmark
3.6
Germany
4.1
Sweden
4.2
CHE
4.3
3.3
Mean
Primary care physicians,
% of total
Denmark
22
Sweden
33
Japan
43
US
43
Australia
45
Germany
45
UK
45
NLD
47
Canada
48
CHE
48
France
54
43
Specialists, % of total France
46
Canada
52
CHE
52
NLD
53
Australia
55
Germany
55
UK
55
Japan
57
US
57
Sweden
67
Denmark
78
57
Nurses per 1000 population UK
8.2
France
9.4
Canada
9.5
Japan
10.5
US
11.1
Sweden
11.2
Australia
11.5
NLD
12.1
Germany
13
Denmark
16.3
CHE
17.4
11.8
Generalist physicians Denmark
NA
CHE
NA
Sweden
86
607
Australia
108
564
NLD
109
586
France
111
769
Japan
124
558a
UK
134
671
Canada
146
286
Germany
154
126
US
218
173
133
723
Specialist physicians CHE
NA
Sweden
98
452
Japana
Denmark
140
505
France
153
180
UK
171
987
Germany
181
243
Canada
188
260
NLD
191
995
Australia
202
291
US
316
000
182
657
Nurses Sweden
NA
CHE
NA
France
42
492
Japan
44
712
UK
49
894
Germany
53
668
Canada
55
349
Denmark
58
891
Australia
64
357
NLD
65
082
US
74
160
51
795
Ratio of generalist
remuneration to mean wage
Japan
NA
Denmark
NA
CHE
NA
Sweden
2
Australia
2.1
NLD
2.1
France
2.6
Canada
3.0
UK
3.1
Germany
3.3
US
3.6
2.7
Ratio of specialists
remuneration to mean wage
Japan
NA
CHE
NA
Sweden
2.3
Denmark
2.6
UK
3.4
NLD
3.6
France
3.6
Australia
3.8
Canada
3.9
Germany
3.9
US
5.3
3.7
Non–health-specific annual
wage, meanb
Japan
39
113
Sweden
42
816
UK
42
835
France
42
992
Germany
46
389
Canada
48
403
Australia
52
063
Denmark
52
580
NLD
52
833
CHE
60
124
US
60
154
49
118
Ratio of nurse remuneration
to mean wage
CHE
NA
Sweden
NA
France
0.99
Denmark
1.12
Japan
1.14
Canada
1.14
Germany
1.16
UK
1.16
NLD
1.23
US
1.23
Australia
1.24
1.1
Hospital beds per 1000
population
Sweden
2.5
Canada
2.7
Denmark
2.7
UK
2.7
US
2.8
NLD
3.3
Australia
3.8
CHE
4.6
France
6.1
Germany
8.2
Japan
13.2
4.8
Long-term beds per 1000
population aged 65 y
Japan
35.1
US
38.8
Denmark
48.9
UK
49.5
Germany
53.1
Canada
53.7
Australia
54
France
59
NLD
65.5
CHE
67.6
Sweden
70.6
54.2
Equipment per 1 million population
Workforce remuneration, US $
Beds
NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands.
See eTable 3 in Supplement 2 for data ordered bycountr y. Generalist physicians
are defined as any practicing physician registered in his or her country as
a generalist physician or a specialist in the field of family medicine, pediatrics,
geriatrics, or internal medicine and excludes students, interns, and
nonpracticing physicians. Remuneration numbers may be an underestimate in
some countries (eg, Canada) because they do not account for practice expenses
for self-employed physicians. Japan is excluded from remunerationmeans with
the exception of nursing. Definitions of specialist and generalist physicians
in regard to remuneration were taken from the Organisation for Economic
Co-operation and Development.
a
The number for Japan , 124 558, is a combined total of ge neralists and specialist s.
b
In 2016 constant prices at 2016 US dollar purchasing power parities.
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pharmaceuticals were largely responsible for high overall spending.
These countries have notably different ways in how they finance
pharmaceuticals; there is considerable variation in both the share
covered by private insurance and the percentage covered by pri-
vate out-of-pocket spending. The United States had high levels of
private spending (36% compared with a mean of 8%), although
similar to Canada (30%), and was below the mean for out-of-
pocket spending at 30% (compared with a mean of 36%). With
regard to antibiotic prescriptions, which are often considered a
measure of inappropriate treatment, the United States was above
the mean, with a defined daily dose (average maintenance dose
per day for a drug used for its main indication in adults) of 24 com-
pared with a mean of 20.2.
Access and Quality
Relative to comparison countries, US performance varied on qual-
ity and access measures (Figure 10 and eTable 6 in Supplement 2).
Of the other countries examined, the United States was the only one
in which a sizeable minority (approximately 10%) of individuals
lacked coverage for basic health care services (Figure 1). For the 3
access measures (ability to get same- or next-day care when sick,
2-mont h wait time to se e a speciali st, and adeq uate time sp ent with
regular physician) the United States generally performed better than
the other countries. In the United States, 51% were able to get same-
or next-day care compared with a mean of 57% in all 11 countries. In
the United States, 6% had a wait time of 2 months or more to see a
specialist compared with mean of 13% in all 11 countries. Waiting
times to see a specialist were longer for national health service
and single-payer systems (ie, percentage with wait times longer
than 2 months: Canada, 39%; United Kingdom, 19%; Sweden, 19%)
compared with insurance-based systems (Netherlands, 7%;
Switzerland, 9%; Germany, 3%; France, 4%), with a mean of 13%.
The United Sta tes ranked near the mean for p atients reporting h av-
ing spent adequate time with their regular physician (81% com-
pared with a mean of 83% in all 11 countries).
The United States had relatively high screening rates for breast
cancer (81% compared with a mean of 67% in all 11 countries) but
lower rates of measles immunization (92% compared with a mean
of 94%) (Figure 10). The United States had considerablylower rates
of all 4 clinical outcome measures than the other countries. Thirty-
day mortality for ischemic stroke was 4.2 per 100 patients in the
United States compared with a mean of 7.9 per 100 patients in all 11
countries. For obstetric traumawithout instrument, the United State s
had 1.5 cases per 100 deliveries, whereas the mean was 2.3 per 100
deliveries in all 11 countries. The United States had high avoidable
hospitalizations for diabetes and asthma relative to comparison
countries (191.0 per 100 000 population compared with a mean of
125.6 per 100 000 population for diabetes, and 89.7 per 100 000
population compared with a mean of 42.4 per 100000 popula-
tion for asthma). When accounting for disease prevalence, the rate
of US hospitalizations for diabetes was similar to that of other coun-
tries, although hospitalizations for asthma were highest in the United
States, closely followed by the United Kingdom. Relativeto the other
countries, the US public reported the lowest satisfaction with their
health system, with only 19% reporting that the system works well.
US Disaggregated Data
When access and quality measures were disaggregated by payer,
the United States performed slightly worse for those covered by
Medicaid, but performance was uneven across insurance groups
(eTable 4 in Supplement 1). Nine percent of both privately insured
individuals and those insured by Medicaid reported a 2-month wait
time to see a specialist; this was lower than rates for Medicare
patients (11%) but higher than for uninsured individuals (8%). On
selected prevention measures, such as measles immunization, pri-
vately insured individuals had the highest rate of coverage at 95%,
Figure 6. Practicing Physicians by Primary Care Specialization
100
80
60
40
20
0
Physicians, %
Specialist
Obstetrics and
gynecology
Geriatrics
Pediatrics
Internal medicine
Family medicine
Generalist, not
further specified
AustraliaJapanCanadaDenmarkSwitzerlandNetherlandsFranceSwedenGermanyUnited
Kingdom
United
States
The total number of physicians, or 100%, differs for each country.Data are 2017
or closest available year.A functionality-based definition to identify primar y
care was used to identify physicians as those who provide a set of activities
whose functions define the boundaries of primary care. This included chronic,
preventive, and acute care in both inpatient and outpatient settings irrespective
of disease: disease prevention, early detection and diagnosis, treatment and
management, care coordination and integration, and health maintenance,
counseling, and/or patient education. The clinicians were often a patient’s first
point of contact for the health system with some degree of longitudinal
responsibility for the patient. This definition was used to reach out to country
experts and identify who is considered a primary care clinician in each
respective country. National workforce data or Eurostatdata, where available,
was then categorized according to expert responses. Physicians specializing in
obstetrics and gynecology are categorized as specialists for all countries but
have their own category in this figure.
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whereas for breast screening, Medicare beneficiaries had the high-
est rates (82%). Conversely, Medicare beneficiaries had the highest
rates of mortality for both ischemic stroke and acute myocardial
infarction. There was also variability in avoidable admissions:
patients with Medicaid insurance had the highest number of
asthma-related admissions and Medicare beneficiaries had the
highest number of admissions for diabetes. When disaggregated
by income or race, life expectancy was significantly different
among US groups, with nonwhite and poorer populations having
shorter life expectancies (eTables 3 and 4 in Supplement 1).
Equity
The United States had the highest horizontal inequity, indicating
the most inequitable access to physicians when adjusted for need. The
United States had an 11% rate of out-of-pocketspending as a percent-
age of total national health spending (compared with a mean of
13% in all 11 countries) and a 2.6% rate as a percentage of house-
hold consumption (compared with a mean of 2.4%) (Figure 11 and
eTable 7 in Supplement 2). However, the United States had a higher
proportion of unmet need in the population, with 22.3% of the popu-
lation reporting that they missed a consultation because of cost com-
pared with the mean of 9.4% for all 11 study countries. Given that the
system hasfree access at the point of entry, the United Kingdom re-
ported one of the lowest levels of barriers to accessing health ser-
vices, but the level was higher than in both Germany and Sweden.
Discussion
In this study based on data primarily from 2013-2016, the United
States spent approximately twice as much as other high-income
countries on medical care and fared worse on common population
health outcomes such as life expectancy and infant mortality.How-
ever, the main findings of this comparison were that, contrary to
some explanations for high spending, US social spending and health
care utilization were relatively similar to other high-income na-
tions. Although utilization of some surgical procedures (such as coro-
nary angioplasty, total knee replacement, and cesarean delivery) was
higher in the United States, this utilization did not appear to ex-
plain a large part of the higher spending in the United States.
Figure 7. Utilization
Discharges per 100
000 population
Acute myocardial infarction
Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11
Japan
89
France
124
UK
160
Denmark
174
NLD
175
US
192
Canada
193
Australia
196
CHE
223
Sweden
273
Germany
287
190
Mean
Mental and behavioral NLD
119
UK
269
Japan
319
France
368
Canada
629
US
679
Australia
856
Denmark
892
Sweden
1068
CHE
1182
Germany
1719
736
Pneumonia Canada
187
NLD
224
CHE
269
France
271
Australia
338
US
365
Japan
378
Germany
380
Sweden
432
UK
459
Denmark
567
352
Chronic obstructive
pulmonary disease
Japan
45
France
138
CHE
142
NLD
161
Sweden
186
US
230
Denmark
234
Canada
241
UK
251
Australia
286
Germany
352
206
Magnetic resonance imaging Sweden
NA
Australia
41
NLD
52
UK
53
Canada
56
CHE
70
Denmark
82
France
105
Japan
112
US
118
Germany
131
82
Examinations per 1000 population
Computed tomography Sweden
NA
UK
79
NLD
81
CHE
100
Australia
120
Germany
144
Canada
153
Denmark
162
France
197
Japan
231
US
245
151
Total hip replacement
per 100
000 population
Japan
90
Canada
136
Australia
171
UK
183
US
204
NLD
216
Sweden
234
France
236
Denmark
237
Germany
283
CHE
292
207
Total knee replacement
per 100
000 population
Japan
NA
NLD
118
Sweden
124
UK
141
France
145
Canada
166
Denmark
168
CHE
176
Australia
180
Germany
190
US
226
163
Hysterectomy per 100
000
women
Japan
NA
UK
161
NLD
167
France
182
Sweden
186
Denmark
197
Canada
232
Australia
262
US
266
CHE
291
Germany
301
225
Cesarean delivery per
100 live births
NLD
16
Sweden
17
Japan
18
Denmark
21
France
21
UK
23
Canada
26
Germany
31
Australia
32
CHE
33
US
33
25
Cataract surgery per 100
000
population
Japan
NA
CHE
438
UK
736
NLD
1005
Germany
1027
Sweden
1029
Denmark
1037
Australia
1060
Canada
1060
US
1110
France
1207
971
Coronary artery bypass graft
surgery
Japan
NA
CHE
NA
UK
26
France
29
Sweden
31
Australia
54
Canada
58
Germany
64
NLD
69
Denmark
73
US
79
54
Coronary angioplasty CHE
NA
UK
128
Canada
157
Australia
172
Denmark
190
Japan
193
Sweden
205
France
237
NLD
248
US
248
France
393
217
Surgical procedures
Normal delivery UK
1.5
Canada
1.6
NLD
1.9
US
2
Sweden
2.3
Australia
2.7
Denmark
2.7
Germany
2.9
CHE
3.6
France
4.1
Japan
5.7
2.8
Length of stay per capita, mean, d
Cardiovascular procedures per 100
000 population
Acute myocardial infarction Japan
NA
Denmark
3.9
Sweden
4.7
Australia
5.4
US
5.4
Canada
5.5
NLD
5.6
France
6
UK
7.1
CHE
7.3
Germany
10.3
6.1
NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands. See eTable 4 in Supplement 2 for data ordered by country.
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The data alsosuggest that some of the more common explana-
tions about higher health care spending in the United States,
such as underinvestment in social programs, the low primary
care/specialist mix, the fee-for-service system encouraging high
volumes of care, or defensive medicine leading to overutilization,
did not appear to be major drivers of the substantially higher US
health care spending compared with other high-income countries.
Instead, the data suggest that the main driving factors were
likely related to prices, including prices of physician and hospital
services, pharmaceuticals, and diagnostic tests, which likely also
affected access to care. In addition, administrative costs appeared
much higher in the United States. These findings indicate that
efforts targeting utilization alone are unlikely to reduce the gap in
spending between the United States and other high-income coun-
tries, and a more concerted effort to reduce prices and administra-
tive costs is likely needed.
Several findings in this report may be surprising to policy mak-
ers. There is broad consensus among US policy makers that the
United States spends too much on health services and too little on
social services. This analysis showed that US social spending ap-
pears to be similar to that in other high-income OECD countries. This
finding calls into question the belief that higher health care spend-
ing is due to a lack of investment in social determinants. In particu-
lar,given that the United States did not appear to be an outlier with
regard to utilization of services, it is unlikely that a lack of social spend-
ing results in higher health care spending due to a misallocation of
resources that results in greater need (and overutilization).
Another common perception among policy makers is that the
US system is often perceived to be disproportionately driven by
specialist care. However, the number of specialist practitioners in
the US system, both as an absolute number and a percentage, was
not considerably different from comparison countries. One expla-
nation may be differences in the way primary care services are
delivered in other countries. In many other countries, nurses and
allied health professionals may make up a higher proportion of the
health care workforce,
21
although we did not find substantially
higher numbers of nurses in the other countries. The extent to
which this explains variation in numbers of physicians across sys-
tems is unclear, but it is unlikely to fully account for why the United
States is not an outlier.
Although the ratio of primary care physicians to specialists was
similar between the United States and other high-income countries,
Figure 8. Performance on Key Measures of Utilization
0.5 1.0 1.5 2.00
No. of Hospital Bed Days per Inpatient
Japan
Germany
France
Switzerland
Sweden
Australia
United Kingdom
The Netherlands
United States
Denmark
Canada
Hospital bed days
C
2.5 2 4 6 8 10 12 14 160
Length of Stay per Inpatient, d
Japan
Germany
France
Switzerland
Sweden
Australia
United Kingdom
The Netherlands
United States
Denmark
Canada
All-cause length of stay
D
18
15050 100 2502000
Hospital Discharges per 1000 Population
Japan
Germany
France
Switzerland
Sweden
Australia
United Kingdom
The Netherlands
United States
Denmark
Canada
Hospital discharges
A
300 102 4 6 8 120
Physician Visits per Capita in a Given Year
Japan
Germany
France
Switzerland
Sweden
Australia
United Kingdom
The Netherlands
United States
Denmark
Canada
Consultationsa
B
14
The vertical dashed lines indicate mean values.
a
Consultations is the mean number of consultations or visits with a physician per person per year in all care delivery settings.
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the salaries paid to both generalist and specialist physicians were
markedly higher in the United States, where specialists were paid
twice as much as those in the United Kingdom or Germany and pri-
mary care physicians and nurses also had substantially higher sala-
ries. However,it can be difficult to compare salaries of workers from
various countries. In general, salaries for professionals are higher in
the United States than in other countries, and in addition, workers
in the United States bear higher costs in some areas, such as for health
care insurance, higher education, or planning for retirement, than
workers in other countries. Some of these issues are accounted for
in the ratio of national average wage, but US physicians and nurses
still had the highest ratio.
Some of the differential observed in cost between physicians
and nurses in the United States and in the other countries may re-
flect differences inproductivity or the extent to which trainingcosts
are borne by the individual, although in either case it is unlikely to
account for the magnitude of the difference. In 2011, Laugesen and
Glied
19
estimated that the investment repayment cost for private
education in the United States would amount to about $21 300 per
year for a primary care physician and about $24 400 for an ortho-
pedic surgeon over a 35-year period.
Taking this investmentinto account, however, does not explain
the more than $200 000 difference in compensation observed for
physicians between countries. Although remuneration varies widely
across systems, the optimal level of compensation remains unclear.
Salaries in the United Statesmay be high, but recent debates on re-
muneration of medical staff in the United Kingdom and France, for
example, suggest that salaries in other countries may be too low.
22
Other indicators, such as average wages for competitive nonhealth
professions or retention of medical graduates, may help inform ap-
propriate salaries of health care professionals in a given country.
Prices of services were not examined directly, but US health
care spending was found to be higher than in other countries
despite similar utilization patterns, suggesting that higher prices
were the primary cause of high health care spending in the United
States relative to other nations. This is consistent with prior work
Figure 9. Pharmaceuticals
Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11 Mean
Retail pharmaceutical spending
per capita, US $
Denmark
573
NLD
292
Sweden
501
UK
383
Australia
346
France
541
CHE
776
Germany
480
Canada
587
Japan
443
US
1026
541
Crestor (cholesterol)
Lantus (diabetes) Denmark
NA
CHE
NA
NLD
NA
Sweden
NA
France
47
Australia
54
Germany
61
Japan
64
UK
64
Canada
67
US
186
78
Prices, US $ per moa
Advair (asthma) Denmark
NA
CHE
NA
NLD
NA
Sweden
NA
UK
NA
Australia
29
France
35
Germany
38
Japan
51
Canada
74
US
155
64
Humira (rheumatoid arthritis) Denmark
NA
CHE
NA
NLD
NA
Sweden
NA
Japan
980
France
982
UK
1158
Canada
1164
Australia
1243
Germany
1749
US
2505
1436
Australia
NA
Canada
NA
Denmark
NA
NLD
NA
Sweden
NA
France
11
Germany
12
UK
16
Japan
18
CHE
26
US
111
NA
New chemical entities, No.b
Public spending US
34
Canada
36
Denmark
43
CHE
43
Australia
49
Sweden
52
NLD
65
UK
66
Japan
71
Germany
75
France
80
56
Private insurance
Private out-of-pocket spending Germany
18
France
19
Japan
28
US
30
NLD
33
Canada
34
UK
36
Sweden
48
Australia
50
Denmark
51
CHE
51
36
Pharmaceutical expenditure by financing type, % of total spending
Australia
0
Sweden
0
UK
0
Japan
1
France
1
NLD
2
Germany
7
Denmark
8
CHE
8
Canada
30
US
36
8
Volume NLD
17
Australia
30
Sweden
44
Denmark
54
CHE
54
Japan
56
Canada
70
France
70
Germany
80
UK
83
US
84
58
Value
Share of generics, % of totalc
Denmark
14
CHE
14
Australia
15
Sweden
15
NLD
16
France
16
US
28
Canada
29
Japan
33
UK
33
Germany
37
23
Japan
NA
NLD
10.7
Sweden
12.9
Germany
14.4
Denmark
16.6
UK
20.1
US
24
Canada
25
Australia
28.3
France
29.9
CHE
NA
20.2Antibiotic prescribing, defined
daily doses per 1000 populationd
Denmark
NA
CHE
NA
NLD
NA
Sweden
NA
Australia
9
France
20
UK
26
Japan
29
Canada
32
Germany
41
US
86
35
NLD
466
Total spending per capita, US $ Denmark
675
CHE
939
Sweden
566
Australia
560
France
697
UK
779
Japan
837
Canada
613
Germany
667
US
1443
749
NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands.
See eTable 5 in Supplement 2 for data ordered bycountr y.
a
US discounted prices are listed; nondiscounted prices are $216.00 for Crestor,
$372.75 for long-acting insulin, $309.60 for Advair, and $3430.82for Humira.
b
A new chemical entity is a compound without any precedent among the
regulated and approved drug products.
c
Volume is most often the proportion of total prescriptions that were for
generic brands. Volumes can be expressed in defined daily doses or as a
number of packages/boxes or standard units. Value is most often the
proportion of total cost (ie, government and patient expenditure) that was for
generic brands. Values can be, for instance, the turnoverof pharmaceutical
companies, the amount paid for pharmaceuticals by third-party payers, or the
amount paid by all payers (third-party and consumers). Market value is most
often at ex-factory prices, while amounts paid by third-party payers and
consumers are in general at retail prices.
d
Defined daily dose is the assumed mean maintenance dose per day for a drug
used for its main indication in adults. Data shown here are actual mean defined
daily doses for each country.
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by Anderson et al,
23
which also illustrated higher health care
spending in the United States despite similar inputs and levels of
care utilization, and more recent work by Dieleman et al.
13
In addi-
tion to differential prices for physician services and pharmaceuti-
cals, these results suggest that prices for nonphysician services and
procedures also appeared to be markedly higher in the United
States. For the select procedures for which comparable data were
available, the United States paid considerably more than its coun-
terparts. In 2013, the International Federation of Health Plans
24
reported that the average cost in the United States was $75345
for a coronary artery bypass graft surgery, whereas the costs
in the Netherlands and Switzerland were $15 742 and $36509,
respectively. Computed tomography was also much higher in the
United States, with an average payment of $896 per scan com-
pared with $97 in Canada, $279 in the Netherlands, $432 in Swit-
zerland, and $500 in Australia in 2013. Similarly, the mean payment
for an MRI in the United States was $1145 compared with $350 in
Australia and $461 in the Netherlands.
Of particular interest to US health policy makers is the role of
the pharmaceutical market and its influence on health care spend-
ing. Not surprisingly, US spending on pharmaceuticals was almost
double the spending in comparison countries. Previous work sug-
gests that this is driven by high prices for brand-name drugs rather
than by utilization, which is comparable with other high-income
countries.
24-27
Across comparison countries, the United States had
the highest volume of generics, accounting for more than 80% of
Figure 10. Access and Quality
Access, %
Able to get same- or next-
day appointmenta
Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11
Japan
NA
Denmark
NA
CHE
NA
Canada
43
Sweden
49
US
51
Germany
53
France
56
UK
57
Australia
67
NLD
77
57
Mean
2-mo Wait time to see specialist Japan
NA
Denmark
NA
Germany
3
France
4
US
6
NLD
7
CHE
9
Australia
13
Sweden
19
UK
19
Canada
39
13
Adequate time with regular
(primary) physician
Japan
NA
Denmark
NA
France
NA
Sweden
78
Canada
79
US
81
Australia
83
CHE
84
NLD
85
UK
86
Germany
88
83
System works well Japan
NA
Denmark
NA
NLD
NA
US
19
Canada
35
Australia
44
Sweden
44
UK
44
France
54
CHE
58
Germany
60
45
Fundamental changes needed Japan
NA
Denmark
NA
NLD
NA
CHE
37
Germany
37
France
41
Australia
46
Sweden
46
UK
46
US
53
Canada
55
45
Measles immunization, %
of children
Canada
90
Denmark
91
France
91
US
92
Australia
93
CHE
93
UK
93
NLD
96
Germany
97
Japan
98
Sweden
98
94
Breast cancer screening, %
of women aged 50-69 yb
Japan
41
CHE
47
France
52
Australia
55
Germany
71
Canada
72
Sweden
75
UK
76
NLD
79
US
81
Denmark
84
67
Complete rebuild of health
system needed
Japan
NA
Denmark
NA
NLD
NA
CHE
3
Germany
3
Australia
4
France
4
UK
7
Canada
9
Sweden
10
US
23
8
Clinical outcomes
30-d Stroke mortality per
1000 patientsc
Japan
NA
Denmark
NA
NLD
NA
US
4.2
Germany
6.4
CHE
6.9
France
7.9
UK
9.2
Australia
9.3
Sweden
9.6
Canada
10
7.9
30-d Mortality per 1000 patients
with acute myocardial infarction
Japan
NA
Denmark
NA
NLD
NA
Australia
4.1
US
5.5
Canada
6.7
France
7.2
UK
7.6
CHE
7.7
Sweden
8.3
Germany
8.7
7
Foreign body left per
100
000 discharges
Japan
NA
Denmark
NA
NLD
NA
US
4.1
Sweden
4.6
Germany
5.5
UK
6.1
France
6.2
Australia
8.6
Canada
8.6
CHE
12.3
7
Obstetric trauma without
instrument per 100 deliveries
Japan
NA
France
0.6
US
1.5
Germany
2.1
Australia
2.4
NLD
2.5
Denmark
2.6
CHE
2.6
Sweden
2.8
UK
2.8
Canada
3.1
2.3
Diabetes hospitalizations per
100
000 populationd
NLD
69.8
CHE
72.6
UK
72.8
Canada
93.7
Sweden
96
Denmark
113.4
Australia
141.1
France
150.6
Japan
162.3
US
191
Germany
218.3
125.6
Diabetes hospitalizations as a
ratio of population with diabetese
CHE
1.20
NLD
1.20
France
1.20
Canada
1.30
UK
1.70
Denmark
1.80
Sweden
1.90
US
2
Germany
2.40
Australia
2.80
Japan
2.80
2.00
Asthma hospitalizations as a
ratio of population with asthmag
Canada
0.20
Japan
0.30
Sweden
0.30
CHE
0.40
Australia
0.60
NLD
0.70
Germany
0.70
Denmark
0.80
UK
1.00
US
1.20
0.70
Asthma hospitalizations per
100
000 populationf
Canada
14.6
Sweden
19
CHE
27.5
Germany
28.7
France
29.6
Japan
34.7
NLD
36
Denmark
50.6
Australia
64.8
France
0.80
UK
71
US
89.7
42.4
Avoidable hospitalizations
Prevention
Perceptions, %
NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands.
See eTable 6 in Supplement 2 for data ordered bycountr y.
a
Able to get same- or next-day appointment when sick, excluding those who
did not need to see a physician or nurse.
b
Women aged 40 to 49 years in Sweden.
c
Thirty-day stroke mortality after hospital admission for ischemic stroke.
d
Limited to a primary diagnosis of diabetes.
e
Diabetes hospitalizations are limited to persons aged 15 years or older, whereas
the denominator (populationwith diabetes) is both adultand pediatric.
f
Limited to a primary diagnosis of asthma.
g
Asthma hospitalizations are limited to persons aged 15 years or older,whereas
the denominator (population with asthma) is both adult and pediatric.
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total pharmaceuticals used by US residents yet just under 30% of
the United States’ total spending on pharmaceuticals. Australia and
Fran ce had mu ch smal ler gen eric ma rket pe netra tion ra tes, pr esum-
ably because brand-name drugs are comparatively affordable.
25
Although the United States’ high prices of pharmaceuticals are
controversial, these prices have been viewed as critical to innova-
tion, including US production of new chemical entities.
18,28
Whether
innovation justifies high levels of spending is not clear.
Performance on access is also a central concern to policy mak-
ers. These data indicated that the United States had the lowest rate
of insurance coverage. However, the percentage of the population
with health insurance is at a historical high and has continued to in-
crease since the passage of the Affordable Care Act. Out-of-pocket
spending was also surprisingly low in the United States, which may
be explained in part by the relatively high proportion of patients who
do not seek care or who skip consultations because of high costs.
Prior work has shown that out-of-pocket spending is more concen-
trated among the poor.
29
Other factors influencing access to care
in the United States aside from affordability likely include the coun-
try’s considerable landmass (and correspondingly large rural popu-
lation). Personal choice is an additional albeit contentious factor.For
example, the Kaiser Family Foundation has found that approxi-
mately 20% of uninsured US residents have incomes of 400% or
more of the federal poverty level and have largely chosen to forgo
insurance.
30
In the other countries in this study with similar health
insurance designs (the Netherlands and Switzerland), the propor-
tion of the population choosing to forego coverage is considerably
less.
31,32
Still, a substantial proportion of people would benefit from
coverage but remain uninsured in the United States, and increas-
ing coverage for these individuals remains a policy priority.
A central concern in the United States is the extent to which
greater health care spending translates to better outcomes. Com-
paring intermediate country-level health care outcomes across a
range of health care services showed that the United States does
perform favorably on certain acute care outcomes but less so for
primary care measures. Notably, the United States had among the
highest breast cancer screening rates and the lowest 30-day mor-
tality rates for acute myocardial infarction and stroke. Although the
rates of avoidable hospitalizations in the United States, such as for
diabetes and asthma, are well above those of most of the countries
in the analysis, accounting for the United States’ higher prevalence
of both diseases reduced this gap considerably. The United States
has relatively poor population health outcomes, which likely repre-
sents a combination of factors including issues with the affordabil-
ity of care. However, the United States average, in comparison
to averages of much smaller, more homogeneous countries, may
lead to erroneous conclusions. For example, the life expectancy of
Minnesota, a state comparable in size and demographics to
Figure 11. Distribution and Equity
Out-of-pocket spending
Rank (highest to lowest) 1 2 3 4 5 6 7 8 9 10 11 Mean
As % of total health expenditure NLD
5.2
France
6.3
UK
9.7
US
11
Germany
13.2
Denmark
13.4
Canada
13.6
Japan
13.9
Sweden
14.1
Australia
18.8
CHE
26.8
13.3
As % of household consumption
Equity
Horizontal inequity index, %aAustralia
NA
Japan
NA
Denmark
NA
CHE
NA
NLD
NA
Sweden
NA
UK
0.40
Germany
1.00
France
1.30
Canada
1.90
US
6
2.10
NLD
1.3
France
1.4
UK
1.4
Germany
1.8
Japan
2.2
Canada
2.3
Denmark
2.6
US
2.6
Australia
3.2
Sweden
3.4
CHE
4.5
2.4
Consultation skipped
because of cost
Japan
NA
Denmark
NA
Germany
2.6
Sweden
3.9
UK
4.2
Canada
6.6
CHE
7
France
9
NLD
12.5
Australia
16.2
US
22.3
9.4
% Unmet need, below-average
income
% Unmet need, above-average
income
Japan
NA
Denmark
NA
Germany
6
Sweden
7
UK
7
Australia
13
Canada
13
France
14
NLD
16
CHE
22
US
32
14.4
Unmet needb
Japan
NA
Denmark
NA
UK
8
Sweden
16
Germany
16
Australia
24
NLD
29
Canada
30
France
30
CHE
31
US
43
25.2
Rural population, % of
total population
Japan
6
NLD
9
Australia
10
Denmark
12
Sweden
14
UK
17
Canada
18
Germany
18
US
18
France
20
CHE
26
15
Population density per sq mile
Geographic breakdown
Australia
3
Canada
4
Sweden
24
US
35
France
122
Denmark
136
CHE
212
Germany
237
UK
271
Japan
348
NLD
505
173
Urban physicians per
1000 population
Denmark
NA
NLD
NA
UK
NA
Germany
2
Australia
2.6
CHE
2.8
Japan
2.9
US
3.2
Canada
4.1
France
4.1
Sweden
4.5
3.3
2.1
Rural physicians per
1000 population
Denmark
NA
NLD
NA
UK
NA
Canada
0.4
Germany
1.3
Japan
1.4
US
1.4
Australia
1.7
France
2.5
Sweden
3.5
CHE
4.4
NA indicates not applicable. CHE indicates Switzerland; NLD, the Netherlands.
See eTable 7 in Supplement 2 for data ordered bycountr y.
a
The horizontal inequity index is the percentage probability of a physician visit
in the past 12 months by wealth. If the index is greater than 0, then
high-income groups access physicians more than low-income groups after
adjustment for relative need.
b
Regarding unmet need, the Commonwealth Fund International Health Policy
Survey poses a number of questions to a representative sample from each
country. Forthis indicator, it was analyzed whether a respondent did not
consult with or visit a physician because of cost, skipped a medical test,
treatment, or follow-up that was recommended by a physician because of
cost, or did not fill or collect a prescription for medicine or skipped doses
of medicine because of cost. Low income is defined as household income
less than 50% of the country median.
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Sweden or Denmark, has more similar population health outcomes
to these countries than Minnesota has in comparison to Mississippi.
This analysis extends to a body of work that has explored US
health care spending
33
by revisiting c omparisons followin g the pas-
sage of the Affordable Care Act, which has both increased cover-
age and spurred health care delivery reform toward the delivery of
high-value care.
9,13
Similar to previous work by Garber and Skinner,
10
Reinhar dt et al,
12
and Anderson et al
23
that examined US health care
spending relative to other OECD countries, we found that the United
States spent significantly more on health care despite having simi-
lar levels of utilization. However,from 2010 onward it appeared that
the United States had similar levels of public social spending com-
pared with other high-income countries. While public social spend-
ing has increased since 2010 (from 15.6% of GDP in 2005 to 19.3%
of GDP in 2010), utilization rates have remained relatively
unchanged.
20,23
This finding suggests that differences in social
spending are less likely to be the main driver of differences in health
care spending than previous works have suggested.
34
This is a simi-
lar conclusion to recent work by Dieleman et al,
13
which identified
prices and intensity of care to be largely related to increases in health
care spending over the past 15 years and negativelyassociated with
disease prevalence or incidence.
This study has several limitations. First, there waslimited avail-
ability of comparable data across health systems, which restricted
the areas of health system performance we were able to compare.
In particular, data on prices across systemswere lacking, as was the
number of indicators on quality and coverage. The indicators se-
lected thus provide a snapshot of performance in some domains—
particularly quality—which may not be representative of quality of
the entire system or may be limited due to data availability across
all countries. For instance, 30-day mortality rates reflect only in-
hospital rates, which may influence the apparent variations ob-
served, particularly given differences in length of stay and dis-
chargepractices acrosscountries. Second,because of the difficulties
in collecting and standardizing indicators across countries, some of
the data used reflect different years, may be out of date, or may have
been measured differently based on country-specific definitions of
variables. Even when data werecollec ted from the same source, is-
sues of comparability remain because of fundamental differences
in how systems are organized and, in turn, how care is categorized.
Two a rea s of parti cul ar co nce rn are out pat ien t spendi ng an d the pri-
mary care workforce. We attempted to address limitations in the
workforce data by utilizing a functionality-based approach to iden-
tifying who provides primary care services in each country and by
cross-referencing resulting numbers with country experts. Third, the
study was able to pr esent only descri ptive comparative fi ndings, and
it is not possible to make any causal inferences. Fourth, the data did
not adjust for factors such as underlying population differences or
system delivery and organizational factors, which likely influence
some of the observed variation in this space. Fifth, the response rate
to some surveys that were the basis for some measures, such as abil-
ity to get same- or next-day appointment and 2-month waittime to
see a specialist physician, were not good across all countries. Sixth,
we did not consider the actual prices of devices, which, given the
increasing number of hip and knee replacements and use of other
devices, are emerging as an important consideration in the cost of
care in the United States.
Conclusions
The United States spent approximately twice as much as other
high-income countries on medical care, yet utilization rates in the
United States were largely similar to those in other nations. Prices
of labor and goods, including pharmaceuticals, and administrative
costs appeared to be the major drivers of the difference in overall
cost between the United States and other high-income countries.
As patients, physicians, policy makers, and legislators actively
debate the future of the US health system, data such as these are
needed to inform policy decisions.
ARTICLE INFORMATION
Accepted for Publication: February 2, 2018.
Author Contributions: Dr Papanicolas and Ms
Woskie had full access to all of the data in the study
and take responsibility for the integrity of the data
and the accuracy of the data analysis.
Concept and design: All authors.
Acquisition, analysis, or interpretation of data: All
authors.
Drafting of the manuscript: Papanicolas, Woskie.
Critical revision of the manuscript for important
intellectual content: All authors.
Statistical analysis: Woskie.
Administrative, technical, or material support: All
authors.
Supervision: Papanicolas, Jha.
Conflict of Interest Disclosures: All authors have
completed and submitted the ICMJE Form for
Disclosure of Potential Conflicts of Interest and
none were reported.
Additional Contributions: We thank Duncan
Orlander, BA, Harvard School of Public Health
Department of Health Policy and Management,
for research assistance (compensated as part
of regular pay).
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Importance Health care spending in the United States increased substantially from 1995 to 2015 and comprised 17.8% of the economy in 2015. Understanding the relationship between known factors and spending increases over time could inform policy efforts to contain future spending growth. Objective To quantify changes in spending associated with 5 fundamental factors related to health care spending in the United States: population size, population age structure, disease prevalence or incidence, service utilization, and service price and intensity. Design and Setting Data on the 5 factors from 1996 through 2013 were extracted for 155 health conditions, 36 age and sex groups, and 6 types of care from the Global Burden of Disease 2015 study and the Institute for Health Metrics and Evaluation’s US Disease Expenditure 2013 project. Decomposition analysis was performed to estimate the association between changes in these factors and changes in health care spending and to estimate the variability across health conditions and types of care. Exposures Change in population size, population aging, disease prevalence or incidence, service utilization, or service price and intensity. Main Outcomes and Measures Change in health care spending from 1996 through 2013. Results After adjustments for price inflation, annual health care spending on inpatient, ambulatory, retail pharmaceutical, nursing facility, emergency department, and dental care increased by $933.5 billion between 1996 and 2013, from $1.2 trillion to $2.1 trillion. Increases in US population size were associated with a 23.1% (uncertainty interval [UI], 23.1%-23.1%), or $269.5 (UI, $269.0-$270.0) billion, spending increase; aging of the population was associated with an 11.6% (UI, 11.4%-11.8%), or $135.7 (UI, $133.3-$137.7) billion, spending increase. Changes in disease prevalence or incidence were associated with spending reductions of 2.4% (UI, 0.9%-3.8%), or $28.2 (UI, $10.5-$44.4) billion, whereas changes in service utilization were not associated with a statistically significant change in spending. Changes in service price and intensity were associated with a 50.0% (UI, 45.0%-55.0%), or $583.5 (UI, $525.2-$641.4) billion, spending increase. The influence of these 5 factors varied by health condition and type of care. For example, the increase in annual diabetes spending between 1996 and 2013 was $64.4 (UI, $57.9-$70.6) billion; $44.4 (UI, $38.7-$49.6) billion of this increase was pharmaceutical spending. Conclusions and Relevance Increases in US health care spending from 1996 through 2013 were largely related to increases in health care service price and intensity but were also positively associated with population growth and aging and negatively associated with disease prevalence or incidence. Understanding these factors and their variability across health conditions and types of care may inform policy efforts to contain health care spending.
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Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure–the Healthcare Quality and Access (HAQ) Index–on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r=0·88), an index of 11 universal health coverage interventions (r=0·83), and human resources for health per 1000 (r=0·77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28·6 to 94·6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40·7 (95% uncertainty interval, 39·0–42·8) in 1990 to 53·7 (52·2–55·4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21·2 in 1990 to 20·1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73·8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-system characteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Funding Bill & Melinda Gates Foundation.
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