U.S. spent most per-capita on health care but had poorest overall care quality

Commonwealth Fund study also showed the U.S. having the widest gap in income levels’ access to care.

The United States spent more per-capita on health care than five other major industrialized countries but got the poorest return on its investment in 2004-2005, according to a patient survey. The United States also had the widest disparity in health care access by income level, and was the only country studied with a large uninsured population.

The United States spent an average $5635 per-person on health care, almost doubling Canada’s average ($3003). Germany ($2996), Australia ($2903), United Kingdom ($2231) and New Zealand ($1886) rounded out the spending order, according to the Commonwealth Fund survey.

“U.S. health care leaders often say that American health care is the best in the world,” said Commonwealth Fund President Karen Davis. “However, recent studies of medical outcomes and mortality statistics suggest that, despite spending more per capita on health care and devoting to it a greater percentage of its national income than any other country, the United States is not getting commensurate value for its money.”

The U.K. ranked first on health care equity, with “no or negligible differences” in high- and low-income patients’ access to care. Australia scored second, New Zealand third.

The report was based on two adult patient surveys. The first tally, conducted in 2004, involved patients in Australia, Canada, New Zealand, United Kingdom and United States. The second study, done in 2005, included those countries and Germany.

Patients rated their home countries’ health care on safety, effectiveness, patient-centered care, timeliness, efficiency and equity. The two surveys updated an earlier study that used data from 2001 and 2002.

Safety and efficiency

Germany ranked highest overall, followed by New Zealand, U.K., Australia, Canada and United States. The U.K. scored highest and the United States ranked lowest on patient safety. Germany scored second highest. The United States had the highest rate of patients receiving incorrect medications or doses in the past two years. American patients were also more likely to receive incorrect laboratory results or receive late notification of abnormal results. Canada also had a high rate of lab errors.

The effectiveness rating included four criteria: prevention, chronic care, primary care and hospital care/coordination. The United States scored highest on effectiveness, followed by Canada, Germany, Australia, United Kingdom and New Zealand. American patients received excellent preventive care and chronically ill patients received particularly good care. Canada also scored well on primary care, with Germany scoring highest on hospital care/coordination. However, all six nations had “considerable room for improvement,” the authors said.

Germany ranked first in efficiency, with New Zealand and the U.K. following and the United States last. American patients were more likely than their peers in other countries to visit an emergency room for a condition that a primary care physician could have treated. They were also more likely to undergo duplicate tests ordered by different practitioners, the report said.

Germany also ranked highest on patient-centered care, which included four criteria: communication, choice and continuity, patient engagement and responsiveness to patient preference. New Zealand ranked highest on communication and patient engagement. Germany scored highest on choice and continuity. Australia scored well on responsiveness to patient preference. The United States scored lowest on almost all patient-centeredness criteria, the authors said.

Germany and New Zealand scored first and second, respectively, on timeliness. The United States ranked third, with Australia fourth, United Kingdom fifth and Canada sixth. German and American patients reported the least difficulty waiting to see a specialist or have elective surgery. However, more Americans and Canadians reported waiting six days or longer for an appointment with a physician or had difficulty getting care on nights and weekends, the report said.

United States called to improve

“The findings suggest that, if the health care system is to perform according to patients’ expectations, the United States will need to remove financial barriers to care and improve the delivery of care,” the authors said. “Disparities in terms of access to services signal the need to expand insurance to cover the uninsured and ensure that the system works well for all Americans. Based on these patient reports, the United States should improve the delivery, coordination and equity of the health care system.”

World Health Organization (WHO) reports using measures like life expectancy, infant mortality, preventable death and expenditures, also showed the United States achieving “the least for its population” of all six countries, the authors reported.

The recent surveys confirmed earlier findings, such as the U.S. ranking last on patient safety, patient-centeredness, efficiency and equity. However, the United States improved in effectiveness, where it progressed from being tied with Australia for last place to first place, the report said.

The Commonwealth Fund organized patient responses according to the Institute of Medicine’s framework for quality and ranked each country’s score on individual items from highest to lowest. For each IOM quality domain, researchers calculated a summary ranking by averaging the individual ranked scores within each country and ranking the averages from the highest score to the lowest.

The study measured patients’ perceptions of quality and did not include more objective data, such as medical records or administrative data, researchers said.

The Commonwealth Fund is a non-profit organization.

For more information:
Davis K, Schoen C, Schoenbaum SC, et al. Mirror, mirror on the wall: An update on the quality of American health care through the patient’s lens. The Commonwealth Fund. Available at cmwf.org/publications/publications_show.htm?doc_id=364436.