Karen Davis, Cathy Schoen, Kristof Stremikis
K. Davis, C. Schoen, and K. Stremikis, Mirror, Mirror on the Wall: How the Performance of the U.S. Health Care System Compares Internationally 2010 Update, The Commonwealth Fund, June 2010.
The U.S. health system is the most expensive in the world, but comparative analyses consistently show the United States underperforms relative to other countries on most dimensions of performance. This report, which includes information from the most recent three Commonwealth Fund surveys of patients and primary care physicians about medical practices and views of their countries' health systems (2007–2009), confirms findings discussed in previous editions of Mirror, Mirror. It also includes information on health care outcomes that were featured in the most recent (2008) U.S. health system scorecard issued by the Commonwealth Fund Commission on a High Performance Health System.
Among the seven nations studied—Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States—the U.S. ranks last overall, as it did in the 2007, 2006, and 2004 editions of Mirror, Mirror. Most troubling, the U.S. fails to achieve better health outcomes than the other countries, and as shown in the earlier editions, the U.S. is last on dimensions of access, patient safety, coordination, efficiency, and equity. The Netherlands ranks first, followed closely by the U.K. and Australia. The 2010 edition includes data from the seven countries and incorporates patients' and physicians' survey results on care experiences and ratings on various dimensions of care.
The most notable way the U.S. differs from other countries is the absence of universal health insurance coverage. Health reform legislation recently signed into law by President Barack Obama should begin to improve the affordability of insurance and access to care when fully implemented in 2014. Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term "medical homes." Without reform, it is not surprising that the U.S. currently underperforms relative to other countries on measures of access to care and equity in health care between populations with above-average and below-average incomes.
But even when access and equity measures are not considered, the U.S. ranks behind most of the other countries on most measures. With the inclusion of primary care physician survey data in the analysis, it is apparent that the U.S. is lagging in adoption of national policies that promote primary care, quality improvement, and information technology. Health reform legislation addresses these deficiencies; for instance, the American Recovery and Reinvestment Act signed by President Obama in February 2009 included approximately $19 billion to expand the use of health information technology. The Patient Protection and Affordable Care Act of 2010 also will work toward realigning providers' financial incentives, encouraging more efficient organization and delivery of health care, and investing in preventive and population health.
For all countries, responses indicate room for improvement. Yet, the other six countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving value for the nation's substantial investment in health.
The U.S. ranks last of seven nations overall. Findings in this report confirm many of those in the earlier three editions of Mirror, Mirror. As in the earlier editions, the U.S. ranks last on indicators of patient safety, efficiency, and equity. Australia and the U.K. continue to demonstrate superior performance. The Netherlands, which was included for the first time in this edition, ranked first overall. In the subcategories, the U.S. ranks first on preventive care, and is strong on waiting times for specialist care and nonemergency surgical care, but weak on access to needed services and ability to obtain prompt attention from primary care physicians.
Any attempt to assess the relative performance of countries has inherent limitations. These rankings summarize evidence on measures of high performance based on national mortality data and the perceptions and experiences of patients and physicians. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients' and physicians' assessments might be affected by their experiences and expectations, which could differ by country and culture.
Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home. Under health care reform, young adults up to age 26 will be eligible for coverage under their parents' insurance plans beginning in September 2010, and low- to moderate-income families will be eligible for assistance in obtaining coverage in 2014.
With the enactment of the American Recovery and Reinvestment Act, the U.S. has accelerated its efforts to adopt health information technology and provide an integrated medical record and information system that is accessible to providers and patients. Those efforts must come to fruition soon for the nation to deliver more effective and efficient care.
Many U.S. hospitals and health systems are dedicated to improving the process of care to achieve better safety and quality, but the U.S. can also learn from innovations in other countries—including public reporting of quality data, payment systems that reward high-quality care, and a team approach to management of chronic conditions. Based on these patient and physician reports, and with the enactment of health reform, the U.S. could improve the delivery, coordination, and equity of the health care system.