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Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens

See the full series of "Mirror, Mirror" publications, with updated data years. 

Executive Summary

U.S. health care leaders often say that American health care is the best in the world. However, recent studies of medical outcomes and mortality and morbidity 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 Commonwealth Fund's cross-national surveys of patients' views and experiences of their health care systems offer opportunities to assess U.S. performance relative to other countries through the patients' perspective—a dimension often missing from international comparisons.

In 2004, we reported on U.S. performance using Commonwealth Fund international survey data from 2001 and 2002. This report updates these findings using data from two recent surveys. The first survey was conducted in 2004 among a nationally representative sample of adults in five nations: Australia, Canada, New Zealand, the United Kingdom, and the United States. The second survey was conducted in 2005 among a sample of adults with health problems in the same five nations and Germany. This report ranks the countries in terms of patients' reports on care experiences and ratings on various dimensions of care. While focusing on a limited slice of the health care quality picture—patient perceptions of care received—as well as a limited number of countries, the surveys nonetheless offer valuable insights.

We organized patients' responses according to the Institute of Medicine's (IOM) framework for quality, outlined in the six bulleted points below. We then ranked each country's score on individual items from highest to lowest. For each IOM quality domain, we calculated a summary ranking by averaging the individual ranked scores within each country and ranking these averages from highest to lowest score.

Overall, the findings indicate that the U.S. health care system often performs relatively poorly from the patient perspective. The U.S. system ranked first on effectiveness but ranked last on other dimensions of quality (Figure ES-1). It performed particularly poorly in terms of providing care equitably, safely, efficiently, or in a patient-centered manner. On measures of timeliness, the U.S. system did not score as well as some of the other countries and rarely received top scores. For all countries, responses indicate room for improvement. Yet, the other five countries spend considerably less on health care per person and as a percent of gross domestic product than the United States. These findings indicate that, from the perspective of the patients it serves, the U.S. health care system could do much better in achieving high-quality performance for the nation's substantial investment in health.

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Key Findings

  • Patient safety: Among sicker adults, Americans had the highest rate of receiving wrong medications or doses in the prior two years. Among sicker adults who had a lab test in the past two years, adults in the U.S. were more likely than their counterparts in the other countries to have been given incorrect results or experienced delays in notification about abnormal results, with rates double those reported in Germany or the U.K. Rates of lab errors were also relatively high in Canada.
  • Effectiveness: The indicators of effectiveness in the 2004 and 2005 surveys were grouped into four categories: prevention, chronic care, primary care, and hospital care and coordination. Compared with the other five countries, U.S. patients fared particularly well on receipt of preventive care and care for the chronically ill, although all countries had considerable room for improvement. Canada scored well on primary care, and Germany ranked first on hospital care and coordination. Across the indicators of effectiveness, the U.S. ranked first and New Zealand ranked last.
  • Patient-centeredness: In 2004 and 2005, survey questions asked patients to rate the quality of their physician care in four areas: communication, choice and continuity, patient engagement, and responsiveness to patient preference. On measures of communication and patient engagement, New Zealand ranked highest. Germany was first on measures of choice and continuity, and Australia performed well on responsiveness to patient preference. Across the measures of patient-centeredness, Germany generally was highest, followed by New Zealand. The U.S. ranked last on nearly all aspects of patient-centeredness.
  • Timeliness: Germany and the U.S. stand out among the six countries in terms of patients with health problems reporting the least difficulty waiting to see a specialist or have elective or non-emergency surgery. Yet Americans, along with Canadians, were more likely to say they waited six days or more for an appointment with a doctor or had trouble getting care on nights and weekends. Across all five measures of timeliness, Germany and New Zealand ranked first and second, respectively. The U.K. ranked fifth, and Canada ranked last.
  • Efficiency: The 2005 survey included four questions on coordination of care that serve as indicators of health care system efficiency. Compared with their counterparts in other countries, sicker adults in the U.S. more often reported that they visited the emergency room for a condition that could have been treated by a regular doctor had one been available and that their medical records or test results failed to reach their doctor's office in time for appointments. About one of four U.S. sicker adults reported these concerns. U.S. sicker adults, along with their German counterparts, also were more likely to be sent for duplicate tests by different clinicians. On measures of efficiency, the U.S. ranked last among the six countries, with Germany and New Zealand ranking first and second, respectively.
  • Equity: Nine measures from the two surveys gauged the extent to which patients' income affected their ability to access care. The U.S. scored last on seven of the nine measures of low-income patients not receiving needed care and had the greatest disparities in terms of access to care between those with below-average and above-average incomes. With low rankings on all measures, the U.S. ranked last among the six countries in terms of equity in the health care system. The U.K. ranked first, with no or negligible differences in terms of patients' access to care by income. The U.S. is the only country surveyed with large numbers of uninsured, and this contributed to its low rating for equity in the health care system. But even among above-average income respondents, the U.S. lagged considerably behind their counterparts in other countries.

Summary and Implications

These rankings summarize evidence on measures of quality as perceived or experienced by patients. They do not capture important dimensions of effectiveness or efficiency that might be obtained from medical records or administrative data. Patients' assessments might be affected by their experiences and expectations, which could differ by country and culture. Yet, reports from the World Health Organization (WHO) that compare health care system performance using measures such as life expectancy, infant mortality, or preventable years of life lost as well as health expenditures also suggest that the U.S. achieves the least for its population among these six countries. A working group—supported by The Commonwealth Fund and with experts from each of the five countries surveyed in 2004, the Organization for Economic Cooperation and Development (OECD), and WHO—developed a set of indicators that provide measures of clinical effectiveness. It found that none of the five countries included in the study—Australia, Canada, New Zealand, the U.K., and the U.S.—were systematically best or worst on measures of clinical effectiveness, confirming the mixed story reported by patients.

On four of the six domains of quality of care included in the Institute of Medicine framework, the U.S. performs relatively poorly from the patients' perspective. On timeliness, the U.S. performs about average. Effectiveness was the only measure on which the U.S. system performed slightly better than the five other countries, due largely to greater use of preventive care services and better care for the chronically ill. Notably, both of these dimensions of quality have been the focus of quality and reporting measurement in the U.S. for more than a decade.

Findings from the 2004 and 2005 surveys confirm many of the findings from surveys in 2001 and 2002. In the earlier surveys, the U.S. ranked last on measures of patient safety, patient-centeredness, efficiency, and equity. However, compared with the earlier surveys, the U.S. has improved on measures of effectiveness, from being tied for last place with Australia to ranking first among the six countries. The earlier surveys included only limited effectiveness measures while the more recent surveys contained a broader array of measures.

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

Publication Details



K. Davis, C. Schoen, S. C. Schoenbaum, A. J. Audet, M. M. Doty, A. L. Holmgren, and J. L. Kriss, Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens, The Commonwealth Fund, April 2006