week 14
Paris04
HealthCareSpendingintheUSandOtherHighIncomeCountries.pdf
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
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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, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, England (i.n.papanicolas @lse.ac.uk).
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T he 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
dr iv ing high uti l izat ion of health care services and poor outcomes. Older studies have found that the United States may underinve st in socia l 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 provide a broader context of overall factors that can contribute 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.
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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 indicates gross domestic product; NA, not applicable. CHE indicates Switzerland; NLD, the Netherlands. See eTable 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 (9 985 000 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 countries, 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 proportion was less than 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 a mean of 18.2%) and also had the highest rate of poverty, with 24% of the population living below the poverty line, followed by Japan (22%) and Canada (21%). The United States ranked below 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 Table. Three countries, the United Kingdom, 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
Sp en
di ng
o n
H ea
lt h
as a
% o
f G DP
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) was similar to that of the life 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 (4.0 deaths per 1000 live births compared with a mean of 2.6), and maternal mortality (26.4 deaths per 100 000 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 mortality 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 $154 126 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 $202 291 in Australia). The remuneration of nurses was also higher in the United States ($74 160) than in other countries, where it ranged from $42 492 in France to $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 107 per 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 for both 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
So ci
al S
pe nd
in g
as a
% o
f G DP
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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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 States had high levels of administrative burden; this was notable in particular for administrative spending, for which the United States was an outlier (8% of GDP spent on administration and 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
1 2 3 4 5 6 7 8 9 10 11
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 total pharmaceutical 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
1 2 3 4 5 6 7 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
JapanaDenmark 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 by country. 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 remuneration means 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 generalists and specialists. 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-month wait time to see a specialist, and adequate time spent 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 States ranked near the mean for patients reporting hav-
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 considerably lower 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 trauma without instrument, the United States 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 100 000 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. Relative to 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
Ph ys
ic ia
ns , %
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 primary 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 Eurostat data, 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-pocket spending 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 has free 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 also suggest 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 daysC
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 stayD
18
15050 100 2502000
Hospital Discharges per 1000 Population
Japan
Germany
France
Switzerland
Sweden
Australia
United Kingdom
The Netherlands
United States
Denmark
Canada
Hospital dischargesA
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
ConsultationsaB
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 in productivity or the extent to which training costs are borne by the individual, although in either case it is unlikely to account for the magnitude of the difference. In 2011, Laugesen and Glied19 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 investment into 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 States may 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
NANew 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 by country. a US discounted prices are listed; nondiscounted prices are $216.00 for Crestor,
$372.75 for long-acting insulin, $309.60 for Advair, and $3430.82 for 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 turnover of 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 Plans24
reported that the average cost in the United States was $75 345 for a coronary artery bypass graft surgery, whereas the costs in the Netherlands and Switzerland were $15 742 and $36 509, 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 by country. 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 (population with diabetes) is both adult and 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 France had much smaller generic market penetration rates, presum- 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, %a Australia 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
2.1Rural 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 by country. 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. For this 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 spending33 by revisiting comparisons following 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
Reinhardt et al,12 and Anderson et al23 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 negatively associated with disease prevalence or incidence.
This study has several limitations. First, there was limited 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 systems were 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- charge practices across countries. 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 were collected 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 areas of particular concern are outpatient spending and 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 present only descriptive comparative findings, 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 wait time 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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Health Care Spending in the United States and Other High-Income Countries Special Communication Clinical Review & Education
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