Comparisons allow healthcare leaders, policymakers, and the public to learn from countries that succeed in ensuring access to affordable, quality care, new study says.
The U.S. healthcare system came in last in a new study that compared the health systems of 11 high-income countries in terms of access to care, affordability, and outcomes.
The report, Mirror, Mirror 2021: Reflecting Poorly—Health Care in the U.S. Compared to Other High-Income Nations, from the Commonwealth Fund, was released today.
The top-performing countries in descending order are:
- The Netherlands
- United Kingdom
- New Zealand
- United States
The United States' performance falls well below the average of the other countries and far below the two countries ranked directly above it, according to the study.
The study used 71 indicators available across five domains:
1. Access to care
The U.S. ranked last in this domain, which measures healthcare’s affordability and timeliness. The U.S. has the poorest performance on the affordability subdomain, scoring much lower than even the next-lowest country, Switzerland.
Compared to residents of the U.S., residents of the Netherlands, the U.K., Norway, and Germany are much less likely to report that their insurance denied payment of a claim or paid less than expected. Residents of these countries are also less likely to report difficulty in paying medical bills.
People in the countries performing the best on the timeliness subdomain are more likely to be able to get same-day care and after-hours care. The U.S. ranks No. 9 on timeliness.
2. Care Process
The U.S. ranks No. 2 on this performance domain, which includes measures of preventive care, safe care, coordinated care, and engagement and patient preferences.
Along with the U.K. and Sweden, the U.S. achieves higher performance on the preventive care subdomain, which includes rates of mammography screening and influenza vaccination as well as the percentage of adults who talked with their provider about nutrition, smoking, and alcohol use.
New Zealand and the U.S. perform best on the safe care subdomain, with higher reported use of computerized alerts and routine review of medications.
The U.S. and Germany achieve the highest performance on the engagement and patient preferences subdomain. Among people with chronic illness, U.S. adults are among the most likely to discuss goals, priorities, and treatment options with their provider, though less likely to receive as much support from health professionals as they felt was needed.
Use of web-based portals for communicating medical concerns and refilling medications is highest among adults in Norway and the U.S.
3. Administrative Efficiency
The U.S. ranks last in administrative efficiency, which refers to how well health systems reduce paperwork and other bureaucratic tasks that patients and clinicians frequently face during care.
U.S. doctors are the most likely to face challenges getting their patients medication or treatment because of restrictions on insurance coverage. Compared to most of the other countries, larger percentages of adults in the U.S. say they spend a lot of time on paperwork related to medical bills.
For nonemergency care, U.S. and Canadian adults are also more likely to visit the emergency department—a less efficient option than seeing a regular doctor.
The study's equity domain focuses on income-related disparities, based on standardized data across the 11 countries, in the access to care, care process, and administrative efficiency performance domains. Similar standardized data are not available for measuring equity in performance with respect to different racial and ethnic groups.
The U.S. consistently demonstrated the largest disparities between income groups, except for those measures related to preventive services and safety of care. U.S. disparities are especially large when looking at financial barriers to accessing medical and dental care, medical bill burdens, difficulty obtaining after-hours care, and use of web portals to facilitate patient engagement.
5. Healthcare Outcomes
Healthcare outcomes refers to those health outcomes that are most likely to be responsive to healthcare, with Australia, Norway, and Switzerland ranking at the top.
Norway has the lowest infant mortality rate (two deaths per 1,000 live births) while Australia has the highest life expectancy after age 60 (25.6 years of additional life expectancy for those who survive to age 60).
The U.S. ranks last overall on the healthcare outcomes domain, ranking lowest on nine of 10 component measures. The U.S. has the highest infant mortality rate (5.7 deaths per 1,000 live births) and lowest life expectancy at age 60 (23.1 years).
The U.S. has exceptionally poor performance on two other healthcare outcome measures. Maternal mortality is one: the U.S. rate of 17.4 deaths per 100,000 live births is twice that of France, the country with the next-highest rate (7.6 deaths per 100,000 live births).
The second is the 10-year trend in avoidable mortality. All countries in this study reduced their rate of avoidable mortality over 10 years, but the U.S., with the highest level in 2007, reduced it by the least amount—5 percent reduction in deaths per 100,000 population by 2017—compared to 25 percent in Switzerland (by 2017) and 24 percent in Norway (by 2016).
Several basic lessons emerged from the study's findings, according to the authors:
- Achieving better health outcomes will require policy changes within and beyond healthcare.
- Improving access to care requires expanding and strengthening insurance coverage.
- Improving access to care requires strengthening primary care and extending it to every local community.
- Reducing administrative burden can free up resources to devote to improving health.
- Smarter spending—not more spending—is required to achieve better health system performance.
Such international comparisons, the study says, allows healthcare leaders, policymakers, and the public to consider alternative healthcare delivery approaches to build better health systems.
"By learning from what's worked and what hasn't elsewhere in the world," the study concludes, "all countries have the opportunity to try out new policies and practices that may move them closer to the ideal of a health system that achieves optimal health for all its people at a price the nation can afford."
“Achieving better health outcomes will require policy changes within and beyond healthcare.”
Mirror, Mirror 2021: Reflecting Poorly—Health Care in the U.S. Compared to Other High-Income Nations
Carol Davis is the Nursing Editor at HealthLeaders, an HCPro brand.
In a new study that compared the health systems of 11 high-income countries, the United States' performance falls well below the average of the other countries.
The study used 71 indicators available across five domains.
These comparisons allow healthcare leaders, policymakers, and the public to consider alternative healthcare delivery approaches to build better health systems.