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America’s healthcare delivers less, costs more than peer nations


New study ranks U.S. last in most performance metrics, but ACA may bring improvement

America’s healthcare continues to trail other industrialized countries in efficiency, equity and outcomes, with lack of access to primary care one of the U.S.’s main deficiencies, according to a new study from The Commonwealth Fund. At the same time, the country spends more on healthcare than anyplace else.

“The United States healthcare system is the most expensive in the world, but comparative analyses consistently show the U.S. underperforms relative to other countries on most dimension of performance,” say the report’s authors.

There is some cause for hope, however. Data for the report were collected before most aspects of the Affordable Care Act (ACA) were implemented, many of which “could further encourage more affordable access and more efficient organization and delivery of healthcare,” according to the study.

The study, the fifth in a continuing series dating to 2004, compares the healthcare systems of 11 countries with advanced economies on measures of quality, efficiency, access to care, equity and healthy lives. As was the case in the four previous studies, the U.S. ranked last overall, despite spending 50% more per-capita ($8,508) than the nation with the second-highest spending (Norway, with $5,669).

The U.K. ranked first overall in the study (per-capita spending: $3,405), followed by Switzerland ($5,643) and Sweden ($3,925). The other nations studied were Australia, Canada, France, Germany, the Netherlands and New Zealand. While all countries showed room for improvement, the fact that the U.S. spends so much more on healthcare than everyone else shows that “the U.S. healthcare system could do much better in achieving value for the nation’s substantial investment in health,” the authors say.

The key difference between the U.S. and the other nations in the study, according to the report, is the absence of universal health coverage. “Other nations ensure the accessibility of care through universal health systems and through better ties between patients and the physician practices that serve as their medical homes,” according to the authors.

Next: Where the U.S. performs well


Among the areas in which the U.S. scores relatively well in the survey are safe care and patient-centered care

David Fleming, MD, FACP(sub-categories of quality), and access to specialized healthcare services (a sub-category of access). That finding comes as no surprise to David Fleming, MD, FACP, president of the American College of Physicians. “Our healthcare system is really based on specialty care and intervention, whereas most other countries have a strong foundation of primary care, with specialty care only as needed,” he says.

Fleming adds that the report’s findings are similar to those of a 2007 ACP position paper, which also compared the U.S. with other industrialized nations. Both studies found that the U.S. spends far more on healthcare than other nations, with no corresponding improvements in quality.

The ACA begins to address the imbalance of primary versus specialty care through provisions such as the primary care bonus payment, notes Reid Blackwelder, MD, FAAFP, president of the American

Reid Blackwelder, MD, FAAFPAcademy of Family Physicians. “But there are still a lot of partisan issues that are not allowing the ACA to be treated as a lot of laws, which is to take what’s good, make it better, and take what needs work and improve it.”

The authors hold out hope that the ACA, with its subsidies for health insurance and provisions for Medicaid expansion, will improve the U.S.’s ability to provide more of its citizens with affordable, quality healthcare.

“With enactment of the ACA we have entered a new era in affordable health care,” Karen Davis, Ph.D., a professor at the Bloomberg School of Public Health at Johns Hopkins University and the report’s lead author said in a statement. “The U.S. performance on insurance coverage and access to care should begin to improve, particularly for low-income Americans. The Affordable Care Act is also expanding the availability and quality of primary care, which should help all Americans have better…health outcomes at a lower cost.”


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Jennifer N. Lee, MD, FAAFP
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