Photo courtesy of NIH
Doctor and patient
The US has similar healthcare utilization as other high-income countries but spends more and tends to have worse health outcomes, according to a new study.
In 2016, the US spent 17.8% of its gross domestic product on healthcare. For 10 other high-income countries, spending ranged from 9.6% to 12.4%.
However, sizes of physician and nursing workforces were comparable between the countries, numbers of hospital discharges were similar, and lengths of hospital stay were lower in the US than in most other countries.
Meanwhile, the US had the lowest life expectancy and the highest rate of infant mortality.
This research was published in JAMA.
“There’s been a lot of interest in international comparisons between America and other high-income countries, and there’s been a lot of vagueness about why exactly our [US] spending is so much higher and our health outcomes are not necessarily better and often worse,” said study author Ashish K. Jha, MD, of Harvard T. H. Chan School of Public Health in Boston, Massachusetts.
“This study really tries to fill in gaps, I think, across a wide range of issues, from structural capacity to utilization to prices to outcomes.”
For this study, Dr Jha and his colleagues analyzed recent healthcare data, primarily from 2013 to 2016. The team compared differences in healthcare spending, performance, and structural features between the US and 10 high-income countries—UK, Canada, Germany, Australia, Japan, Sweden, France, Netherlands, Switzerland, and Denmark.
Spending
In 2016, healthcare spending, as a percentage of gross domestic product, was as follows:
US—17.8%
Switzerland—12.4%
Sweden—11.9%
Germany—11.3%
France—11%
Japan—10.9%
Denmark—10.8%
Netherlands—10.5%
Canada—10.3%
UK—9.7%
Australia—9.6%.
“The big differences in spending really seem to be driven by prices,” Dr Jha said, noting that salaries for doctors and nurses, administrative expenditures, and pharmaceutical costs are “much higher” in the US.
The total spending on pharmaceuticals per capita was $1443 in the US but ranged from $466 (Netherlands) to $939 (Switzerland) in the other countries.
Administrative costs accounted for 8% of the total national health expenditure in the US but 1% (France, Japan) to 3% (Germany) in the other countries.
Outpatient care expenditures ranged from 22% (Netherlands) to 42% (US). Inpatient care expenditures ranged from 17% (Canada) to 32% (Netherlands), with 19% for the US. And expenditures for medical goods ranged from 10% (Denmark) to 20% (Germany), with the US at 14%.
Physicians’ and nurses’ salaries were higher in the US than other countries. For example, generalist physicians earned $218,173 in the US in 2016 but anywhere from $86,607 (Sweden) to $154,126 (Germany) in the other countries.
Utilization
Although US doctors and nurses earned more than their counterparts in comparator countries, there were no substantial between-country differences in the size of the physician and nursing workforces.
The number of working physicians for every 1000 people ranged from 2.1 (UK) to 4.3 (Switzerland), with the US at 2.6. The number of working nurses for every 1000 people ranged from 8.2 (UK) to 17.4 (Switzerland), with 11.1 for the US.
The US had comparable numbers of hospital beds as some of the other countries. The range was 2.5 (Sweden) to 13.2 (Japan) beds per 1000 people, with the US at 2.8.
The US ranked 6th when it came to hospital discharges for acute myocardial infarction (AMI, 192 per 100,000 people; range, 89 to 287), mental and behavioral issues (679 per 100,000 people; range, 119 to 1719), pneumonia (365 per 100,000 people; range, 187 to 567), and chronic obstructive pulmonary disease (230 per 100,000 people; range, 45 to 352).
The US had greater utilization of computed tomography than the other countries, with 245 examinations per 1000 people (range for other countries, 79 to 231). And US utilization of magnetic resonance imaging was higher than most countries, with 118 examinations per 1000 people (range, 41 to 131).
However, the US ranked on the lower end of the spectrum for length of hospital stay. The length of stay for a “normal delivery” childbirth ranged from a median of 1.5 days (UK) to 5.7 days (Japan), with the US clocking in at 2 days. The median length of stay for AMI ranged from a median of 3.9 days (Netherlands) to 10.3 days (Germany), with the US at 5.4 days.
“So much of the debate about healthcare these days is about over-utilization—that somehow our health system is uniquely bad at avoiding unnecessary services,” Dr Jha said. “I think these data really put that argument to rest. Except for a few pockets, utilization is not really different between us and these high-income Northern European countries, so maybe we need to spend a little less time focusing on that and a little bit more time focusing on prices of our healthcare system.”
Outcomes
The US ranked on the lower end of the spectrum for some mortality outcomes. Thirty-day stroke mortality per 1000 patients ranged from 4.2 in the US to 10 in Canada. Thirty-day AMI mortality per 1000 ranged from 4.1 (Australia) to 8.7 (Germany), with the US at 5.5.
However, infant mortality was highest in the US, at 5.8 deaths per 1000 live births (range for other countries, 2.1 to 5.1). And life expectancy was lowest in the US, at 78.8 years (range for other countries, 80.7 to 83.9).
The researchers noted that the US had the highest percentage of overweight or obese individuals age 15 and older, at 70.1% (range for other countries, 23.8% to 63.4%), but a low percentage of smokers (11.4%; range, 11.2% to 22.4%) and moderate alcohol consumption (8.8 L per capita; range, 7.2 to 11.9).
Limitations of this study include some differences in approaches to collecting and standardizing data across countries, as well as missing data for some countries.