U.S. Health Care System Lags Behind on Key Indicators, Researcher Says

The failure of the United States to adopt a systematic approach to health care has made the American health care system more fragmented, more costly and less efficient than health care systems in other industrialized nations. That's according to a leading health care researcher who spoke during a primary care forum sponsored by the AAFP’s Robert Graham Center here on May 23.

Cathy Schoen, M.S., senior vice president at The Commonwealth Fund, said the U.S. health care system suffers from "high overhead costs, duplication and a lack of information systems," undermining the nation’s ability to use its resources aptly when compared with other countries.

For example, Schoen said, the United States is a leader when it comes to health care costs, spending about 16 percent of its gross domestic product on health care -- far more than other industrialized countries. "We are a good 50 percent higher than the next highest country as a percent of income," said Schoen.

That higher spending level, however, has not necessarily translated into better health outcomes, according to Schoen. In 1997 and 1998, for instance, the United States ranked 15th out of the 19 industrialized nations evaluated in terms of preventing early deaths from certain chronic diseases, such as diabetes and asthma; it now ranks dead last, at 19 out of 19, she said.

Schoen noted that although the United States made progress in managing patients with these diseases during that period, those gains were much less than those achieved by other countries. "We improved by 4 percent, while some of the leaders increased their rates (of preventing early deaths from disease) by 16 percent over the time period," said Schoen. "We are seeing rapid improvement in other countries as they take a systems approach (to health care)."

Schoen laid out key strategies for achieving a systems-based approach to health care in the United States. These strategies include

Schoen zeroed in on the lack of affordable health insurance as a critical flaw in the U.S. health care system. Without adequate insurance, the uninsured and underinsured are unable to access necessary care and, as a result, are showing up in the hospital setting.

The uninsured and underinsured also often receive duplicative care and are less likely to manage their chronic conditions effectively because there is little, if any, followup on their care, said Schoen.

According to Schoen, strengthening the primary care provider base is at the core of a stronger health care system. She cited a 2007 international survey conducted by The Commonwealth Fund that showed patients in other countries who had access to medical home practices experienced greater patient safety, better coordination of their care and better chronic care management than patients without access to patient-centered care. These patients also reported higher satisfaction rates, said Schoen.

But without affordable and adequate insurance, patients cannot access patient-centered medical homes in a timely manner -- making insurance coverage a linchpin of a systems-based approach to health care, she said.

"If we continue to go down the line of uninsured and underinsured patients, it will be extraordinarily difficult to run effective primary care," warned Schoen. "Patients just don’t come in. They go to the emergency room first."

Schoen also pointed out that other industrialized countries are forging ahead of the United States in implementing information technology and electronic health records, or EHRs. For example, Denmark, with the help of IBM, has developed a comprehensive EHR system that has transformed the way primary care is practiced there, Schoen said. Nearly all physician practices and hospitals are connected electronically, allowing physicians to electronically prescribe and share patient information.

Health information technology enables new routes for patient access and also saves physician time, she said. Denmark even pays physicians for e-mail consultations on a fee-for-service basis.

With the EHR system in place, Danish physicians are no longer chasing paperwork or making phone calls, said Schoen. Patients, for their part, are spending less time in waiting rooms, are able to access their own records and can learn more