Challenges in International Comparison of Health Care System

Health is the product of numerous factors, including but not limited to the delivery of health care. So what counts? Should highway safety regulations, which prevent deaths from motor vehicle crashes, be considered part of the health system? Should a nation with a long tradition of bicycle use and therefore lower rates of obesity and diabetes mellitus be deemed to have a better health system? Or should a country with greater poverty and therefore more poverty-related health problems be seen as having a low-performing health system? A host of factors, some of which are characterized as social determinants of health, influence health; determining the extent to which comparisons of health systems should consider these is critical.

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July 26—Hospitals are ramping up spending on the social determinants of health, according to a recent survey—even as some question the approach.

Hospitals spend a median of $200 per patient or individual (some initiatives include non-patient local residents) to address social needs each year, according to a recent Deloitte Center for Health Solutions nationally representative online survey of about 300 hospitals and health systems.

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Myriad factors are driving hospitals and care systems to address the nonmedical determinants of population health. Most notably, the Affordable Care Act implicitly and explicitly promotes a population health management approach to care delivery. Not only does this legislation expand health insurance to a majority of the United States population, it compels hospitals to address the socioeconomic, behavioral and environmental factors that affect people before hospital admission and after discharge. The ACA is accelerating the shift of reimbursement models from fee-for-service to value-based, a structure that promotes better health outcomes, improved quality of care, illness prevention and coordination across the continuum of care. Care systems are now being held accountable for the health of their patient population and are responsible for implementing health improvement strategies to address community health needs. Adopting a population-based approach to care that encompasses the spectrum of determinants of health is essential for care systems to thrive in the ACA era.

To improve health outside their walls, hospitals and care systems must engage in multisectoral partnerships with community-based groups, health departments and public health organizations. By bringing together stakeholders from across the health care system and local community, hospitals can collaborate to identify population health priorities and develop strategies to address the health issues unique to their specific community. The federally mandated community health needs assessment process can provide a forum for enhanced collaboration between hospitals and their partners.

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While some measures, such as amenable mortality, which considers mortality for conditions considered responsive to timely and effective health care, are better at addressing this issue, they too have challenges. For example, how much of ischemic heart disease mortality is amenable to the performance of the health care system? Variations in underlying genetics and environmental factors across nations will have a profound influence on cardiovascular mortality rates, as will advances in medical care. In the United States, mortality from ischemic heart disease is 128 per 100 000 deaths, just above average among high-income countries (as measured by the Organisation for Economic Co-operation and Development [OECD]), yet mortality following a hospital admission for acute myocardial infarction is 5.5%, much lower than the OECD average (8.0%). Both numbers are useful, but each leads to different conclusions about the relative performance of the US health care system.3 One of the measures often used to compare health care systems is infant mortality, but countries vary widely in the birth registration procedures they have in place, particularly around births at the borderline of viability (such as infants born at gestational ages of 22-24 weeks or with birth weight <500 g).4 For example, although the United States is ranked worse than the OECD average in infant mortality, the United States is ranked among the best in the world in the survival of infants with extremely low birth weights.

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A final consideration is that indicators selected for comparison reflect inherent value judgments. Without recognizing these, it is difficult to understand the results of any corresponding analysis. Different health systems are optimized for different conditions and populations, reflecting their design and national priorities. Thus, to be able to learn what findings can be translated across countries and how to interpret variations in performance, it is necessary to understand how these features differ across countries.

For example, although readmission rates are higher in the United States than across many other European countries, median length of stay is shorter in the United States.6 The US health care system is optimized for short lengths of stay, tolerating a somewhat higher readmission rate (but fewer total days in the hospital per population). Whether this means that US performance is worse than performance in countries in which lengths of stay are much longer but readmission rates are lower is unclear.

Additionally, patients in different systems have different expectations regarding acceptable levels of performance, depending on what they perceive to be normal. In the United Kingdom or Canada, for example, patients wait much longer to see a specialist than patients in the United States. However, surveys from these countries suggest that patients perceive fewer barriers to timely access, due largely to differing expectations.7

Moreover, taking a broader perspective, people in the United States are far more likely to see health care as an individual responsibility as opposed to a societal or governmental one. The US health care system therefore has greater inequities based on income—inequities that some individuals in the United States are more willing to tolerate.8 The US system is optimized for individuals with private insurance and Medicare (who compose approximately 65% of the population) and does less well for individuals who are uninsured and those with Medicaid.9 Yet international comparisons examining average effects fail to capture this variation. Comparing the entire United States with a homogeneous country like Finland with a population of 5.4 million (comparable to Minnesota) and a commitment to an equitable, tax-funded health care system may yield misleading conclusions.

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Greenbeard said:

An interesting recent JAMA perspective piece from a pair of researchers: Challenges in International Comparison of Health Care Systems

Their argument boils down to: "There are at least 3 key challenges of conducting international comparisons: drawing the boundaries of the health system, managing limitations of data, and accounting for different values inherent in national systems."

That first point is interesting, as there are lots of things that influence health outcomes that arguably don't fall under the umbrella of the health care system itself, including the so-called social determinants of health. The authors write:



That's an important point as it gets at the reality that while we famously spend more as a nation on health care than others, we also spend less on complementary social services that influence health.

But that then raises the question of the degree to which the health care system is picking up some of that slack (and thus some of it being captured in our heath spending stats). E.g.,

Amid Criticism, Hospitals Fund Social Determinants Spending


This is especially relevant now, when we're moving toward reimbursement models that implicit ask providers to take on responsibility for the health of the populations they serve (and thus the socioeconomic currents that help shape it).

Trends in Hospital-based Population Health Infrastructure

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However, differences in outcomes are not simply attributable to individuals. For example, the population of Minnesota has achieved outcomes that are as good as those in many European countries and a mortality rate from amenable causes that is less than half the rates of Mississippi and the District of Columbia.47 Factors in these different outcomes included receiving care according to guidelines and being treated adequately by primary care providers to reduce unnecessary hospital admissions.

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Greenbeard said:

One question that occurs to me is whether a score card comparison like The Commonwealth Fund's well-known Mirror, Mirror reports are really lining up comparable units of analysis.

Measures, and data considerations, and philosophical questions raised above aside, that comparison matches "The United States" up again a few hand-picked members of OECD, or Europe, etc. But within the United States, there's huge variation in health care performance and outcomes across states--as CMWF well knows, since they also produce a Scorecard on State Health System Performance. Vermont and Mississippi have the same health care system, at least structurally in terms of payers (i.e., they've got Medicare, Medicaid, ESI, an exchange, etc), but according to the 2017 scorecard they're on opposite ends of the performance spectrum.

I'm curious how they'd do if one were to cherry-pick the best-performing states in the U.S., like Vermont, Minnesota, Hawaii, Rhode Island, and Massachusetts, and individually stack those up against the handful of other countries selected as comparison points. Certainly they'd do better than "The United States" without low-performers like Alabama, Arkansas, Louisiana, Oklahoma, and Mississippi dragging them down. The metrics used across the international and inter-state score cards don't quite allow for that comparison but I'd still be fascinated to see it.

One of the primary outcomes indicators that CMWF uses in their international comparison is mortality amenable to health care but a few years ago in "In Amenable Mortality—Deaths Avoidable Through Health Care—Progress In The US Lags That Of Three European Countries" the authors acknowledge:



You wouldn't look at that and say "Mississippi should adopt the health system Minnesota has!" There may be things (lots of things!) that Minnesota does that Mississippi would do well to adopt--policies, practices, interventions--but the fundamental multi-payer structure of the health care market isn't one of them, since they are the same.

And yet the primary thing people always take away from these international comparisons is that the only thing that matters to performance is the payer structure. Lots of things matter!

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