The burden of rheumatoid arthritis and access to treatment: uptake of new therapies

This paper presents data on international differences in use of TNF inhibitors. It is part of a study on burden and cost of RA, access to new therapies and the role of HTA in determining access and cost-effectiveness. United States has the fastest most extensive use of the new drugs, about three times the average in the western European countries and Canada. Eastern and central European countries as well as Australia, South Africa and Turkey lag far behind. However, some smaller European countries, most notably Norway and Sweden have use of the new drugs not far behind the United States. While the income level of the country, and thus the health care expenditures per capita is a major factor for determining use in low and middle income countries, there are still considerable differences among countries with similar high total health care expenditures. Differences in prices are considerable between the US and Europe due to the changes in exchange rates between the US dollar and the Euro, but high and low use is not systematically related to differences in price.     

Access to care, health status, and health disparities in the United States and Canada: results of a cross-national population-based survey

Objectives. We compared health status, access to care, and utilization of medical services in the United States and Canada and compared disparities according to race, income, and immigrant status.

Methods. We analyzed population-based data on 3505 Canadian and 5183 US adults from the Joint Canada/US Survey of Health. Controlling for gender, age, income, race, and immigrant status, we used logistic regression to analyze country as a predictor of access to care, quality of care, and satisfaction with care and as a predictor of disparities in these measures.

Results. In multivariate analyses, US respondents (compared with Canadians) were less likely to have a regular doctor, more likely to have unmet health needs, and more likely to forgo needed medicines. Disparities on the basis of race, income, and immigrant status were present in both countries but were more extreme in the United States.

Conclusions. United States residents are less able to access care than are Canadians. Universal coverage appears to reduce most disparities in access to care.

     

Measuring financial protection in health in the United States

One rationale for health insurance coverage is to provide financial protection against catastrophic health expenditures. This article defines a lack of financial protection as household spending on health care when: (1) out-of-pocket (OOP) health expenditures exceed 10% of family income; (2) out-of-pocket expenditures exceed an absolute level of 2000 US dollars per family member on an annual basis; and (3) combined out-of-pocket and prepaid health expenditures exceed 40% of family income. The article explores how the likelihood of households in the United States surpassing these thresholds varies by income level, extent of insurance coverage, and the number of chronic conditions. The results show clearly that there is a lack of financial protection for health services for a wide segment of the US population-particularly so for poor families and those with multiple chronic conditions. The results are placed in an international context. Similar studies in other countries would allow for more in-depth comparisons of financial protection than are currently possible.     

Inequities in access to medical care in five countries: findings from the 2001 Commonwealth Fund International Health Policy Survey

OBJECTIVE: To examine across five countries inequities in access to health care and quality of care experiences associated with income, and to determine whether these inequities persist after controlling for the effect of insurance coverage, minority and immigration status, health and other important co-factors. DESIGN: Multivariate analysis of a cross-sectional 2001 random survey of 1400 adults in five countries: Australia, Canada, New Zealand, United Kingdom, and United States. MAIN OUTCOME MEASURES: Access difficulties and waiting times, cost-related access problems, and ratings of physicians and quality of care. RESULTS: The study finds wide and significant disparities in access and care experience between US adults with above and below-average incomes that persist after controlling for insurance coverage, race/ethnicity, immigration status, and other important factors. In contrast, differences in UK by income were rare. There were also few significant access differences by income in Australia; yet, compared to UK, Australians were more likely to report out of pocket costs. New Zealand and Canada results fell in the mid-range of the five nations, with income gaps most pronounced on services less well covered by national systems. In the four countries with universal coverage, adults with above-average income were more likely to have private supplemental insurance. Having private insurance in Australia, Canada, and New Zealand protects adults from cost-related access problems. In contrast, in UK having supplemental coverage makes little significant difference for access measures. Being uninsured in US has significant negative consequences for access and quality ratings. CONCLUSIONS: For policy leaders, the five-nation survey demonstrates that some health systems are better able to minimize among low income adults financial barriers to access and quality care. However, the reliance on private coverage to supplement public coverage in Australia, Canada, and New Zealand can result in access inequities even within health systems that provide basic health coverage for all. If private insurance can circumvent queues or waiting times, low income adults may also be at higher risks for non-financial barriers since they are less likely to have supplemental coverage. Furthermore, greater inequality in care experiences by income is associated with more divided public views of the need for system reform. This finding was particularly striking in Canada where an increased incidence of disparities by income in 2001 compared to a 1998 survey was associated with diverging views in 2001.     

Differences in disease prevalence as a source of the U.S.-European health care spending gap

The United States spends more on health care than any European country. Previous studies have sought to explain these differences in terms of system capacity, access to technologies, gross domestic product, and prices. We examine differences in disease prevalence and treatment rates for ten of the most costly conditions between the United States and ten European countries using surveys of the noninstitutionalized population age fifty and older. Disease prevalence and rates of medication treatment are much higher in the United States than in these European countries. Efforts to reduce the U.S. prevalence of chronic illness should remain a key policy goal.     

Comparing health and health care use in Canada and the United States

Results from the Joint Canada/United States Survey of Health (2002-2003) reveal that health status is relatively similar in the two countries, but income-related health disparities exist. Americans in the poorest income quintile are more likely to have poor health than their Canadian counterparts; there were no differences between the rich. In general, Canadians were more like insured Americans regarding access to services, and Canadians experienced fewer unmet needs overall. Despite higher U.S. levels of spending on health care, residents in the two countries have similar health status and access to care, although there are higher levels of inequality in the United States.     

An analysis of whether higher health care spending in the United States versus Europe is 'worth it' in the case of cancer

The United States spends more on health care than other developed countries, but some argue that US patients do not derive sufficient benefit from this extra spending. We studied whether higher US cancer care costs, compared with those of ten European countries, were "worth it" by looking at the survival differences for cancer patients in these countries compared to the relative costs of cancer care. We found that US cancer patients experienced greater survival gains than their European counterparts; even after considering higher US costs, this investment generated $598 billion of additional value for US patients who were diagnosed with cancer between 1983 and 1999. The value of that additional survival gain was highest for prostate cancer patients ($627 billion) and breast cancer patients ($173 billion). These findings do not appear to have been driven solely by earlier diagnosis. Our study suggests that the higher-cost US system of cancer care delivery may be worth it, although further research is required to determine what specific tools or treatments are driving improved cancer survival in the United States.     

Health reform in Brazil: lessons to consider

US analysts and decisionmakers interested in comparative health policy typically turn to European perspectives, but Brazil-notwithstanding its far smaller gross domestic product and lower per capita health expenditures and technological investments-offers an example with surprising relevance to the US health policy context. Not only is Brazil comparable to the United States in size, racial/ethnic and geographic diversity, federal system of government, and problems of social inequality. Within the health system the incremental nature of reforms, the large role of the private sector, the multitiered patchwork of coverage, and the historically large population excluded from health insurance coverage resonate with health policy challenges and developments in the United States.     

Privatizing health care: caveat emptor

Many Western European countries are moving toward privatization of their health care systems. The United States' health care system, since it is almost entirely privatized, is therefore worthy of study. Doing so raises several questions. How is privatization being managed in the US? How could its management be improved? What management lessons must be kept in mind if it is to be used effectively? What potential pitfalls should European countries consider as they move toward greater privatization? With operating costs, European countries must avoid the mistakes that have led to dramatic increases in annual health care costs in the US, simultaneous with reductions in access and quality. Doing so requires designing systems that promote hospital behavior consistent with a country's health objectives. With capital costs, an approach must be designed that allows policy-makers to work closely with both managers and physicians in order to make strategically sound choices about access and quality. Such an approach will require physicians to incorporate their clinical judgments into community standards of care, and to adopt a regional (rather than an institutional or personal) perspective in the determination of any incremental capital expenditures. By making regulation proactive and strategic, rather than punitive, health policymakers in Western Europe can achieve the best privatization has to offer without feeling the sting of its unintended consequences. In so doing they can help to move their health systems toward achieving the multiple and illusive goals of access, quality and reasonable cost.     

How much do cancer specialists earn? A comparison of physician fees and remuneration in oncology and radiology in high-income countries

The main driver of higher spending on health care in the US is believed to be substantially higher fees paid to US physicians in comparison with other countries.We aim to compare physician incomes in radiology and oncology considering differences in relation to fees paid, physician capacity and volume of services provided in five countries: the United States, Canada, Australia, France and the United Kingdom.The fee for a consultation with a specialist in oncology varies threefold across countries, and more than fourfold for chemotherapy. There is also a three to fourfold variation in fees for ultrasound and CT scans.Physician earnings in the US are greater than in other countries in both oncology and radiology, more than three times higher than in the UK; Canadian oncologists and radiologists earn considerably more than their European counterparts.Although challenging, benchmarking earnings and fees for similar health care activities across countries, and understanding the factors that explain any differences, can provide valuable insights for policy makers trying to enhance efficiency and quality in service delivery, especially in the face of rising care costs.     

The Role of the World Health Organization on Pharmaceuticals in Europe

The World Health Organization (WHO) is the specialized agency of the UN on public health. It gives worldwide guidance in the field of health, sets global standards for health, cooperates with governments to strengthen national health care programs, and develops and transfers appropriate health technology, information, and standards. Within the WHO European region, health status and health expenditures vary greatly. In this paper, disparities between health status, health services, and health care expenditures between countries of the WHO European region are presented. The objectives, performance, and dilemmas facing health care systems are discussed, including the recent performance ranking published by the WHO. The paper focuses particularly on access to medicines, their appropriate use, and rising drug expenditures. Strategies used by European countries to improve drug use and contain health care expenditures are outlined. Finally, the future of pharmaceuticals and public health is explored.     

A comparison of prenatal care use in the United States and Europe.

OBJECTIVES. We sought to describe prenatal care use in the United States and in three European countries where accessibility to prenatal care has been reported to be better than it is in the United States. METHODS. We analyzed the 1980 US National Natality Survey, the 1981 French National Natality Survey, a 1979 sample of Danish births, and a survey performed from 1979 to 1980 in one Belgian province. RESULTS. The proportion of women who began prenatal care late (after 15 weeks) is highest in the United States (21.2%) and lowest in France (4.0%). This contrasts with the median number of visits, which is greater in the United States (11) than in Denmark (10) or in France (7). Across all maternal ages, parities, and educational levels, late initiation of prenatal care is more frequent in the United States, and median number of visits in the United States is equal to or higher than that in the other countries. CONCLUSIONS. In countries that offer nearly universal access to prenatal care, women begin care earlier during pregnancy and have fewer visits than women in the United States.     

Medical savings accounts: a core feature of Singapore's health care system

In 1984 Singapore adopted a system of Medisave accounts, individually owned accounts used to pay for many of the health care expenditures that in Germany would normally be covered by the obligatory or private health insurance. The fact that people are spending their own money rather than that of a third-party insurer has helped to curtail Singapore's health care costs, which were about 2.6% of gross domestic product in 1999 (Germany: 10.5%). Even with these low expenditures, the income of Singapore physicians is about the same in relation to average wages as physician income in Germany or the United States, and patients have easy access to such technology as computerised axial tomography, organ transplants and bypass surgery.      

International variations in trust in health care systems

Public trust in health care systems has been measured in many countries, but there have been few studies of the intercountry variability in trust, or the degree to which such variability is because of population or structural characteristics. We used data from the health care survey conducted by the International Social Survey Program from 2011 to 2013 in 31 countries to assess whether intercountry variability was significantly greater than intracountry variability using general linear models in which country was treated as a fixed factor. We also assessed the extent to which intercountry variability was because of respondent and economic circumstances (gross national income per capita). Public trust in the health care system varied significantly across countries (P < .001), even after adjustment for 8 within‐country predictors and gross national income per capita. One of the strongest predictors of trust was the respondents' most recent health care experience. Higher respondent education, urban residence, and a lower country's gross national income predicted less trust in the health care system. After countries with the 10% highest health expenditures per capita (United States) and the 10% lowest health care expenditures per capita (China and the Philippines) were removed, public trust in the health care system was positively associated with the remaining countries' health care expenditures per capita (Pearson correlation coefficient, 0.490; P = .008) and gross national income per capita (Pearson correlation coefficient, 0.495; P = .007). There is significant variation in public trust in health care across the countries studied. The intercountry differences are due, in part to economic circumstances.     

Comparing population health in the United States and Canada

Background  

The objective of the paper is to compare population health in the United States (US) and Canada. Although the two countries are very similar in many ways, there are potentially important differences in the levels of social and economic inequality and the organization and financing of and access to health care in the two countries.     

International review of the utilisation and cost of percutaneous transluminal coronary angioplasty

We reviewed information published between 1990 and March 2001 to ascertain trends in the utilisation of percutaneous transluminal coronary angioplasty (PTCA) and to determine the availability of cost data. Our review encompassed Australia, Canada, France, Germany, Italy, Sweden, the United Kingdom, and the United States. The number of PTCAs increased in all countries studied during the 1990s. While the rate of PTCA use in all European countries lags behind that of the US, Germany and France are approaching the US rate, and the uptake of PTCA among European countries is increasing rapidly after a slow start. With regard to PTCA cost data, direct international comparisons are difficult since patient populations, methodological factors, and the timing and location of each study contributed to the differences observed between and within the studies reviewed. The increasing number of patients receiving PTCA emphasises the need for accurate cost data.     

The Contribution of National Disparities to International Differences in Mortality Between the United States and 7 European Countries

Objectives. This study examined to what extent the higher mortality in the United States compared to many European countries is explained by larger social disparities within the United States. We estimated the expected US mortality if educational disparities in the United States were similar to those in 7 European countries.Methods. Poisson models were used to quantify the association between education and mortality for men and women aged 30 to 74 years in the United States, Belgium, Denmark, Finland, France, Norway, Sweden, and Switzerland for the period 1989 to 2003. US data came from the National Health Interview Survey linked to the National Death Index and the European data came from censuses linked to national mortality registries.Results. If people in the United States had the same distribution of education as their European counterparts, the US mortality disadvantage would be larger. However, if educational disparities in mortality within the United States equaled those within Europe, mortality differences between the United States and Europe would be reduced by 20% to 100%.Conclusions. Larger educational disparities in mortality in the United States than in Europe partly explain why US adults have higher mortality than their European counterparts. Policies to reduce mortality among the lower educated will be necessary to bridge the mortality gap between the United States and European countries.The United States has lower life expectancy at birth than most Western European countries. In 2009, life expectancy in the United States was 76 years for men and 81 years for women, between 2 and 4 years less than in several European countries.1 The disadvantage is greater for women than for men and originated in the 1980s.2 The US health disadvantage is found not only for life expectancy, but also for self-reported health measures,3,4 biomarkers,3 and many specific causes of death5,6 across the entire life course.3–5,7A recent report by the National Research Council suggests that smoking and obesity explain an important part of the US mortality disadvantage.2,8,9 However, an approach that solely emphasizes behavioral differences is impoverished by ignoring the role of socioeconomic and environmental determinants.10 A substantial body of research suggests that most behavioral risk factors are socially patterned; lower education or income are associated with a higher prevalence of smoking, excessive alcohol consumption, obesity, and poor dietary patterns.11–19 In addition, European countries and the United States differ in many aspects of the physical and social environment that can affect population health and that are in turn socially patterned within each country. For example, the socioeconomic distribution of access to healthy food differs between countries.20 Social environmental factors related to safety, violence, social connections, social participation, social cohesion, social capital, and collective efficacy have also been shown to influence health and in turn differ between countries and socioeconomic groups.21 Indeed, differences in mortality between the United States and Europe are larger among those with a lower educational level,6 suggesting that larger educational disparities in mortality, which partly coincide with differences in behavior, partly explain why Americans have higher mortality than Europeans.The United States is characterized by relatively higher levels of income inequalities,22 residential and racial segregation,23–25 and financial barriers to health care access2,26 than any European country. Social protection policies and benefits are also less comprehensive in the United States than in Europe, including policies on early education and childcare programs,27 access to high-quality education,28 employment protection and support programs,29,30 and housing29,31 and income transfer programs.31,32 A plausible hypothesis is that the more unequal distribution of resources and less comprehensive policies contribute to the more unfavorable risk factor profile and poorer health of lower-educated Americans as compared with corresponding Europeans.4,33,34 A follow-up report by the National Research Council and the Institute of Medicine published in 2013 concluded that there is a lack of evidence on how these factors explain the US health disadvantage.21 The aim of this article is to assess to what extent larger educational disparities in mortality explain why Americans have higher mortality than Europeans.