Health care in US ranks lowest among developed countries

BMJ 2008; 337 doi: (Published 21 July 2008) Cite this as: BMJ 2008;337:a889
  1. Bob Roehr
  1. 1Washington, DC

    The United States ranked last across a range of measures of health care in a comparison of 19 industrialised countries, despite spending more than twice as much per person on health as any other of the countries, says a report published last week.

    The report shows improvements in some areas since the previous rating two years ago but found that other countries had improved more quickly. It analysed 37 measures, including access to care, quality of care, and health outcomes.

    Overall, said Karen Davis, president of the Commonwealth Fund, the charity that developed the report, “the US scored far short of the best performance, either in other countries or within the best performing hospitals in the US.”

    She added, “It is a demonstration that we are losing ground.”

    Cathy Schoen, a senior author of the report, said that the overall US score had fallen from 67 to 65, on a scale of 100, over the past two years. Although modest improvements were shown in efficiency and equity, these were offset by falls in quality and in healthy lives, a measure that is based on preventable mortality and limitations in patients’ activity.

    Access to care was the single most important factor contributing to the US’s decline. “We are being pulled down by rising numbers of uninsured and underinsured,” said Ms Schoen. “And the trend is getting worse. (This is before the slowdown in the economy.) It is moving up to the middle class.”

    If the US attained the same performance indicators achieved in other industrialised countries, Ms Schoen added, “we could save at least 100 000 lives per year and at least $100bn [£50bn; €63bn].”

    The report tied much of the problem to a weak base of primary care doctors. Patients do not have easy access to them, it said, and their numbers are too small and are projected to shrink, with looming retirements. It also said that the healthcare system is fragmented, with insufficient tools such as electronic medical records for primary care doctors to coordinate and manage care where specialists are needed.

    Low rates of reimbursement from the Medicare programme contribute to the problems of access to care and continuity of care after discharge from the hospital, resulting in a rate of readmission to hospital within 30 days of discharge that is 50% higher than in other countries for similar procedures.

    Christine Cassel, president of the American Board of Internal Medicine, said that most of the US system is “hamster care . . . that pays people to do more, not for results.” It is a running wheel that keeps healthcare workers going in circles, she argued.

    “We need to expect more from our physicians, and we need to create a financial environment where they are rewarded, not punished, for taking more time [with patients] rather than just generating more bills.”

    “Accountability, not just for quality but also for managing resources,” will be crucial to reform, said Dr Cassel. She thinks it important to move from a physician centred to a team centred approach to health care.

    Most observers see the post-election period of 2009 as a window of opportunity to reform the US healthcare system. Ms Schoen said that any policy changes must be coherent, “with the triple aim of improving access, quality, and cost. We need to be doing this simultaneously.”


    Cite this as: BMJ 2008;337:a889


    • Why Not the Best? Results from the National Scorecard on US Health System Performance, 2008 is available at

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