The U.S Health Care Paradox: How Spending More is Getting Us Less

Transcription

1 The U.S Health Care Paradox: How Spending More is Getting Us Less Elizabeth H. Bradley Yale School of Public Health Lauren A. Taylor Harvard Divinity School 1

2 The paradox Then there's the problem of rising cost. We spend one and a half times more per person on health care than any other country, but we aren't any healthier for it. PRESIDENT OBAMA, JOINT SESSION OF CONGRESS ON HEALTH CARE, (9/9/09) 2

3 Research objective To examine the role of social service expenditures in explaining the US health care paradox 3

4 Spending on health care 4 $5,348 $5,135 $4,886 $4,786 $4,385 $4,346 $4,317 $4,225 $3,944 $3,930 $3,911 $3,711 $3,670 $3,539 $3,379 $3,271 $3,252 $3,097 $3,035 $3,005 $2,923 $2,697 $2,524 $2,071 $2,066 $2,048 $7,990 $1,864 $1,559 $923 $913 $1,385 $1,365 $1,210 Poland Chile Mexico Turkey Estonia $9,000 $8,000 $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 Per capita, US$ PPP $1,000 $0 United States Norway Switzerland Netherlands Luxembourg Denmark Austria Canada Germany Ireland France Belgium Sweden Australia Iceland United Kingdom Finland OECD Spain Japan Italy New Zealand Portugal Slovenia Israel Slovak Republic Czech Republic Korea Hungary Data downloaded from OECD.StatExtracts. Available at stats.oecd.org

5 Health outcomes US Ranking out of 34 OECD countries Maternal Mortality: 25 th Life expectancy: 26 th Low birth weight: 28 th Infant mortality: 31 st Source: OECD, Health at a Glance 2009: OECD Publishing 5

6 Total health care investment in US is less 35.0 Total Social Service Expenditures Total Health Service Expenditures France Sweden Austria Switzerland Denmark Germany Belgium Italy Finland Netherlands Portugal Hungary United States Norway Greece Spain Slovenia United Poland Luxembourg Japan New Zealand Canada Czech Australia Iceland Israel Slovak Ireland Chile Estonia Turkey Korea Mexico Expenditures as % of GDP In OECD, for every $1 spent on health care, about $2 is spent on social services In the US, for $1 spent on health care, about 55 cents is spent on social services

7 2.50 Ratio of social to health spending is different

8 Statistical analysis Using OECD pooled data from on 29 countries, multivariable regression Outcomes: 5 key health indicators Independent variable: ratio of social to health spending Adjusted for year, country, and log GDP at purchasing power parity Bradley et al., BMJ Qual and Safety

9 Findings The ratio of social to health spending was significantly associated with better health outcomes: Less infant mortality, low birth weight, premature death; longer life expectancy Non significant for maternal mortality This remained true even when the US was excluded from the analysis Bradley et al., BMJ Qual and Safety

10 Qualitative study In depth interviews and site visits with health and social care front line providers and users, selected using snowball sampling in multiple regions Continued sampling until we reached theoretical saturation, which occurred after 60 interviews at 35 organizations and agencies Audio taped and professionally transcribed; line by line review to extract recurrent themes 10

11 Recurrent themes 1. The health care sector is bearing the brunt of an inadequate social service sector. 2. Frontline personnel are stretched to respond to the concerns of service users with limited resources. 3. A more holistic approach was desired by both health care and social service providers. 4. Difficulties in establishing relationships between social services and health care have many roots. 11

12 Health care bearing the brunt It s like you have one thing and everything leads up to, uh, like a disaster, you know? In the end, well you end up in the hospital. Client, Veterans Community Center 12

13 Frontline personnel stretched I am sitting here writing a prescription [for] this person who has limited ability to afford the medication or have insight on the situation, who can t go outside because the neighborhood is unsafe and I am totally unable to do my job. Internist 13

14 More holistic approach is desired What we do is an all treaters call everyone who is involved with the person, we will sit down at the table and discuss the person, what is the best care that we can give them.we can get three or four agencies working simultaneously side by side for one person; the key is communication and cooperation because if you don t cooperate, it doesn t get you anywhere. Case manager 14

15 Many barriers to holistic care Lack of resources Differences in cultural and professional norms Data limitations Even if you got past the privacy issues, it is very hard to tie in all of the information that was useful for the hospital based provider, the outpatient based provider, and social services to be able to capture what an individual is thinking or feeling at a given point in time, to know what intervention is necessary. Radiologist 15

16 Discussion Policymakers, practitioners, and researchers might consider the role of social services in health reforms aiming to limit costs and improve health outcomes. ACOs could reward health care providers for addressing the social, not just the medical, determinants of health. Research on successful integrative models across social and health sectors is needed to guide such reforms. 16

17 Thank you The American Health Care Paradox: Why Spending More Is Getting Us Less November 5, 2013 Public Affairs Books 17