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Available online 1 July 2010.
In its latest Mirror, Mirror on the Wall Report, published by the US-based Commonwealth Fund, the US health-care system overall still ranks bottom out of seven countries—as it had done in similar reports in 2004, 2006, and 2007. The Netherlands, which was included for the first time, came first overall. The authors used 74 indicators derived from surveys completed over the past 3 years of more than 27 000 physicians and patients in Australia, Canada, Germany, the Netherlands, New Zealand, the UK, and the USA. These indicators were grouped into five dimensions: quality; access; efficiency; equity; and long, healthy, and productive lives. In all these dimensions, the USA came last or second to last despite spending almost double the amount of money per person than other countries.
Rankings and comparisons, of course, have many problems and limitations. Whereas the WHO effort of ranking countries' health systems in 2000 was criticised for not including information directly obtained from patients, the Commonwealth Fund report could be criticised for not including more objective measures, such as clinical data from medical records. Patients' expectations and perceptions of their health system might differ and skew the results. However, it is still sobering that 54% of surveyed US patients with a chronic health disorder stated that they did not obtain a prescription, get a recommended test or treatment, or visit a doctor when needed because of cost. Those with chronic disorders in the USA were also the least likely to report having a regular doctor. Only Germany, where patients have direct access to specialist care and often consult multiple specialist physicians, had a worse score in coordinated care. With changing demography and high obesity prevalence, chronic disorders will become more common. Coordinated and efficient care of those with multiple chronic disorders will be crucial for any affordable health-care system in the future.
Not all news was bad. The USA did relatively well in reminding patients about preventive care, as well as giving advice on diet and exercise. US patients who were admitted to hospital were the most likely to receive a written care plan at discharge and a high proportion had arrangements for follow-up visits. However, unsurprisingly, with more than 46 million people uninsured, the USA did particularly badly in dimensions of access, equity, and efficiency. And even when only high-income people with health insurance were included, US respondents were more likely than those from other countries to report difficulties obtaining needed care because of costs.
So, the big question is whether President Obama's landmark Affordable Care Act, which was signed into law a little over 90 days ago, can change the US health-care system from being fragmented, unaffordable, ineffective (at the population level), and unfair to one that stands up to independent scrutiny in future international comparisons. To mark the first 3 months of the Act, Obama unveiled a Patient's Bill of Rights under the new legislation on June 22. For example, from September, there can be no more discrimination against children with pre-existing conditions. Lifetime limits or restrictive annual limits of coverage will be abolished by 2014 with a threshold of lower limits set in the meantime. Insurance companies will not be allowed to drop somebody's policy retroactively when they fall ill on the grounds that they made a mistake during their application. From January, 2011, onwards, insurers must spend 80–85% of their income on medical care or improvement of quality of care to limit profits, bonuses, and administrative costs.
These are all long overdue steps. Obama's victory on health-care reform is certainly the most important achievement of his presidency so far. Arriving at near universal insurance coverage is the much needed prerequisite. But the road ahead is long and full of obstacles and traps. It will probably take a decade until such indices as those in the Commonwealth Fund report will consistently improve. One of the areas that needs the most urgent attention now is primary care. US primary-care physicians need to be paid as much as their specialist colleagues and primary care itself must be made an attractive career choice for medical students. Primary-care physicians can make a system more efficient and effective by acting as public health and prevention advocates, coordinators and educators for patients with chronic diseases, and gatekeepers to avoid unnecessary or duplicate tests. With a strong primary health-care workforce, the US health-care system might just be able to look into the mirror with pride one day quite soon.
Volume 376, Issue 9734, 3 July 2010-9 July 2010, Page 1
"...siempre seguí la misma dirección, la difícil,
la que usa el salmón..."
Claudio Guido Mori Gonzales