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United United
States Kingdom
GDP per capita, 2006 ($)a 45489 35669
Health expenditure, 2006 (%, GDP)b 15.3 8.4
Public Health expenditure, 2006 (%, GDP)c 7.0 7.3
Private Health expenditure,2006 (%, GDP)d 8.3 1.1
Per Capita health expenditure, 2006 ($)e 6959 2996
Obesity Rate, 2005 (%)f 32 23
Administration Costs, 2006 ($ per capita)i 465 172
Doctors per 1000, 2006d 2.4 2.1
Acute Hospital Beds per 10,000, 2005d 2.7 2.3
MRI's per million, 2006d 26.5 5.6
Male Life Expectancy, 2005 (yrs)m 75.2 77.1
Female Life Expectancy, 2005 (yrs)n 80.4 81.1
Deaths per 1000 live birthso 5 6.9
Reduction in “avoidable” deaths 19997/98- 5.1 27.2
2002/03 (per 100,000)p
a-e, m-o i
OECD, (2009(a)) Peterson & Burton, (2007)
f-g p
ACP, (2008) Nolte and McKee, (2008)
Healthcare spending has risen steadily over time but the US rate outpaces the
UK:
It misconception that aging and, in the case of the US, increased administration
costs are the main drivers behind this increasing spend. As the table shows, in
real terms administration makes up to low a proportion (Garber & Skinner, 2008)
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and aging has much too gradually an impact. Though the retirement of the
‘baby-boomers’ will increase demand it will happen far too slowly to account for
all the increase. In the US, Reinhardt, (2003, p.30) shows that after modelling for
factors such as “medical care price inflation; greater resource intensity of
treatments, including the availability of new technology; overall population
growth; and so on” aging will add only 0.5% a year to a forecasted total
expenditure growth of 8.4%. Gray (2005) discusses studies that indicating similar
proportions in the UK contrasted with lower overall growth; these also show
stronger correlation between spend and proximity to death. In the UK 15.7% are
aged 65+ yet consume 43.7% of resource in the US it’s 12.3% and 48.8%
respectively (Blank and Burau, 2007 p.7)
Health is a service industry; 70% of costs are on salaries, getting value for
money here is paramount to efficiency however success of pay for performance
reform has been limited. (Walshe & Smith, 2006) In the UK the consultant
contract was not signed as it would result in thorough management of clinical
activity deemed “unacceptable to the profession and its trade union” and the
QAF has also resulted in GP’s being reimbursed much more without significant
improvements in health outcomes (Maynard, 2005(a) p.73) In the US also, fee for
service also dominants and efforts to control this prove particularly difficult
under private healthcare. Capitation has been instigated with public funds in the
hope this would help curb private price cost inflation but with little success.
(Reinhardt, 2005) One man’s cost is another’s income; US citizens pay a lot more
simply because healthcare is more expensive. A study based on tracer diseases
including diabetes and lung cancer found they used approximately 30% more
inputs per capita spending roughly 75% more on increased prices. (Anderson et
al., 2003)
Both countries have tried to reduce overuse, underuse and misuse through
assessing new health technologies and implementing evidence based medicine.
As Banta (2003 p.121) shows, in the US there have been attempts at state levels
and by large private insurance companies, however, “with no effective national
co-ordination, HTA activities are carried out in many organisations with different
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goals in mind, often using different methods.” whereas the UK established NICE
in 1999. However due to political difficulties faced in overtly rationing health,
these organisations shy away from it and the ‘elephant-in-the-corner’ remains
cost containment. (Fuchs et al., 2007) As NICE (2008 p.9) indicate, “statutory
instruments and directions do not allow (them) to take budgetary impact or
affordability into account when advising on cost effectiveness.” In 2003 it
became a legal requirement that funding for all positive advice be made
available within three months of publication. This has led to pressure on PCT’s to
fund new technologies with marginal benefit at the expense of increasing
funding to more cost effective areas. (Maynard, 2005(a)) Rationing is an
anathema to private healthcare; however the state of Oregon did attempted to
explicitly ration public healthcare mathematically. Here to there were also
problems as patient and government pressure forced managers to move services
up and down the list by hand. Results were modest; however the amount of
people without coverage was reduced from 18% to 11%. (Oberlander, 2001)
Public Health and social networks; bridging the gap between structure
and agency
US health problems are amplified by the lack of universal coverage; this alone
goes a long way in explaining their slightly reduced life expectancy; slightly
greater infant mortality and much smaller reduction in preventable deaths
compared with the UK. Public health problems correlate with inequality not
income. Willkinson & Pickett (2009 p.111) show “people in more equal societies
live longer, a smaller proportion of children die in infancy and health is better”
(see appendix). The social determinants of health have been known about for
some time. Marmot et al., (1978 p.249) found the lowest grade civil servants had
a mortality rate three times higher than those in the highest grade; concluding
"more attention should be paid to the social environments, job design, and the
consequences of income inequality." Recent US work into social networks by
Christakis & Fowler (2007 p.376) quantifies the strength of social networks,
showing for example “among married couples, when an alter became obese, the
spouse was 37% more likely to become obese.” Successful public health
management requires multifaceted approaches at a societal level but this is hard
to achieve and both systems struggle, the US in particular. (Marmot, 2010)
Klein argues (2005) once a particular system takes root it can be calculated with
some certainty as being more costly to change in comparison to any benefits
that might potentially be gained. Believing that by eschewing private funding the
NHS deprives itself of potential additional income and by having a fundamentally
top down approach, which ultimately constrains choice; it is less effective at
maximising returns when given more money.
A World Health Report (2000) ranked the US 37th out of 191 countries, coming
top for responsiveness, with the UK coming in 26th here and 18th overall. By its
controversial measures the UK fell short for offering to little choice and the US for
not providing universal coverage. Many US citizens argue they happily pay for
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what they want; they earn more so any net benefit comes at reduced cost to
them and as early adopters they subsidise others as new technologies eventually
trickle-down to the less well-off at lower cost. (Reinhardt, 2005) With any
comparative analysis ‘best’ comes down to a matter of perspective and reform is
limited by path dependencies; bringing into question the validity of such an
approach. The second part of this essay will turn to analysing this.
Comparative analysis is at the core of ‘hard’ science and its rigour produces
some profound findings in healthcare. It has helped show the relative effects of
aging, discounting it alone as a major cost driver and in the work of Christakis
and Fowler (2007) allowed for comparison against a theoretical network that
would arise if distribution were random, proving the large strength of social ties
in obesity. However there is a problem in comparing only the US and UK by the
numbers because the US is so often an outlier and an N value of only two often
proves little. This is evident in Wilson and Pickets graphs; the trend, both
between and within nations, only becomes apparent though analysing groups of
countries, or states. (Mills et. al, 2006)
why I think numbers often seem more descriptive in social science; though
science argues this is a reductionist form of analysis.
As Pawson and Tilly (1997) highlight, the difference in the social sciences is
Context + Mechanism = Outcome (CMO). Since it is impossible to control against
everything, the effect of any management initiative taken from one country and
introduced to another will always differ simply because the environment differs.
This has been evident with different US states, binging into question the validity
of comparing the UK against a ‘nation of nations’. (Mills et. al, 2006) The OECD
caution:
With regard to public health, Tan et al., (2005 p.43) discuss how historically
public health management was about identifying the ‘cause’ of a disease usually
traced back to an acute infection. With advances in our understanding of health
todays epidemics have fuzzier boundaries being a result “of the interplay of
genetic predisposition, environmental context, and particular life styles.” The
limits this complexity places on management means in the short term it is also
feasible to introduce a degree of perturbation, measure small changes and
observe some limited connections. However in the long term management must
be social in the sense that consensus on broadly acceptable course of action
must be agreed upon and worked towards.
Since Willkinson and Picketts (2009) work shows equity having strong correlation
over a large range of variables in health-outcomes it be what chaos theory terms
a ‘strange-attractor’ of health; strange as it can’t be fully differentiated, limiting
predictability. When combined with the work of Christakis and Fowler (2007) this
gives limited insight as to social causes, a small inroad in bridging the macro-
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micro gap. Mason (2006 p.23) believes mixing qualitative methods with
quantitative structure helps us to think “beyond the micro-macro divide, and to
enhance and extend the logic of qualitative explanation” By meshing or linking
rather than integrating we can develop multi-nodal dialogic explanations that
“allow the distinctiveness of different methods and approaches to be held in
creative tension.” Though it is positivistic to say so, I feel such approaches have
much merit.
However, results are never neutral in the sense that they can be judged from
differing perspectives. The use of absolute compared to percentage figures also
gives rises to debate about relative attribution. In absolute terms Americans
clearly spend more on healthcare than the UK but by thinking about this in
proportion to their total earnings the difference is reduced. (Mills et. al, 2006)
Comparative analysis is rarely performed for purely academic reasons; often the
goal is for convergence toward what is perceived, and presented as ‘best’
evidence based practice. Pollitt (2001 p.491) argues we should distinguish
between different stages of policy: “discourse, decisions, practice and results;”
with each requiring different research strategies; decisions being the most
straightforward and results is the most difficult. This has been evident in the
analysis; the political rhetoric is relatively easy to distinguish as were the
intentions of reform however there was much debate as to best practice and the
merits of results.
Conclusion
Part one indicated how even two fundamentally different systems experienced
similar problems in managing the health of their citizens. It was found that
increasing spending on healthcare in both systems was mainly related to our
increasing ability to consume it, particularly in the latter stages of life. Rationing
was shown to be difficult in both systems with reform often being a protracted
affair, yielding limited improvement. It was argued that many reasons the US
experiences reduced returns on investment was due to the fact their society is
less equal and coverage is not universal.
Part two briefly discussed the nature of evidence in social science and the
difficulties in controlling against context and determining causation. Pollitt’s
framework was found to be particularly useful in differentiating between rhetoric,
intentions, actions and results and it was decided that whilst it might be possible
to adopt scientific management in the short term, particularly with evidence
based practise; in the long term management decisions must be about social
consensus. It was argued by mixing quantify with qualitative methods the value
of comparative analysis to policy makers could be increased.
with words from a Conservative Prime Minister: “Two nations between whom
there is no intercourse and no sympathy; who are as ignorant of each other’s
habits, thoughts, and feelings, as if they were dwellers in different zones, or
inhabitants of different planets: the rich and the poor.” (Disraeli, 1845)
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Bibliography
ACP - American College of Physicians (2008) . Achieving a high-performance
health care system withuniversal access: what the united states can learn from
other countries. Annals of Internal Medicine 2008 January 1;148(1):55–75.
Anderson, G. Reinhardt, U. Hussey, P and Petrosyan, P. (2003) It’s the prices,
stupid: why the united states is so different from other countries. Health Affairs
22(3):89-105
Banta, D. (2003) The development of health technology assessment. Health
Policy 63 121-132
Brennan, T. and Mello, M. (2009) Incremental health care reform. JAMA.
301(17):1814-1816
Blank, R and Burau, V. (2007) Comparative health policy. Palgrave: London
Christakis, N. and Fowler, J. (2007) The spread of obesity in a large social
network over 32 years. NEJM 357(4):370-379
Dartmouth Atlas of Health Care (2006) CMS-FDA collaborative. a report by the
dartmouth atlas of health care cms-fda collaborative. Available at
http://www.dartmouthatlas.org [Accessed 8th March 2010]
Disraeli, B (1845) Sybil or the two nations. London
Emanuel, E; Fuchs, V; Garber, A (2007) essential elements of a technology and
outcomes assessment initiative. JAMA. 298(11):1323-1325
Garber, A and Skinner, J. (2008) Is american health care uniquely inefficient? J
Econ Perspect; 22(4): 27–50.
Gleick, J. (1987) Chaos: making a new science. Vintage: New York.
Gray, A. (2005) Population ageing and health care expenditure. Ageing Horizons
(2)15-20
Green, J. (2000) Epistemology, evidence and experience: evidence based health
care in the work of accident alliances, Sociology of Health and Illness 22(4) 453-
476.
Hantrais, L. (1999) Contextualization in cross-national comparative research.
International Journal of Social Research Methodology, 2(2): 93-108
Klein, R. (2005) The public-private mix in the UK. in the public private mix for
health pp.43-63 Radcliffe Ltd: Oxfon
Mason, J (2006) Mixing methods in a qualitatively driven way. Qualitative
Research 6(9): 9-25
Maynard, A. (2005(a)) UK healthcare reform: continuity and change In the public
private mix for health pp. 63-83 Radcliffe Ltd: Oxfon
Maynard, A. (2005 (b)) Enduring problems in health care delivery. in The public
private mix for health pp.294- 309 Radcliffe Ltd: Oxfon
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Reinhardt, U. (2005) The mix of public and private payers in the US health
system. in the public private mix for health pp.83- 117 Radcliffe Ltd: Oxfon
Tan, J. Wen, J. and Awad, N. (2005) Health care and services delivery systems as
complex adaptive systems. Communications of the acm. 48(5): 36-44
Walshe, K & Smith, J. (2006) Healthcare management. Maidenhead: Open
University Press
Wellards. (2008) Wellards NHS guide 2008. JMH Publishing Ltd, East Sussex
World Health Report – WHO (2000). The world health report 2000 - health
systems: improving performance. Available at http://www.who.int/whr/2000/en/
[Downloaded 8th March 2010]
Willkinson & Pickett (2009). The spirit level: why more equal societies almost
always do better. London: Allen Lane. Slides available from
http://equalitytrust.org [Downloaded 8th March 2010]
NB The Title, unreferenced, is the opening line from William Shakespeare’s
Romeo and Juliet. 1597 and this essay was largely written before Obama,
thankfully, managed to pass a health care reform bill, but obviously before
any papers were available analysing it’s effects.
Appendix
Willkinson & Pickett (2009) graphs are created from statistical sources and
methods detailed in full at:
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In our book, for all of our international comparisons, we use the 20:20 ratio
measure of income inequality from the United Nations Development Programme
Human Development Indicators, 2003-6. As survey dates vary for different
countries (from 1992 to 2001), and as the lag time for effects will vary for the
different outcome we examine, we took the average across the reporting years
2003-6. For the US comparisons we use the 1999 state-level Gini coefficient
based on household income produced by the US Census Bureau. Sources:
US Census Bureau. Gini ratios by state, 1969, 1979, 1989, 1999. Washington,
DC: US Census Bureau, 1999 (table S4).
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