“Which country has the world’s best health care system?”
I get this question at almost every speech I give. Most of the time the question comes from someone who wants to know which country the United States should model itself after to create the world’s best system here at home. But sometimes I wonder whether I’m really being asked a question about medical tourism—whether the questioner wants to know which country they should go to if they need to get some medical service, such as dental care, a hip replacement, or cataract surgery.
This is the type of question I usually love.
I rank everything. I rank the 10 best meals I’ve ever had (#1 Alinea in Chicago, #2 Tanja Grandits in Basel, and #3 OCD in Tel-Aviv). I rank chocolates (#1 Askinosie, #2 Dick Taylor of California, and #3 Fruition of New York). I rank Alpine cheeses (#1 is a tie between Alpha Tolman and Alp Blossom). I rank colleges. I rank academic departments of bioethics and health policy that compete with my own. I rank the meals I cook, the races I run, the bike rides I take, the speeches I give.
I should love ranking health systems. But I don’t. When asked, I answer, “That is a terrible question.” You cannot just take the world’s “best” system, whether it is the Dutch or Swiss or Norwegian or Australian one, and plunk it down in the United States and think we will get better health care. Health care is path dependent. We have built up numerous institutions over decades that constrain and limit our ability to change the system. And each country prioritizes different values that color which policy options they adopt. Some of these systems, like Norway, provide free insurance with no co-pays for children and people who need a lot of health care. Others, like the United States, emphasize making patients have more “skin in the game.” Some emphasize hospital-based care, others want more care in the home. Some, anticipating the aging of the population, have proactively instituted mandatory long-term care insurance. Others prioritize more comprehensive, free care for children. Still others are more passive, waiting for a crisis to stimulate policy changes.
Consider where the US system is now. About half of all Americans get their coverage through employer-sponsored insurance, with employers “paying” most of the premium as a pre-tax fringe benefit. (I use “paying” ironically because the money really comes from reduced worker wages. Although economists believe and can prove that, no one else seems to accept the idea.) The majority of other Americans are covered by 2 government-financed programs: Medicare and Medicaid. Nearly 5,000 private community hospitals and hundreds of thousands of privately employed physicians deliver care. Insurers organize these hospitals and physicians into preferred networks and adjust co-payments to encourage patients to stay in network. We have built up extensive networks of private home health care agencies and home hospices, commercial dialysis centers, ambulatory surgical centers, and skilled nursing facilities. Myriad governmental bodies—from state insurance commissioners and physician and nurse licensure boards to the federal Food and Drug Administration (FDA) and the Federal Trade Commission—regulate various components of the system. Private organizations, such as the Joint Commission and boards of medical and surgical specialties, help ensure quality of care. All these institutions—the way they are paid, how they deliver care, and what they regulate—shape how the system operates and constrain what reforms can be instituted.
Other countries lack many of these core features. Norway doesn’t have a fragmented insurance market with employer-sponsored insurance, a separate government program for the elderly, and another one with different benefits for low-income individuals. Switzerland has an individual mandate to buy insurance—but not a tax exclusion to help people pay for it. Germany has employer-sponsored insurance; it also has no tax exclusion, but employer and employee contributions go to a single agency that then pays the insurance companies a uniform premium. Similarly, Germany has almost no health care provider networks or financial incentives to stay in network. We cannot eliminate preexisting institutional structures to become like the Norwegian or Swiss or German systems overnight—or even over decades. One of the reasons the Clinton health care reform proposal in the early 1990s failed was because it tried to change too much of that preexisting institutional structure in one go. Insurers, some of which were threatened with extinction, fought back. These organizations would do the same today if we tried to adopt foreign health care systems.
Another reason I dislike this ranking system is that I have read many different rankings of health care systems—none of which agree. The granddaddy of rankings is the World Health Organization (WHO)’s World Health Report 2000, which ranked the health care systems of 191 countries. France won, followed by Italy, with the United States coming in a distant 37th. Many people still cite this ranking, implying it is the definitive criterion of system success. But there are reasons not to take it seriously. First, it was published nearly 20 years ago and has not been updated. Second, it focused on 5 broad categories of care and weighted them haphazardly. Third, its methodologies have been roundly criticized as favoring certain countries—notably France. But most importantly, it doesn’t pass the common-sense test. The idea that the health care systems of Oman or Greece or Portugal or Colombia or Cyprus are all ranked higher than the United States might be believable, but they are all ranked higher than Germany, Canada, Australia, and Denmark as well.
Those results should raise more than a few skeptical eyebrows. Indeed, it led 2 British health economists to wryly observe that there was a “significant relationship between a country’s FIFA [soccer] ranking and its ranking by the WHO. Taken at face value, the statistical analysis suggests that, if the national football [soccer] team does well, the WHO score improves.” The WHO’s authors’ use of fancy equations and colored graphs to justify the rankings does not make the results seem more plausible; it only conjures up Mark Twain’s comment that “there are three kinds of lies: lies, damned lies, and statistics.”
Nevertheless, the WHO report opened the floodgates. Many groups have since gotten into the ranking game. A group of French academics identified 9 different rankings of health care systems. Not surprisingly, the rankings don’t agree on what measures matter and which countries are the best. The Health Consumer Powerhouse, which only ranks European countries, concludes that the top 4 are the Netherlands, Switzerland, Denmark, and Norway. Legatum has a wholly different result: (1) Luxembourg, (2) Singapore, (3) Switzerland, (5) Netherlands, (13) Norway, and (23) Denmark. Bloomberg looks only at efficiency and finds the top European country is Italy (3), with France (8) and the UK (10) close behind. All surpass the Scandinavian countries, Germany, and Switzerland—countries with much better reputations for efficiency. Public surveys about the quality of their country’s health care system produce yet another set of rankings, with Denmark at the top, followed by Sweden, Canada, and the UK. Switzerland, Germany, and Norway are not in the top 10. Do their systems perform less well? Or are these countries’ cultures less conducive to appreciating their own institutions?
Ranking these rankings, as it were—different results with different “top” countries—is head spinning and confusing. It is hard to know which country is the best—or even good. Interestingly, there is only one thing these rankings seem to agree on: the United States does not rank in the top 10 in any of them.
Moreover, none of these rankings seem to answer the question that patients are often really asking: Where can I get the best health care for my condition? There are few rankings of countries by treatment for certain ailments; those rankings that exist are often superficial. For example, the United States is often purported to be the best place for cancer care, but if that care is unaffordable, the high quality is not doing anyone any good. A patient dealing with chronic illness might look at the WHO rankings and think they ought to move to France, but they may not realize that although France finances chronic care well, the delivery is not on par with countries like the Netherlands or even care for chronic illnesses in parts of the United States where new chronic care coordination techniques are being pioneered. Those who need long-term care might think Taiwan is a cheap place to get it, but Germany or the Netherlands would serve them better. Anyone whose children need a lot of health care would do best in Norway, where children’s health insurance is basically free. And low-income individuals are well covered by the German system, which requires no cost-sharing for people below a certain income threshold.
So which country has the world’s best health care system?
When answering this question at a talk, I would say that no one can know what the real rankings are and that I do not spend much time thinking about other countries’ health care systems because they cannot help us reform the dysfunctional American system.
I have repeated these points for years. But the question keeps coming up. Clearly, I have not satisfied my audiences. And after a while, repeating the “path dependence” answer and the problem of the numerous rankings began to feel hollow to me too.
One day I stopped dismissing the question. I realized I was wrong. I was not being curious—just dismissive. So a few years ago I began to seriously consider what we can learn from a comparative study of the health systems of other, high-income countries.
As it turns out, thinking about other health care systems can be extremely valuable—who knew? Even though path dependence prevents the United States from adopting another country’s health care system in toto, there are some lessons to learn by studying these systems. Although the question posed by my audiences may not be the best one, there is a point to seriously pondering what we can learn from other systems, even if we cannot rank or mimic them. There are at least 4 lessons that a comprehensive comparative study of other health care systems can elucidate.
The first lesson is that no health care system is perfect or even performing in the A+ or A range. (There I go with a ranking!) Although other countries may be doing better than the United States (not a high bar), all high-income countries’ health care systems face significant challenges. Even the countries that regularly get high scores by the various rankings have serious problems and face difficulties in addressing them. For instance, Germany has an oversupply of hospital beds and a rigid separation of hospital-based physicians and ambulatory care (outpatient) physicians, making care coordination a real challenge. Eliminating hospital beds is extremely difficult, but maintaining them is inefficient, expensive, and exacerbates the country’s nursing shortage. In Norway the federal government finances hospital care, while local governments largely finance outpatient care. This means local governments have little incentive to encourage—and may even discourage—less expensive care at home or in outpatient settings. Despite being ranked number 1 by the WHO, France continues to struggle with treating patients with chronic illnesses. As I delineate in this book, other countries face similar challenges. These problems are not the ordinary ones of any large organization serving millions of people—problems of administrative efficiency and bureaucratic coordination—but rather fundamental financial and structural problems, problems that are typically among the most pressing domestic issues facing governments. And confronting them will require painful choices and trade-offs. Consequently, learning from the challenges that confront other health care systems can help us understand the challenges of our own system and help us imagine potential solutions.
A 2nd lesson—and a corollary to the first one—is this: a comparative study of health care systems reveals common problems in high-income countries as well as which ones are particular to one or a few systems. The commonalities suggest that these issues are not unique to the United States’ financing and delivery systems but instead arise from several factors, such as the aging of the population. No country has yet figured out a sustainable, efficient way to address mental health care, to completely contain the rising costs of chronic conditions, or to eliminate low-value care.
Conversely, challenges present only in the American system or in just a few systems suggest that they arise from some particular organizational or structural factors. Many other countries have a budget for health care that limits total spending. Neither the United States nor Switzerland does, and they have the highest per capita health care spending, which continues to grow at high rates. The United States’ tendency to solve a problem by layering on another system—such as Medicaid for the poor, Children’s Health Insurance Program (CHIP) for children, and the exchanges for the uninsured above a certain income—is problematic. The American system is an order of magnitude more complex and difficult for patients to navigate than any other health care system I studied. Yes, all countries struggle with high drug prices, but the United States does not regulate drug prices and is an outlier in drug spending—but not because we are hypochondriacs using a lot of medications. Some other countries have some form of national long-term care insurance. Many countries, including the United States, have been unable to institute this policy and are facing challenges financing long-term care. This distinction between common challenges and unique issues allows us to focus attention more carefully on what might be the source of a particular problem or set of problems.
A 3rd lesson is the realization that there is probably no “best” health care system in the world. This is true of any ranking project. Despite my tendency to rank restaurant meals, there probably is no single-best restaurant. You can tell a good one from a bad one and a great one from a good one. But not the best overall. One restaurant might be more innovative at desserts or at the aesthetics of presentations or at combining different flavors, textures, and temperatures. It may be possible to compare in more focused domains—for example, desserts or wine pairings—but not in overall performance. Similarly, there are various dimensions on which to evaluate health care systems, and systems perform differently on those dimensions. One country’s health care system might be outstanding at choice—allowing consumers to use whatever services they desire without a gatekeeper—but might not excel at getting value for money or quality of care. A system that excels at getting value for money spent might not excel at simplicity or innovation. And one that excels at innovation might not provide the highest quality care.
Fundamentally, so much of health care is value driven. Value arguments are often conflated with “better” or “worse” care. For instance, there are multiple ways to provide insurance to an entire population, be it through a single public payer or a comprehensive network of private insurers. Each strategy has strengths and weaknesses, but both can be “good”—or “bad.”
This means the real question is not “Which country has the world’s best health care system?” but rather something closer to “Which country has the health care system that allows the most consumer choice?” or “Which country has the most innovative health care system?” or “Which country best addresses the needs of chronically ill patients?” We need to define the particular dimension we are going to compare countries on.
Indeed, one of the insights I gleaned from this comparative study is that even the US health care system, which does not perform well—let alone the best—on many dimensions, is best in at least one domain: innovation. And I am not speaking only about innovation in drugs or devices or surgical procedures, but also innovation in payment to hospitals and physicians and how to deliver care. In the 1970s and early 1980s the United States pioneered the DRG—Diagnosis Related Group—payment formula for hospitals, and almost all other countries have since adopted, adapted, and revised it. In the last few years Switzerland has become one of the latest countries to do so. Today, the United States is pioneering many new risk-based payment methods, such as bundled payments and capitation with bonuses for quality and reducing total cost of care. As before, other countries are interested in how that innovation is going and considering whether to adopt some of these payment methods. Even a system with many problems can still excel along some dimensions, providing lessons for other countries.
This leads us to the 4th lesson: comparing systems and seeing which ones excel at which dimensions and how they do it can help inform the design of particular reforms in other countries. Countries’ health care systems cannot be imported wholesale—what one commentator called “lift and shift”—but understanding how one country solves a problem or fails to solve a problem may inform other countries facing a similar problem. Reforms of particular aspects of another country’s health care system can be adapted. US policymakers can learn something from countries that operate health insurance exchanges similar to the American state-based exchanges. We can learn from other countries about how to incentivize the provision of home-based, long-term care. We can learn from other countries about the advantages and disadvantages of the different approaches to regulating drug prices. The United States can learn what makes strong primary care gatekeeper models work effectively and what their limitations are.
THIS BOOK ASSESSES the health systems of the United States and 10 other countries: Australia, Canada, China, France, Germany, the Netherlands, Norway, Switzerland, Taiwan, and the United Kingdom. I chose these countries for several reasons. First, I wanted to study different kinds of financing and delivery systems. The United Kingdom has the traditional socialized health care system in which most financing is public and most of the hospitals and physicians are government owned and operated. Canada and France have state financing but predominantly private delivery systems. Germany has mandatory payroll deductions for health care, but the financing flows through private insurance companies—called sickness funds—that pay privately employed physicians and hospitals. Switzerland has a mandate that all people purchase private health insurance. The major Swiss hospitals are public, but there are many private hospitals, and physicians are private.
Second, I selected countries that many people are familiar with from the American health care debates, adding a few that people may be unfamiliar with so as to enrich future discussions. Canada and Britain are often invoked in debates about health reform. Yet their health systems are both poorly understood and frequently mischaracterized. Including them allows us to clarify their history, financing, and delivery system structures. Conversely, the French, Australian, Taiwanese, and Chinese systems are rarely—if ever—cited in debates about health policy. Few Americans—even health policy experts—know much about their evolution, how they are financed, and their care delivery systems’ structure. Although language barriers may explain ignorance of the French, Taiwanese, and Chinese systems, including them allows us to expand the discussion of alternatives and lessons to be learned.
Third, I selected countries that might have plausible claims to being ideal systems—or at least best along some critical dimensions—for the United States to emulate. Since the WHO’s 2000 ranking, many people believe France is the best. Many conservative commentators tout the Swiss system. American liberals regularly look at the Scandinavian countries, such as Norway, as offering excellent models that the United States should emulate. People who experience the Taiwanese system often sing its praises. Some leading American health policy experts like the Dutch system because of its emphasis on regulated competition and a strong gatekeeper role for primary care physicians. The Chinese system is notable for high coverage rates in an enormous population. All the while the Canadian system, frequently denounced as “socialized medicine” by conservative commentators, may ironically be the most similar system to American health care abroad.
To compare the various health care systems thoroughly and to determine “the best” along the various dimensions, I have described all systems along the same 8 topics: (1) history, (2) coverage, (3) financing, (4) payment, (5) the delivery of care, (6) prescription drug regulation, (7) human resources, and (8) future challenges. In a later chapter I compare the countries on their performance based on different dimensions organized by these 8 topics, such as most consumer friendly, most choice of providers, innovation, generosity of coverage, and equality of care.
BEFORE I DELVE into the details of each health care system, I will delineate 7 major challenges that are common to every system. These challenges manifest in different ways in each system, and therefore solutions may not be generalizable. But it is useful to consider the commonalities as we proceed through each country.
One common problem facing all high-income countries is cost pressure. Spending just under 18% of GDP on health care makes the United States a very expensive outlier. Nevertheless, all countries face health care cost pressures and anticipate growing crises with their aging populations and the introduction of new technologies. Citizens demand ever more care, yet they strenuously object to higher taxes and premiums to pay for it. Thus, all governments of high-income countries are wrestling with how to satisfy—and perhaps adjust—public expectations and demands while reining in future health care cost growth.
A 2nd and particular manifestation of the cost pressure is the high and rising cost of drugs. Again, the United States is an outlier—with just over 4% of the world’s population, we account for about half of the world’s drug spending. Other countries regulate drug prices. Nevertheless, all countries find rising drug costs burdensome. These drug cost pressures will escalate with the growing prevalence of chronic illness as well as new specialty drugs and cell and gene therapies with 6- or 7-figure prices. All countries are looking for ways to moderate future drug cost increases.
A 3rd common challenge relates to reducing the inefficiency in the provision of care as well as the unnecessary care in the system. In 2009 the US National Academy of Medicine estimated that the United States wasted over $140 billion on the inefficient delivery of health care services and provided over $200 billion in unnecessary services that, moreover, did not improve patients’ health.
These problems of inefficiency and unnecessary care are not unique to the United States. For instance, many policymakers in Germany believe that unnecessary admissions drive the country’s high hospitalization rate. In general, the substantial differences between the United States and European countries on cost do not exist exclusively because other countries provide care more efficiently or have lower use of services; quite the contrary: many have greater use of hospitals and drugs. Many experts believe these countries have substantial rates of unnecessary care.
A 4th challenge is the coordination of care for patients with chronic illnesses. Coordination between hospitals and outpatient health care providers is necessary for comprehensive care of patients with chronic illnesses. Yet the long-standing financial, administrative, and other divisions between hospitals and ambulatory care physicians in most countries impede this coordination. Chronic care coordination requires health care providers to be proactive and initiate frequent interactions with patients. Such proactive care systems are not well developed anywhere. The challenge is thus to develop and deploy at scale the right structures that provide coordinated outpatient chronic care for millions.
A 5th and related challenge is the mismatch between health care delivery institutions and the population’s chronic health care needs. The existing health care institutions have evolved over the last 100 years largely to respond to infections, trauma, and other acute illnesses. Hospitals have come to dominate all health care systems in high-income countries and consume approximately a quarter to a third of health care spending in almost all countries. Yet today’s most serious health problems are those of chronic illness—congestive heart failure, chronic obstructive pulmonary disease, diabetes, asthma, hypertension, stroke, cancer, and inflammatory conditions. Episodic interventions in acute care hospitals do not lead to optimal management of lifelong conditions. All health care systems are trying to modify or shift away from these institutions, but doing so is difficult. Citizens are often enamored of their local hospitals and mightily fight downsizing or closing them. The common challenge in high-income countries is how to match 21st-century health needs for chronic care with anachronistic but well-entrenched, hospital-based models for the delivery of care.
A 6th challenge in every country is the provision of mental health care. For over 100 years mental health had been stigmatized largely because there was no recognized understanding of its biological basis. One consequence was the segregation of mental health care services from somatic care ones: they had different hospitals, different medical records, and different financing mechanisms. This may have been useful once, but not in the 21st century.
We now understand that mental health conditions are widespread and costly, even if they are less visible than physical ones. In the United States mental health care is the 4th most expensive health care service area. A large proportion of patients with chronic conditions also experience comorbid depression, anxiety, and other mental health conditions that dramatically increase their use of all health care services. Integrating mental health care into somatic care is another challenge facing every country, although it is not always fully appreciated even by policymakers.
Finally, all countries face the challenge of how to provide long-term care and how to pay for it. In every country hundreds of thousands—if not millions—of older people are living longer and require custodial care in addition to medical care. Institutional care in nursing homes is extremely expensive on a per-person basis. However, many older people do not have family to provide appropriate personal care. A few countries, such as Germany and the Netherlands, have instituted universal long-term care insurance. While universal long-term care insurance provides a financing mechanism, it does not necessarily make the costs manageable or create an effective delivery infrastructure.
These 7 challenges are common to all high-income countries. Importantly, they will become more intense and pressing because of 2 inevitable mega-trends: the aging population and the development of expensive health care technologies. These changes will increase (1) the number of people with (multiple) chronic conditions, (2) the need for more chronic care coordination, and (3) the demand for long-term care. This in turn will increase use of drugs and medical services. And all of this will intensify cost and access pressures.
THIS EFFORT TO compare different health care systems is not the first such attempt. In addition to the various rankings, there are books and academic articles. In 2009 T. R. Reid, a renowned Washington Post correspondent and Frontline TV reporter, published The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care. It was a light-hearted exploration of 10 different systems for treatment of his bum shoulder. It is a fun and accessible read, but the subjective comparisons are not systematic. Plus, by looking at the problem through the lens of one medical condition, it ignores many key elements of health care systems, such as drug coverage, mental health care, care for chronic illnesses, and long-term care.
The European Observatory on Health Systems and Policies produces a more rigorous series, Health Systems in Transition (HiT). These are comprehensive books—upward of 150 pages each—that exhaustively outline the technical aspects of many countries’ health systems. They are written from the viewpoint of the particular country’s domestic policy experts and are directed toward other academics and policymakers. They are excellent as references, but they are not comparative. The reader must draw comparisons after reading thousands of pages about several countries. In addition, they are published episodically over years, so they may not address recent changes. They are thus of little interest to health care workers, citizens, students, policymakers, or journalists who want to understand multiple different systems efficiently—and accessibly.
The Commonwealth Fund publishes excellent profiles of many countries written by experts from each country using a question-and-answer format. Unlike the Health Systems in Transition (HiT) series, they are manageable in length and updated periodically. There are obvious areas of overlap with this book—both use a standard framework for each country that includes analyses of coverage, financing, and the delivery of care. Yet there are several important differences between the Commonwealth Fund’s country profiles and ours.
First, because of the importance of path dependence, this book stresses the different systems’ histories. Current structures and arrangements result from the past policy decisions that, in turn, reflect each country’s politics and culture. Considering history challenges us to think harder about how we might adopt another country’s practices.
Second, there are important differences in emphasis. For example, the Commonwealth Fund profiles have a substantial focus on electronic health records (EHRs); this book does not. Instead, because of the importance of global drug costs, this book has a much greater focus on drug price regulation. In addition, Which Country Has the World’s Best Health Care? is written by a team of outsiders that visited the countries, not insiders. My team did not assume cultural knowledge that a nonresident would lack. I hope the descriptions of each country are accessible to readers unfamiliar with a particular country’s system.
Finally, there is a difference in how I assess the countries. The Commonwealth Fund compares countries on quantitative measures, frequently from the Organisation for Economic Co-operation and Development (OECD), and on surveys of citizens asking, for instance, about experiencing a medical, medication, or lab error or gaps in hospital discharge planning. These are important. But I chose to take a qualitative tack.
Quantitative assessments are today’s ascendant way of thinking. Experts often repeat the phrase, “if you can’t measure it, you can’t manage or improve it.” This perspective is often attributed to the guru of quality improvement, W. Edwards Deming. After World War II he helped revive Japanese industry by introducing statistical process control in manufacturing, uniform product quality, the removal of waste in production, and especially the Plan-Do-Study-Act cycle. Deming rejected the myopia behind the attempt to measure everything. While he was an engineer, statistician, and management consultant, he argued that those things that are measured are managed. However, he emphasized that this is different from believing that if you cannot measure it, you cannot manage it. He recognized that the philosophy of “if you can’t measure it, you can’t manage it” is a costly myth—and a wrong one too. Trying to run a business based only on numbers was, he believed, one of the 7 deadly sins of management. For some important things we don’t have data. Some important metrics cannot be measured, like judgment and corporate culture. According to Deming, we still need to manage and improve those things we cannot measure.
I have also learned that quantitative measures often entail qualitative judgments. What might seem to be similarly titled categories are different, rendering cross-country comparisons less accurate and useful. For example, there is no international standard on where to differentiate social and health services, so comparing spending on long-term care is rarely apples to apples. Some countries, like the Netherlands, consider elderly custodial care delivered at home or in residential homes to be part of health care spending. Others, like Australia, classify most long-term care as a social welfare service. Both countries pay for long-term care through government-run programs, but only one counts that money as a health care expenditure.
Drug spending is also difficult to compare. In some countries the drug spending reported is that in retail pharmacies, while others include all drug spending both in retail pharmacies and in hospitals, physician offices, and other settings. In addition, what drugs are sold and measured in the retail pharmacy category in some countries might be counted in hospital drug costs in others. For instance, Humira, the world’s best-selling drug, is categorized in the Netherlands in hospital spending, but in other countries it is placed in retail pharmacy spending. This makes international comparisons on “retail drug spending” indirect as well as inaccurate.
Furthermore, the complicated payment systems for drugs in all countries—including consumer rebates, secret price negotiations, and dozens of other innovations—make getting accurate, comparative data on drug costs nearly impossible. Total invoice level (i.e., manufacturer revenue) pharmaceutical spending rarely matches the sum of government-reported retail and nonretail drug spending. Prescriptions and other measures of utilization vary across countries, and over-the-counter medicines and drugs not covered by insurance are often not counted. In an effort to get clarity, I reached out to IQVIA—the leading industry consultancy that produces detailed drug spending reports for the United States and other countries. They provided generous, detailed data on drug spending and costs, but their data didn’t match canonical OECD or government figures. Their staff were very clear: the numbers had to be taken with heaping grains of salt.
Similarly, in some countries, such as Norway, specialists are paid through hospitals and budgeted accordingly. In many other countries, though, specialists run their own offices and are classed under physician and ambulatory care services. There is no one right way to quantify these kinds of activities. But emphasizing quantitative comparisons across different countries that ultimately measure different things can be more deceptive than illuminating.
As I assessed countries, I realized that most of the important dimensions may not have comparable data between countries or may not necessarily be amenable to quantification. For instance, one important dimension is patient choice of providers. This seems more amenable to a qualitative assessment. The case is similar with innovating care delivery and with having a thorough, transparent process for determining drug prices. Hence, I have opted not for a score or number but for qualitative assessments along 19 different qualitative dimensions organized into 8 topics. In chapter 12 I will discuss the “winners” on these qualitative dimensions. One implication is that different countries excel at different dimensions.
THIS BOOK BEGAN as a way to answer questions posed by American audiences and find insights for reforming the American health care system. Along the way, though, I learned that these lessons are not just relevant for the United States; they can also help policymakers imagine different ways to improve their individual country’s health care system. All countries are experiencing problems—and searching for solutions. A book outlining the way other countries organize health care can help non-American policymakers address challenges.
As Dr. Stephan Hofmeister, one of the physician heads of the German National Association of Statutory Health Insurance Physicians (Kassenärztliche Bundesvereinigung [KBV]), which is the equivalent of the American Medical Association (AMA), noted,
[Comparing] health care systems throughout the world is very important to our daily work. Politicians around the world tend to compare their respective systems with those in other countries. Most of the time these comparisons seem to be apples-to-pears that ignore substantial differences in basic structures of those countries. In order to avoid short sighted policies with potential for long-term backlash on the functioning of the health care system, we have increased our efforts to exchange knowledge with health care experts in other countries to help implement truly sustainable reforms.
I learned that many citizens and policy leaders have no holistic understanding of their own health care system. World’s Best Health Care should also serve as a resource for citizens and people who work in health care. It will educate them about how their own country’s system works and how it compares on specific dimensions to other countries.
This was most clearly demonstrated in Norway. No one—including many of the country’s leading health policy experts—could offer a succinct history of the system, how it came into being, and the key pieces of legislation that helped it evolve into its current structure. They could not even offer an article that summarized the history. Many noted that a brief summary of the country’s system would be an invaluable resource for Norwegian medical, nursing, public health, and health administration students. Educators knew that few students or practitioners would read the 160-page book, Norway, Health System Review, produced by the European Observatory, but they might read a 15-page summary of the system, especially if it compared Norway to other countries.
A 3rd audience for this book is health policy–focused journalists and politicians. They often have little knowledge of health care before they are assigned a beat or committee seat in a legislative chamber. When they compare their own health care system to another country’s, they often have little knowledge of the structure of the other country’s financing or delivery system. The summaries in this book can provide a good comparative reference for them to quickly learn about the complexities of health care and potential ways of addressing current challenges.
The book can also help patients who might be thinking about getting treatments abroad—the medical tourists—when selecting different countries.
I HOPE THIS BOOK satisfies my audiences’ curiosity—a curiosity I learned to embrace. I hope it helps students in health care fields and practitioners understand their work’s international context. I also hope it can help policymakers in the United States and other countries as they confront the difficult choices about how to reform their own health systems. Maybe they can learn how to adapt some of the good policies found in other countries and avoid repeating others’ mistakes.