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, , London School of Economics

*% GDPOECD countries allocate about 9% of their GDP to health.This share varies from 16% in the United States to less than 6% in Mexico and Turkey1. Public and private expenditures are current expenditures (excluding investments).2. Current health expenditure..3. Health expenditure is for the insured population rather than resident population.Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).

Chart1

4.101.65.7

2.703.25.9

4.6-0.11.96.4

5.8016.8

3.703.16.8

6.600.77.3

5.202.27.4

6.101.57.6

5.2-0.12.67.7

6.601.58.1

6.102.18.2

6.901.58.4

6.102.48.5

5.902.88.7

6.7028.7

6.440.032.41333333338.8833333333

7.501.48.9

7.401.79.1

7.3-0.22.19.2

7.701.69.3

5.803.89.6

8.20.11.59.8

7.30.81.79.8

7.102.89.9

7.702.410.1

7.10310.1

7.40.42.410.2

802.410.4

6.404.410.8

8.702.311

7.308.716

Public expenditure

Residual

Private expenditure

Total

Sheet1

TotalPublic expenditurePrivate expenditureResidual

Turkey5.74.11.60

Mexico5.92.73.20

Poland6.44.61.9-0.1

Czech Republic6.85.810

Korea6.83.73.10

Luxembourg37.36.60.70

Hungary7.45.22.20

Ireland7.66.11.50

Slovak Republic7.75.22.6-0.1

Japan8.16.61.50

Finland8.26.12.10

United Kingdom8.46.91.50

Spain8.56.12.40

Australia8.75.92.80

Italy8.76.720

OECD8.88333333336.442.41333333330.03

Norway8.97.51.40

Sweden9.17.41.70

New Zealand29.27.32.1-0.2

Iceland9.37.71.60

Greece9.65.83.80

Denmark9.88.21.50.1

Netherlands19.87.31.70.8

Portugal9.97.12.80

Austria10.17.72.40

Canada10.17.130

Belgium110.27.42.40.4

Germany10.482.40

Switzerland10.86.44.40

France118.72.30

United States167.38.70

The number of physicians per capita has increased in all OECD countries since 1990, except in Italy2007 (or latest year available)1990-2007 (or nearest year)1. Ireland, the Netherlands, New Zealand and Portugal provide the number of all physicians entitled to practise rather than only those practising.2. Data for Spain include dentists and stomatologists.Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).

Across OECD countries, health expenditure has grown by slightly more than 4% annually over the past ten yearsAnnual average real growth in per capita health expenditure, 1997-2007Source: OECD Health Data 2009, OECD (http://www.oecd.org/health/healthdata).

1%5%10%55%69%27%Source: Monheit 2003 and Berk and Monheit 2001Distribution of health expenditure for the US population, by magnitude of expenditure, 199950%97%$27,914$7,995$4,115$351expenditure threshold (2004 US$)

% of population % of expenditureThe well-known 20/80 distribution actually the 5/50 or 10/70 problem - Germany 2011How can we predict who these 5 or 10% are?

Treatment for chronic diseases is not optimal. Too many persons are admitted to hospitals for asthma 1. Does not fully exclude day cases.2. Includes transfers from other hospital units, which marginally elevates rates.Asthma admission rates, population aged 15 and over, 2007Source: OECD Health Care Quality Indicators Data 2009 (OECD).

too many persons are admitted to hospitals for diabetes complications, highlighting the need to improve primary careDiabetes acute complications admission rates, population aged 15 and over, 20071. Does not fully exclude day cases.2. Includes transfers from other hospital units, which marginally elevates rates.Source: OECD Health Care Quality Indicators Data 2009 (OECD).

Note: In-hospital case-fatality rates within 30 days of admission. Age-sex standardized rates.In-Hospital Mortality After Admission for Acute Myocardial Infarction* per 100 Patients, 2009Source: OECD Health Care Data 2012.** 2008.** 2007.

Chart1

2.5

2.9

3.2

3.2

3.9

4.3

4.5

4.6

5.2

5.3

6.8

Sheet1

2009

DEN2.3

NOR2.5

SWE**2.9

NZ3.2

AUS3.2

CAN3.9

US*4.3

SWIZ*4.5

OECD Median4.6

UK5.2

NETH**5.3

GER6.8

JPN*9.7

Note: Age-sex-SDX standardized rates.Foreign Object Left in Body During Procedure per 100,000 Hospital Discharges, 2009Source: OECD Health Care Data 2012.** 2008.

Chart1

2.6

3.4

4.9

5.5

5.7

8.7

9.7

9.8

13.8

Sheet1

2009

DEN**1.82010

SWE2.6

GER3.4

US*4.9

FR5.5

UK5.7

NZ8.7

CAN9.7

AUS9.8

SWIZ*13.8

Note: Age-sex-SDX standardized rates.Post-Operative Sepsis per 100,000 Hospital Discharges, 2009Source: OECD Health Care Data 2012.** 2008.

Chart1

354

540.7

769.2

858

926.1

1077.2

1451.5

1455

Sheet1

2009

SWIZ*354

GER540.7

DEN***753.8

CAN769.22010

FR858

SWE926.1

US*1077.2

NZ1451.5

AUS1455

Expected Resource Use (Relative to Adult Population Average) by Level of Co-Morbidity, British Columbia, 1997-98Source: Broemeling et al. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver, BC: University of British Columbia, 2005.Thus, it is co-morbidity, rather than presence or impact of chronic conditions, that generates resource use.

NoneLowMediumHighVery HighAcute conditions only0.10.41.23.39.5Chronic condition0.20.51.33.59.8High impact chronic condition0.20.51.33.69.9

Primary Care Strength and Premature Mortality in 18 OECD Countries*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77.Source: Macinko et al, Health Serv Res 2003; 38:831-65.Starfield 11/06IC 3496 n

Average Number of Physicians per AMI Patient (Quartiles) with Changes in Survival and Spending, 1968-2002Source: Skinner et al, Health Aff 2006; W6:W34-W47.

Practical uses DARTS diabetic studyMortality Post Myocardial InfarctionYears Post MI% aliveDiabet Med 2002; 19, 448-55

Some are very proud oftheir quality certificate:Foto: J. Szecsenyi, 2005

Foto: J. Szecsenyi, 2005But does it really reflect reality?

*******However, when it comes to in-hospital mortality after acute myocardial infarctions, or heart attacks, U.S. performance was middling. Our mortality rates were better than in five countries but worse than in five others.

However, when it comes to in-hospital mortality after acute myocardial infarctions, or heart attacks, U.S. performance was middling. Our mortality rates were better than in five countries but worse than in five others.

However, when it comes to in-hospital mortality after acute myocardial infarctions, or heart attacks, U.S. performance was middling. Our mortality rates were better than in five countries but worse than in five others.

08 Bellagio chronic care Apr**08 Bellagio chronic care Apr**08 Bellagio chronic care Apr**These data, from one province in Canada, show that there is little difference in resource use for people with only acute conditions, people with any chronic conditions, or people with only serious chronic conditions when the morbidity burden is the same. However, increasingly higher morbidity burden (i.e., more multi-morbidity) is associated with progressively higher resource use, and the increase is the same regardless of the type of diagnosis (acute, chronic, major chronic). Chronic conditions alone do not, by themselves, imply high need for resources. Source: Broemeling A-M, Watson D, Black C. Chronic Conditions and Co-morbidity among Residents of British Columbia. Vancouver, BC: University of British Columbia, 2005. *09 Copenhagen general practice May**In an international comparison of 18 OECD countries, they were rated* according to whether their primary care systems were strong (high scores) or weak (low scores). Trends in potential years of life lost were examined after also taking into account other influences on health. Even after considering changes in gross domestic product, percentage of elderly people, total number of doctors per capita, average income, and smoking and drinking percentages, people in countries with strong primary care had fewer years of life lost than people in the poor primary care countries, and the differences widened over time.

*according to the method described in Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press, 1998, chapter 15. Source: Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res 2003; 38(3):831-865.Source: Skinner JS, Staiger DO, Fisher ES. Is technological change in medicine always worth it? The case of acute myocardial infarction. Health Aff 2006; W6:W34-W47 (also available at http://content.healthaffairs.org/cgi/reprint/hlthaff.25.w34v1). ****