Ashish Jha is a health care professor at Harvard. And there’s this thing he used to say when he gave talks, a thing he thought was definitely true about the American health care system.
”I have probably said in more than a dozen talks that our health care system is much more specialty care-driven, whereas in Western Europe there are more primary care physicians, and that mix is just really different,” he’s said. “That mix is really different, and that drives the use of high-cost services. I’ve repeated those words.”
Jha isn’t quite sure where he learned this — it was just a truism of American health care that he took for granted (and, to be fair, a truism that I’ve also taken for granted as a health care reporter).
But Jha doesn’t believe this anymore. Earlier this month, he and two co-authors published a paper in the Journal of the American Medical Association that is one of the most comprehensive studies of what actually drives high health care spending in the United States.
He looked at whether his talking point was true: that the United States hops right to specialty care while our peer countries rely more on primary care services. He found that it wasn’t: The United States looks pretty average when it comes to its primary and specialty care mix. As he writes in the JAMA study, “the proportion of US physicians who were primary care physicians (43%) was the same as the mean of 11 other countries.”
”That punctured a myth that I had,” Jha says. “More broadly, it was a reminder that American health care, except for a couple of very specific things, kind of looks like health care in other countries.”
This is what I found especially striking about Jha’s new paper: It shows that in nearly every way, the American health care system looks a lot like other health care systems. Americans, for example, don’t actually go to the doctor more than people in other countries. You can see that in this chart, which looks at things like doctor visits and hospital stays. The United States comes out slightly below average.
It is true that there are other types of procedures where the United States comes out above average — and a handful, like knee replacements and MRI scans, where we come out at the very top. You can see that in this data below (the US is still the yellow boxes).
”I think if I say to you, on a list of 10 there are five where we are above average and five where we are below average, that’s basically another way of saying we look pretty average,” Jha argues.
(Not all health economists agree with this read of the data. In particular, Zeke Emanuel at the University of Pennsylvania published an editorial in the same journal arguing that the United States’ reliance on certain high-cost, high-frequency procedures like MRIs and knee replacements does set us apart and explains a portion of our health care spending.)
What does, of course, set the American health care system apart from its peers — what makes the US exceptional and not average — are the prices patients face when they do seek treatment. That is why the United States doesn’t look average on this other chart, which looks at our health care spending overall.
I asked Jha how this research would shape his own views of the American health care system. He says it suggests to him that a lot of structural reforms — increasing the number of primary care doctors, for example, or trying to reduce the amount of health care we use — won’t make us look more like our peer countries since we already do in that regard.
”Quantity is not what separates us from other countries,” he says. “It’s not that we don’t have an overuse problem — we probably do have an overuse problem — but that does not explain our exceptional spending. That is the key point: Overutilization is driven by a bunch of factors that appear to be common in other health care systems.”
In other words, the thing that separates us from other countries isn’t quantity. It’s price — and that’s the key issue to focus on if we want a health care system that will look more similar to those of our peers.
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