GLOBAL: International comparison of healthcare systems

A new Commonwealth Fund report has assessed seven industrialized countries on the performance of their health system in five areas: quality, efficiency, access to care, equity and the ability to lead long, healthy, productive lives. The Commonwealth Fund is a private foundation supporting independent research on health policy. 27,000 patients and primary care doctors were surveyed across all seven countries as part of the study.

The Netherlands ranked first overall, closely followed by the UK and Australia. The UK performed well when it came to quality of care and access to care. In relation to access, the study says: "The UK has short waiting times for basic medical care and non-emergency access to services after hours, but has longer waiting times for specialist care and elective, non-emergency surgery." The Netherlands ranked very highly on all waiting times measurements. When it came to efficiency, the UK and Australia ranked first and second.

Despite having the most expensive health care system, the United States ranks last overall. While there is room for improvement in every country, the U.S. stands out for getting poor value for its health care dollars, ranking last despite spending $7,290 per person on health care in 2007 compared to the $3,837 spent per in the Netherlands, which ranked first overall.

Report author Karen Davis comments, "It is disappointing, but not surprising that, despite significant investment in health care, the U.S. continues to lag behind other countries. With enactment of the Affordable Care Act, we have entered a new era in American health care. We will begin strengthening primary care and investing in health information technology and quality improvement, ensuring that all Americans can obtain access to high quality, efficient health care."

On measures of quality the United States ranked sixth out of the seven countries. On two of four measures of quality ? effective care and patient-centred care ? the U.S. ranks in the middle. However, the U.S. ranks last when it comes to providing safe care, and next to last on coordinated care. On measures of efficiency, the U.S ranked last due to low marks when it comes to spending on administrative costs, use of information technology, re-hospitalization, and duplicative medical testing. On measures of access to care, people in the U.S. have the hardest time affording the health care they need, with the U.S. ranking last on every measure of cost-related access problems.

Overall rankings -

1. The Netherlands

2. United Kingdom

3. Australia

4. Germany

5. New Zealand

6. Canada

7. United States

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EUROPE : A French view on the EU cross-border healthcare plans

Presenting to fellow European members of parliament her recommendations on cross-border health care for a second reading, French rapporteur Francoise Grossetete insisted she would be uncompromising on the issue of prior authorisation. While she does not question this principle, she rejects the quality and security criteria added by the Council, which would make it possible for a member state to arbitrarily refuse to grant authorisation to a patient, “I believe that this criterion is unacceptable because it would make it possible for prior authorisation to be refused at any time without explanation. It is inconceivable and would, in the end, lead to new appeals before the European Court of Justice”.

The objective of the proposal for a directive is to standardise case law of the Court of Justice of the European Union and avoid the ambiguity faced by patients. The Commission is attempting to clarify the rights of patients treated in another member state, including the issue of the reimbursement of care. As a general principle, it establishes that patients treated in another member state will receive the same level of reimbursement anticipated for the same treatment or for a similar treatment in their national health system, if they are entitled to this treatment in their country of affiliation.

Grossetete is an influential MEP and her stance could help influence changes in the Second Reading later this year. Her worry is that the latest version still enables member states to limit the application of rules relating to the reimbursement of cross-border health care by demanding prior authorisation for certain treatments. According to the rapporteur, prior authorisation must be based on the need for health care planning and rationalisation, but cannot be abused in order to deny patients the right to travel for treatment. She therefore proposes even tougher restrictions- limiting prior authorisation to hospital treatment (a stay of more than one night in hospital), specialised care or treatment that poses a particular risk to the patient or the population.

Grossetete believes that this text must be urgently concluded under the best possible conditions because the question has been open for too long. She makes a valid point that less than one per cent of the European population would even consider state paid healthcare in another country, as most people prefer to be treated at home. Her argument is that if states are offered the opportunity for prior authorisation and reimbursement, unless carefully controlled, the practice in some member states will make the whole concept unmanageable.

Grossetete will be intransigent on the issue of rare diseases, as she wants patients suffering from rare diseases to have access to care in another member state and be reimbursed, particularly if the treatment is not provided in their member state. She joins an increasing number of MEPs arguing that rare diseases must not be subject to prior authorisation. She points out an area that was not resolved in the latest version from Council, but appears to be yet another get out clause agreed earlier this year by health ministers. This is the stipulation that patients who have obtained prior authorisation must provide advance payment to the hospital .Her argument is that this makes a nonsense of the whole agreement and the logic must be that if any advance payment is allowed, then this should only be in those few countries where at home, the patient has to pay an advance fee to the hospital before reclaiming from the state after the treatment.

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