Doctors are rich in America

Why the US healthcare system is so expensive

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London - The US spends twice as much money on health care as other countries, yet life expectancy is lower and child mortality is higher. Economists search for the reasons in an analysis in the US-American Ă„rzteblatt (JAMA 2018; doi: 10.1001 / jama.2018.1150).

The figures are well known: In 2016, the USA spent around 17.8 percent of its gross domestic product on healthcare, in ten other countries with a similar economic output it was only between 9.6 percent (Australia) and 12.4 percent (Switzerland). . Life expectancy in the United States was the lowest of all eleven countries at 78.8 years. In the other countries, people live between 80.7 years (Germany) and 83.9 years (Japan). Infant mortality, at 5.8 per 1,000 live births, is significantly higher than in Canada (5.1 per 1,000 births) or Japan (2.1 per 1,000 births). In the United States, only 90 percent of the population have health insurance; in all of the other ten countries whose data Irene Papanicolas and colleagues from the London School of Economics and Political Science researched, the proportion is between 99 and 100 percent.

Why is US healthcare so expensive without performing better? The widespread belief that the US population is consuming more health services is incorrect, according to Papanicolas. There are fewer doctors in the USA (2.6 per 1,000 inhabitants) than in Germany (4.1 / 1,000) and the proportion of specialists (57 versus 55 percent in Germany) is no higher than in the other countries.

The number of hospital beds (2.8 versus 8.2 per 1,000 inhabitants in Germany) is lower and the hospital stays significantly shorter. The USA is also in the middle of the field for hospital treatments for myocardial infarction (192 versus 287 per 100,000 in Germany) or mental illness (679 versus 1,715 per 100,000 in Germany). Fewer hip replacements (204 versus 283 per 100,000 in Germany), but slightly more knee replacements (226 versus 190 per 100,000 in Germany) are implanted.

The high rate of caesarean sections (33 versus 16 percent in the Netherlands) does not explain the higher health care costs either. Imaging procedures such as computer or magnetic resonance tomography and, above all, mammography are carried out relatively frequently in the USA.

High prices for medical services

However, the main price driver in the US is prices. Medical services cost significantly more than in other countries. This is especially true for medication. The per capita expenditure in the USA is 1,443 US dollars versus 667 US dollars in Germany. The monthly treatment costs for the statin Crestor (rosuvastatin) are 86 US dollars compared to 61 US dollars in Germany. For Lantus (insulin glargine) it is 186 US dollars compared to 38 US dollars in Germany, for Advair (fluticasone plus salmeterol) 155 US dollars compared to 38 US dollars in Germany, for Humira (adalimumab) 2,505 US dollars compared to 1,749 US dollars in Germany.

The high costs of imaging procedures are also responsible for the fact that significantly more money is spent per capita in the USA than in the Netherlands (220 versus 23 US dollars).

Doctors (and nurses) earn significantly more in the US than in any other country. The average annual income of a general practitioner in the USA is US $ 218,173 (US $ 154,126 in Germany), specialists earn US $ 316,000 (US $ 181,243 in Germany), nurses US $ 74,160 per year (US $ 53,668 in Germany).

Administrative expenses put a strain on the health budget

The administration has a not insignificant share in the high costs for the health system. They account for 8 percent of total spending in the United States. In the other countries it is only between 1 and 5 percent.

Papanicolas' information on more than a hundred different items of expenditure shows where the differences are, but cannot explain the underlying causes. Patent protection and the high rate of new developments play a role in drug prices.

But the increasing monopoly position also allows some manufacturers to dictate prices on the market, writes Stephen Parente of the University of Minnesota in Minneapolis in an editorial. The very high incomes of doctors would be partly explained by the fact that most doctors would have to take out loans of between 300,000 and 400,000 US dollars to study.

The bill for the high health care costs - because Medicare, Medicaid and the US veterans authorities negotiate cheap discounts - are mainly paid by the employer-funded family health insurance: They recently spent an average of 18,764 US dollars per household. That's nearly a third of the median household income in the US, up from 59,039 in 2016. This is a sharp increase since 2000, when health insurers only had to spend $ 6,438 per household, or 17.8 percent of median income. As a result, fewer Americans have employer-sponsored health insurance (55.7 versus 64.1 in 2000).

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