International Differences in Medical Care Practices
McPherson, Kim, Health Care Financing Review
International differences in medical care practices
An overview of several aspects of international comparisons of medical care utilization is presented with a discussion of the usefulness of such comparisons in identifying geographic variations in utilization and in elucidating the nature of clinical decisionmaking regarding various procedures. The discussion includes the purposes of conducting international studies as well as the methodological and policy issues involved. Brief descriptions of some of the studies that have been conducted are also provided.
Health care is consuming ever-increasing proportions of developed nations' budgets. As populations age and the ability to provide effective intervention increases, medical care inflation continues to outstrip retail price indices. The aggregate utility of these expenditures, as well as each new increment that results from new diseases such as acquired immunodeficiency syndrome, new techniques such as organ transplants, technological advances in diagnostic equipment, and more sophisticated drug therapies are being questioned by governments faced with the provision of adequate health care that requires more real funding in each year than it did in the previous one.
We are entering an age, therefore, where questioning will be axiomatic in health care provision. New techniques will no longer be universally implemented without evaluating value versus cost. Even common procedures will come under more intense scrutiny as the need for justification increases. The nature of this progression increasingly becomes a rationing process. However, to ration in medicine is to do something which is quite alien to health care provision as it has evolved. One has to be absolutely certain that real benefit is not being withheld; incontrovertible evidence of efficacy or lack of it is needed as a prerequisite for rationing.
The resolution of the health care dilemma is hindered by two factors. The first is that this era of questioning is somewhat threatening to the medical profession, which has taken, and been given, decisionmaking responsibility and power (Friedson, 1972). The second, and in the end the real hindrance, is the difficulty with which many of the important questions can actually be answered.
If limited resources are to be focused on the provision of appropriate care, one must know what appropriate care is. In health care, there is a diversity of accepted opinion on the need for and value of alternative treatments. In many situations, equally qualified physicians might disagree on which treatment is optimal. There is often no scientifically correct way to practice much of medicine. Many accepted theories concerning the treatment of illness have not been adequately assessed, and consensus based on knowledge of treatment outcomes is the exception rather than the rule.
The aggregate cost to a population of hospital health care, measured in terms of annual costs per capita, is the product of two independent components. The first is the average cost per admission. This is intensively studied and relatively easily measured, and attempts to monitor contributing factors, such as diagnostic tests, length of stay, or manpower costs, can greatly affect its magnitude. The second component, less intensively studied but often more important, is average annual admission rates per capita. This component is often assumed to reflect medical need and, as such, is not subject to questioning; to question admission itself assumes a broader concept of efficiency than is usual. However, many causes of admission are associated with large variations in their per capita rates and, therefore, can be strong determinants of per capita health expenditure.
Overall efficiency requires that the aggregate activity of the hospital service maximizes the benefit-to-cost ratio of all alternative admission and process options. …