problem that seems to have worsened in recent years (Himmelstein et al., 2009). Health insurance premiums are consuming an increasing proportion of U.S. household income (Commonwealth Fund Commission on a High Performance System, 2011).

Apart from challenges with access, many Americans do not experience optimal quality when they do receive medical care (Agency for Healthcare Research and Quality, 2012), a problem that health policy leaders, service providers, and researchers have been trying to solve for many years (Brook, 2011a; Fineberg, 2012; Institute of Medicine, 2001). In the United States, health care delivery (and financing) is deeply fragmented across thousands of health systems and payers and across government (e.g., Medicare and Medicaid) and the private sector, creating inefficiencies and coordination problems that may be less prevalent in countries with more centralized national health systems. As a result, U.S. patients do not always receive the care they need (and sometimes receive care they do not need): one study estimated that Americans receive only 50 percent of recommended health care services (McGlynn et al., 2003).

Could some or all of these problems explain the U.S. health disadvantage relative to other high-income countries? This chapter reviews this question: it explores whether systems of care are associated with adverse health outcomes, whether there is evidence of inferior system characteristics in the United States relative to other countries, and whether such deficiencies could explain the findings delineated in Part I of the report.

DEFINING SYSTEMS OF CARE

The panel defines “health systems” broadly, to encompass the full continuum between public health (population-based services) and medical care (delivered to individual patients). As outlined in previous Institute of Medicine reports (e.g., 2011e), health systems involve far more than hospitals and physicians, whose work often focuses on tertiary prevention (averting complications among patients with known disease). Both public health and clinical medicine are also concerned with primary and secondary prevention.1 The health of a population also depends on other public health services and policies aimed at safeguarding the public from health and injury risks (Institute of Medicine, 2011d, 2011e, 2012) and attending to the needs of people with mental illness (Aron et al., 2009). There

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1Examples of primary prevention include smoking cessation, increased physical activity, administering immunizations to eliminate susceptibility to infectious diseases, and helping people avoid harmful environmental exposures (e.g., lead poisoning). Secondary prevention includes early detection of diseases and risk factors in asymptomatic persons (e.g., cancer and serum lipid screening).



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