is mounting evidence that chronic illness care requires better integration of professions and institutions to help patients manage their conditions, and that health care systems built on an acute, episodic model of care are ill equipped to meet the longer-term and fluctuating needs of people with chronic illnesses. Wagner and colleagues (1996) were among the first to document the importance of coordination in managing chronic illnesses. Many countries differ from the United States because public health and medical care services are embedded in a centralized health system and social and health care policies are more integrated than they are in the United States (Phillips, 2012).

The panel believes that the totality of this system, not just the health care component, must be examined to explore the reasons for differences in health status across populations. For example, a country may excel at offering colonoscopy screening, but ancillary support systems may be lacking to inform patients of abnormal results or ensure that they understand and know what to do next. Hospital care for a specific disease may be exemplary, but discharged patients may experience delayed complications because they lack coverage, access to facilities, transportation, or money for out-of-pocket expenses, and those with language or cultural barriers may not understand the instructions. The health of a population is influenced not only by health care providers and public health agencies but also by the larger public health system, broadly defined.2

Data are lacking to make cross-national comparisons of the performance of health systems, narrowly or broadly defined, in adequate detail. Only isolated measures are available, such as the 30-day case-fatality rate for a specific disease or the percentage of women who obtain mammograms. Nor is it clear what the ideal rate for a given health system measure (e.g., optimal wait times or density of physicians) should be for any given country. Out of necessity, this chapter focuses on the “keys under the lamppost”—the health system features for which there are comparable cross-national data—but the panel acknowledges that better data and measures are needed before one can properly compare the performance of national health care systems.

Based on the data that do exist, how well does the U.S. health care system prevent and treat injury and disease when compared with other high-income countries? As noted earlier, this chapter and the four that follow address three core questions. For this chapter, the three core questions are:


2The larger public health system includes not only public health agencies, but also public and private entities involved with food and nutrition, physical activity, housing and transportation, and other social and economic conditions that affect health (Institute of Medicine, 2011e). As discussed further in Chapter 8, public- and private-sector leaders are increasingly recognizing the health implications of “nonhealth” policies that relate to agriculture, transportation, land use, energy, housing, and other environmental conditions.

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