A new international survey of patients indicates that despite the amount of money the United States spends on health care, the people who use medical services are less satisfied than patients in other countries.

The United States spends more than any other country on health care, and both industry leaders and patients often say we Americans have the best health care system in the world.

But despite that, other Americans - including many doctors - question a system that has produced an infant mortality rate about the same as Poland's, or life expectancy no better than Cuba's, but at a much higher cost per person.

"What is disturbing about these findings is that while the U.S. ranks first on health care spending in the world, we are often last in measures of quality of care. Higher spending doesn't mean that we receive more or better care; we simply pay more," says Karen Davis. She heads the Commonwealth Fund, a foundation that supports research on health care. In a survey of patients in the United States and other wealthy democracies the Americans scored their system lowest overall. They gave high marks to American medicine for preventive care, but low marks for safety, access to care, and equity of care.

"These shortfalls are a result of our fragmented system of care in the U.S., a system that is weak on primary care," said Davis. "In other countries they invest more in primary care and less in specialist care, perhaps gaining more value per dollar spent."

In some areas, the United States does very well. For example, almost all women (85 percent) now get mammograms to screen for breast cancer. In other areas, though, the picture is bleaker. Compared with other countries, the American patients said they were more likely to get the wrong medicine, or late or incorrect lab results. The survey found that about half of all Americans didn't see a doctor or take medicine because of the cost.

"On 21 of the 30 indicators we found wide and statistically-significant differences in the U.S. by income. In other countries, differences by income were rare," said Cathy Schoen, another Commonwealth Fund official

Commenting on the report, Professor Donald Berwick of the Harvard University School of Public Health said the six-nation comparison highlighted shortcomings in the way Americans get their health care.

"The fundamental conclusion from this report is that the U.S. is far from the best-performing health care system in the world, even though it's by far the most expensive," he said. "Except in preventive services, we lag significantly behind these other nations studied, and especially for people of low income and uninsured. We have the largest gap in care for the uninsured."

Andrew Bindman of the University of California - San Francisco says one fault in the U.S. system is the tremendous resources that have gone into expensive, high-tech medicine have sometimes come at the expense of primary care, the regular doctor who first sees a patient. "We're seeing, for example, a decline in the numbers of individuals from U.S. medical schools, for example, going into primary care fields. We're seeing an erosion of the primary care practice and infrastructure that I think is contributing to some of the feelings of fragmentation that are also reinforced system-wide by the challenges people face with regard to health insurance."

It's important to note that this report was based not on measurable outcomes, such as infant mortality, but rather on how patients themselves assessed their satisfaction with the health care they receive. It was based on surveys conducted in the United States, Australia, Canada, New Zealand, Britain, and Germany.