MAY 7, 2014 Webinar Cathy Schoen, Senior Vice President Commonwealth Fund

Learning by Comparing: Experiences of Adults in Eleven Countries

Findings from the Commonwealth Fund 2013 International Health Policy Survey and Health Affairs article, Dec. 2013

MAY 7, 2014 WEBINARCathy Schoen, Senior Vice President

Commonwealth Fund

22Key National Insurance Design and

Cost-Sharing Policies, 2013AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US*

Universal Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No

Deductible No No No No Yes No No No Yes No Yes

Limit on out-of-pocket spending

Yes No No Yes No No Yes Yes Yes No No

Core benefits include:Drugs ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Dental (adults) ✔ ✔ ✔ ✔

* US: Before insurance market reforms take effect in 2014.Source: Thomson, Osborn, Squires, and Jun, International Profiles of Health Care Systems, 2013, The Commonwealth Fund, Nov. 2013. Swiss, Dutch, German 1-3% uninsured

US (17.7%)

NOR (9.3%)

SWIZ (11.0%)

NETH (11.9%)

CAN (11.2%)

GER (11.3%)

FR (11.6%)

SWE (9.5%)

AUS (8.9%)*

UK (9.4%)

NZ (10.3%)

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000 $8,508

$5,669 $5,643$5,099

$4,522 $4,495$4,118 $3,925 $3,800

$3,405 $3,182

Health Spending per Capita, 2011Adjusted for Differences in Cost of Living

* 2010.Source: OECD Health Data 2013.

% GDP

$US

3

44

Key Findings• Coverage and benefit design matter for access and affordability

US adults stand out for forgoing care because of costs, and trouble paying medical bills, even when insured

Wide country variation in out-of-pocket costs

• Access to primary care and specialists vary significantly US and Canada long waits for primary care and high ER use Swiss, UK, US, Dutch and German rapid access to specialists;

Norway and Canada longer waits

• Insurance complexity can pose significant health system costs Consumes time and resources for patients and clinicians

• Experiences influence views of the country health systems• US adults the most likely to call for fundamental reform

• International perspective provides insights looking forward

55

Cost-Related Access Barriers in the Past Year

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.* Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.

UK SWE NOR CAN SWIZ GER AUS FR NZ NETH US0

10

20

30

40

4 610

13 13 15 16 1821 22

37

27

Percent*

US Insured

66

UK SWE NOR CAN GER AUS NETH NZ SWIZ FR US0

10

20

30

40

14

6 7 7 8 9 10 1013

23

15

Serious Problems Paying or Unable to Pay Medical Billsin the Past Year

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

US Insured

77Spent $1,000 or More Out-of-Pocket on Medical Care

in the Past Year

SWE UK FR NETH NZ GER CAN NOR SWIZ AUS US0

10

20

30

40

50

60

2 37 7 9 11

1417

24 25

41 42

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Percent

US Insured

88U.S. Adults’ Access and Cost Concerns,

by Insurance Status

Spent $1,000 or more out-of-pocket

Serious problems/ unable to pay medical bills

Went without care because of costs

0 20 40 60 80 100

42

15

27

39

42

63

UninsuredInsured all year

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

9

UK GER SWIZ SWE NETH FR CAN NOR AUS NZ US0

15

30

45

60

75

26

10

22

10

19

2723

11

28

41

27

6 8 11 1219 20 21

2529 32 33

Did not visit dentist/hygenist/dental clinic in past two yearsSkipped dental care because of cost in past year

Gaps in Dental Care

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

1010

Access

Primary Care, Emergency Department Use, and Specialist Care

1111

GER NZ

NETH AU

SSW

E FRNO

R UK US CAN

0

25

50

75

100

76 7263 58 58 57 52 52 48

41

Access to Doctor or Nurse When Sick or Needed Care

Percent

NZ AUS

NETH

GER FR UK

SWE US

NOR

CAN

514 14 15 16 16

22 26 28 33

Same-day or next-day appointment

Waited six days or morefor appointment

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Note: Question asked differently in Switzerland.

12

GER NETH SWE SWIZ NZ AUS NOR UK US CAN FR0

20

40

60

80

10090

84 84 82 80 79 78 75 7367 63

When Calling Regular Doctor or Practice with a Question, Always or Often Hear Back on the Same Day

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Base: Has a regular doctor/place.

13

UK NOR

GER

NETH NZ

SWIZ

AUS US CAN FR

SWE

0

20

40

60

80

100

6958 56 56 54 49 46

39 38 36 35

Access to After-Hours Care

Percent95 95 90 90

81 80 78 7668

4635

Adults, 2013Easy getting after-hours care

without going to the ER

Primary care physicians, 2012Practice has arrangement for

patients’ after-hours care to see doctor or nurse

Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.

Base: Needed care after hours. * In Norway, doctors asked whether their practice had arrangements or there were regional arrangements.

14

AUS GER NETH UK NZ NOR SWIZ FR SWE US CAN0

25

50

75

22 22 24 27 28 28 28 31 3239 41

48

Used the Emergency Department in Past Two YearsPercent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

US Uninsured

1515

SWIZ UK US

NETH

GER NZ

SWE

AUS FR

NOR

CAN

0

25

50

75

100

80 80 76 75 7259 54 51 51 46

39

Wait Times for Specialist Appointment

Percent

3 3 6 7 1017 18 18 19

26 29

Less than four weeks Two months or more

Base: Needed to see specialist in the past two years.Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

1616

Insurance Complexity

NOR SWE AUS NZ CAN NETH GER SWIZ FR US$0

$100

$200

$300

$400

$500

$600

$700

$35 $55 $70$128 $148

$199$237 $266 $277

$606

Spending on Health Insurance Administration per Capita, 2011Adjusted for Differences in Cost of Living

Source: OECD Health Data 2013.

$US

17

Adults, 2013Spent a lot of time on paperwork or

insurance did not cover in past year*

Insurance Complexity and Restrictions Create Concerns for Patients and Doctors

SWE UK NZ

NOR

CAN

AUS

GER

NETH FR

SWIZ US

0

25

50

75

4 4 7 815 16 17 19 23 25

32

Percent

UK AUS

NOR

SWE NZ FR

CAN

SWIZ

NETH

GER US

10 11 12 1218 20 23 24 28

41

54

Primary care physicians, 2012Insurance coverage restrictions

pose major time concern**

Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.

* Adults spent a lot of time on paperwork or disputes over medical bills and/or insurance denied payment or did not pay as much as expected in the past year.** Amount of time doctor or staff spend getting patients needed medications/treatments because of coverage restrictions is a major problem.

18

1919Overall Views of Health Care System, 2013

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

USFR

CANGERSWENOR

NZAUS

NETHSWIZ

UK

0% 20% 40% 60% 80% 100%

25404242444647485154

63

4849

50484642

4543

4440

33

2711

81010

1289

574

Works well, only minor changes Fundamental changes Completely rebuild

Percent of adults

2020Insights from Global and Domestic Perspectives

• Coverage and benefit design matter for access and affordability Especially if vulnerable due to chronic disease or low incomes

• Insurance benefits and policies targeted at primary care can improve access, including after-hours care

• Insurance complexity can pose significant health system costs Consumes time and resources for patients and clinicians United States provides a cautionary example

• Safeguarding access while confronting costs will require vigilance and attention to consequences of insurance design changes

• International policy variations provide insights looking forward Opportunities to learn from internal and global experiences

2013 International Health Policy Survey: Description21

• Landline and cell phone survey of adults age 18 or older in Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, United Kingdom, and United States

• Final samples 20,045 in 11 countries

• Australia (2,200), Canada (5,412), France (1,406), Germany (1,125), Netherlands (1,000), New Zealand (1,000), Norway (1,000), Sweden (2,400), Switzerland (1,500), United Kingdom (1,000), U.S. (2,002)

• Field from February to June 2013, conducted by Social Science Research Solutions and country contractors.

• Published in Health Affairs: C. Schoen, R. Osborn, D. Squires, M.M. Doty, “Access, Affordability, and Insurance Complexity are Often Worse in the United States Compared to Ten Other Countries,” Dec. 2013.

• Also see 2012 Survey of Primary Care Physicians: Schoen, Osborn, Squires et al. “Survey of Primary Care Doctors in Ten Countries Shows Progress in Use of Health Information technology, Less in Other Areas, Health Affairs, Dec. 2012.