1 Health System Performance in Selected Nations: A Chartpack Compiled by Katherine K. Shea, Alyssa L. Holmgren, Robin Osborn, and Cathy Schoen May 2007

1

Health System Performance in Selected Nations: A Chartpack

Compiled by Katherine K. Shea, Alyssa L. Holmgren,Robin Osborn, and Cathy Schoen

May 2007

2

Outline

I. Quality of CareII. Access to CareIII. Efficiency of Health SystemIV. Equity of Health SystemV. Ability to Ensure Long, Healthy and

Productive LivesVI. Views of the Health Care System:

Physicians and PatientsVII. Country Rankings

3

Data Sources

• 2004 Commonwealth Fund International Health Policy Survey of Adults' Experiences with Primary Care (Random, representative samples of adults 18 and older)

• Sample sizes: 1,400 in Australia, 1,410 in Canada, 1,400 in New Zealand, 3,061 in U.K., and 1,401 in U.S.; total sample of 8,672 adults.

• 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Adults in six countries who met at least one of four criteria: rated their health as fair or poor; reported that they had a serious illness, injury, or disability that required intensive medical care in the past two years; or reported that in the past two years they had major surgery or had been hospitalized)

• Sample Size: 700–750 sicker adults in Australia, Canada, and New Zealand and 1,500 or more in the United Kingdom, United States, and Germany; total sample of 6,958 sicker adults.

• 2006 International Health Policy Survey of Primary Care Doctors (Primary care physicians)

• Sample Size: Australia: 1,003, Canada: 578, Germany: 1,006, Netherlands: 931, New Zealand: 503, UK: 1,063, US: 1,004; total sample of 5,157 primary care physicians

• OECD Health Data from 2004 and 2005

4

Data References• K. Davis, et al., Mirror, Mirror on the Wall: An Update on the Quality of

American Health Care Through the Patient's Lens, (New York:The Commonwealth Fund, May 2007)

• C. Schoen, R. Osborn, P. Trang Huynh, M. Doty, J. Peugh, K. Zapert, On The Front Lines of Care: Primary Care Doctors' Office Systems, Experiences, and Views in Seven Countries, Health Affairs Web Exclusive (Nov. 2, 2006):w555–w571

• C. Schoen, M.S., Robin Osborn, M.B.A., Phuong Trang Huynh, Ph.D., Michelle Doty, Ph.D., Kinga Zapert, Ph.D., Jordon Peugh, M.A., Karen Davis, Ph.D. Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries, Health Affairs Web Exclusive (November 3, 2005): W5-509–W5-525

• C. Schoen, M.S., Robin Osborn, M.B.A., Phuong Trang Huynh, Ph.D., Michelle Doty, Ph.D., Karen Davis, Ph.D., Kinga Zapert, Ph.D., and Jordon Peugh, M.A. Primary Care and Health System Performance: Adults' Experiences in Five Countries, Health Affairs Web Exclusive (October 28, 2004): W4-487–W4-503

• P. T. Huynh, C. Schoen, R. Osborn, and A. L. Holmgren, The U.S. Health Care Divide: Disparities in Primary Care Experiences by Income, (New York: The Commonwealth Fund, April 2006)

• J. Cylus and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2006 (New York: The Commonwealth Fund, May 2007).

5

Quality: Right Care

6Patient Reports on Reminders forPreventive Care, 2004

37 3844

49 50

0

25

50

75

AUS CAN NZ UK US

Percent of adults receiving preventive care reminders

2004 Commonwealth Fund International Health Policy Survey

7

828

61

9383

18

14

3265

5

16

24

20

18

0

25

50

75

100

AUS CAN GER NET NZ UK US

Y es, using a manual systemY es, using a computerized system

Physicians Reporting Routinely Sending Patients Reminder Notice for Preventive or Follow-Up Care, 2006

Percent of physicians

Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

8

Preventive Care, 2004

Percent received: AUS CAN NZ UK US

Pap in past 3 years, Women age 25-64 78 77 81 77 89

Mammogram in past 3 years, Women age 50-64 80 79 81 77 86


9Percentage of Population over Age 65 with Influenza Immunization in 2004

43.0%

48.0%49.2%

59.2%62.4%

64.6%68.0%

71.0%73.0%

79.1%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

Australia Netherlands United

K ingdom

France United

States

Canada OECD

Median

New

Zealand

Germany J apan

aa aa

Source: J. Cylus and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2006 (New York: The Commonwealth Fund, Apr. 2007).

10

Prevalence of Chronic Conditions, 2004

47 48 50 51 52

0

25

50

75

NZ CAN AUS US UK

Percent of adults with at least one of six chronic conditions*

*Hypertension, heart disease, diabetes, arthritis, lung problems, and depression2004 Commonwealth Fund International Health Policy Survey

11

* Adult reported at least one of six conditions: hypertension, heart disease, diabetes, arthritis, lung problems (asthma, emphysema, etc.), or depression..Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).

6558 56

5045

37

0

50

100

CAN US NZ AUS UK GER

Percent of sicker adults with chronic conditions* whose doctor gave plan to manage care at home

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 11

Sicker Adults with Chronic Conditions:Receipt of Self-Management Plan in Six Countries, 2005

12Received Recommended Carefor Chronic Condition, Sicker Adults, 2005

Percent received recommended care:

AUS CAN GER NZ UK US

Hypertension* 78 85 91 77 72 85

Diabetes** 41 38 55 40 58 56

* Blood pressure and cholesterol checked.

** Hemoglobin A1c and cholesterol checked, and feet and eyes examined.

2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

13Sicker Adults with Hypertension or DiabetesWho Received Recommended Care by

Self-Management Plan or Nurse Involvement, 2005

6167

50

68 64

7974 78 77 81

8691

0

50

100

NZ AUS UK CAN US GER

Neither self-management plan or nurse Self-management plan and/or nurse


Includes blood pressure and cholesterol for hypertension; Hemoglobin A1cand cholesterol checked, and feet and eyes examined for diabetes

Percent

14

Percent of Doctors Reporting Practice Is Well Prepared to Care for Chronic Diseases, 2006

Percent of physicians reporting “well prepared”:


Patients with multiple chronic diseases

69 55 93 75 67 76 68

Patients with mental health problems

50 40 70 65 48 55 37


15Doctor’s Office Has a NurseRegularly Involved in Care Management, Sicker Adults, 2005

16 19

3641

4752

0

25

50

75

AUS CAN NZ US GER UK

Percent who have a nurse involved in case management

2005 Commonwealth Fund International Health Policy Survey 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults

Base: Adults with chronic disease

16Prescription Medication Advice Among Sicker Adults with Chronic Conditions, 2005

Percent saying doctor:* AUS CAN GER NZ UK US

Does NOT review all medications taking, including prescribed by other doctors

46 38 35 42 42 40

Does NOT explain side effects

36 40 47 33 48 49


* Doctor sometimes, rarely, or never.


Base: Adults with chronic disease who use prescription medications regularly

17Patients Did Not Receive Counseling About Exercise and Diet in Past Year, Sicker Adults, 2005

29 3136 36

4550

0

25

50

75

US CAN NZ AUS UK GER


Base: Adults with chronic health condition

18Physician-Reported Use of Multi-Disciplinary Teams

and Non-Physicians, 2006


Practice routinely uses multi-disciplinary teams:

Yes 32 32 49 50 30 81 29

Practice routinely uses clinicians other than doctors to:

Help manage patients with multiple chronic diseases

38 25 62 46 57 73 36

Non-physicians provide primary care services

38 22 56 33 51 70 39


19Capacity to Generate Patient Information, 2006


2637

81

63

80

68

92

25

37

55 59

72 74

88

0

25

50

75

100

CAN US GER NET NZ AUS UK

List of patients by diagnosis

List of patients' medications, including Rx by other doctors

Percent of primary care practices reporting very or somewhat easy to generate

20

Quality: Safe Care

21

Medical, Medication, and Lab Errors Among Sicker Adults, 2005

22 23 25 2730

34

0

25

50

75

UK GER NZ AUS CAN US

Percent reporting medical mistake, medication error, or lab error in past two years

Data: Analysis of 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults; Schoen et al. 2005a.


22Patients Reporting Any Error by Numberof Doctors Seen in Past Two Years, Sicker Adults, 2005

Percent


12 14 14 12 1522

28 3135 37 40

48

0

25

50

75

UK GER NZ AUS CAN US

1 doctor 4 or more doctors


23

2340

8093 87 91

6 6

10

3128

33

102

0

25

50

75

100

CAN US GER AUS NET NZ UK

Y es, using a manual systemY es, using a computerized system

Doctors Reporting Routinely Receiving Alerts about Potential Problem with Drug Dose/Interaction



24Incorrect Lab/Diagnostic Test orDelay in Receiving Abnormal Test Results, Sicker Adults,

2005

9 11 14 1418

23

0

25

50

75

GER UK NZ AUS CAN US


Percent reporting either lab test error in past two years

25Doctors Reporting Routinely Receiving Alerts to Provide

Patients with Test Results, 2006


6 15

51 5332

52

30

17

16

98

403714

0

25

50

75

100

NET CAN US NZ UK GER AUS

Yes, using a manual systemYes, using a computerized system


26Medical Mistake or Medication ErrorOccurred Outside the Hospital, Sicker Adults, 2005

60 63 63 63 6777

0

50

100

CAN AUS GER NZ UK US

Percent saying error occurred outside the hospital


Base: Experienced medical mistake or medication error


27Developed Infection While in the Hospital, Sicker Adults, 2005

37 7 8 10 10

0

25

50

GER CAN US AUS NZ UK


Base: Hospitalized in past 2 years

Percent

28Deaths Due to Surgical or Medical Mishaps per 100,000 Population in 2004

0.7

0.6

0.5 0.5 0.5

0.4 0.4

0.2 0.2

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

United

States

Germany Canada France United

K ingdom

Australia OECD

Median

J apan Netherlands

a2003b2002

ab

b

bb

b

J. Cylus and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2006 (New York: The Commonwealth Fund, Apr. 2007).

29

Quality: Coordinated Care

30Length of Time with Regular Doctor, Sicker Adults, 2005

Percent: AUS CAN GER NZ UK US

Has regular doctor 92 92 97 94 96 84

Less than 2 years 16 12 6 19 14 17

5 years or more 56 60 76 57 66 42

No regular doctor 8 8 3 6 4 16


31Patient Report of Care Coordination, Sicker Adults, 2005

Percent saying in the past 2 years:


Test results or records not available at time of appointment

12 19 11 16 16 23

Duplicate tests: doctor ordered test that had already been done

11 10 20 9 6 18

Percent who experienced either coordination problem

19 24 26 21 19 33


32

Doctors’ Reports of Care Coordination Problems, 2006

Percent saying their patients “often/ sometimes” experienced:


Records or clinical information not available at time of appointment

28 42 11 16 28 36 40

Tests/procedures repeated because findings unavailable

10 20 5 7 14 27 16

Problems because care was not well coordinated across sites/providers

39 46 22 47 49 65 37


33Coordination Problems by Number of Doctors, Sicker

Adults, 2005Percent


15 1623

711

2227

31 30 3026

43

0

25

50

75


1 doctor 4 or more doctors

* Either records/results did not reach doctors office in timefor appointment OR doctors ordered a duplicate medical test

34Receive Information Back after Referrals of Patients

to Other Doctors/Specialists, 2006

Percent of physicians reporting receive for “almost all” referrals (80% or more)

827675

686261

37

0

25

50

75

100

US NET CAN GER UK AUS NZ


35Deficiencies in Transition PlanningWhen Discharged from the Hospital, Sicker Adults, 2005

Percent who reportedwhen discharged:


Did NOT receive instructions about symptoms to watch and when to seek further care

18 17 23 14 26 11

Did NOT know who to contact with questions about condition or treatment

9 12 12 9 12 8

Hospital did NOT make arrangements for follow-up visits

23 30 50 23 19 27

% any of the above 36 41 60 33 37 33



36Doctors’ Reports of Length of Time to Receive a Full

Hospital Discharge Report, 2006

1723

28

4852 53

58

0

25

50

75

100

NZ US AUS NET UK GER CAN

Percent of physicians saying 15 days or more or rarely receive a full report


37

86

7773 72

69 67

0

50

100

GER AUS UK CAN NZ US

Percent of hospitalized patients with new prescription who reported prior medications were reviewed at discharge

Medications Reviewed When Discharged from the Hospital,Among Sicker Adults in Six Countries, 2005

Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).


38

Quality: Patient-Centered Care

39

Patient Reports about Doctor-Patient Relationship, 2004

Percent saying doctor: AUS CAN NZ UK US

Always listens carefully 71 66 74 68 58

Always explains things so you can understand

73 70 73 69 58

Always spends enough time with you

63 55 66 58 44


40Missed Opportunities toEngage Patient in Care, Sicker Adults, 2005

Percent saying doctor:* AUS CAN GER NZ UK US

Does NOT give you clear instructions

19 24 18 15 27 27

Does NOT make goals and plans clear

19 19 21 16 27 25

Does NOT tell you about treatment choices or ask your opinions

45 38 39 38 51 49

* Doctor only sometimes, rarely, or never.


Base: Adults with chronic disease

41Were Risks Explained Before a Hospital Procedure

in an Understandable Way?, Sicker Adults, 2005

Percent who said risks were NOT explained

2116 17 18

1412

0

25

50

GER US UK NZ AUS CAN



42Did Doctors and Nurses Involve You asMuch as You Wanted in Care Decisions? , Sicker Adults, 2005

1619 21 22 22

27

0

25

50

US NZ GER AUS UK CAN



Percent NOT involved as much as would like

43Top Two Most Important Types ofInformation About Surgeons, Sicker Adults, 2005

Percent: AUS CAN GER NZ UK US

Experience with specific conditions

68 59 59 67 59 55

Outcomes of specific surgery or treatment

52 53 47 49 43 55

Patient satisfaction ratings

36 36 33 36 43 41

Training 23 32 36 26 19 34


Base: Had major surgery in the past 2 years

44Missed Opportunity to Engage Patientson Choice and Quality, Sicker Adults, 2005

Percent who said: AUS CAN GER NZ UK US

Did NOT have a choice of surgeons

34 36 23 38 44 23

Did NOT have any quality information about the surgeon

63 48 53 54 65 53


Base: Had major surgery in the past 2 years

45

Quality: Quality Improvement Efforts

46Physician Participation in Activities to Improve Quality

of Care, 2006


Percent of physicians in past 2 years who:

Participated in collaborative QI efforts

58 48 76 70 78 58 49

Conducted clinical audit of patient care

76 45 69 46 82 96 70

Percent reporting their practice:

Sets formal targets for clinical performance

26 27 70 35 41 70 50


47

Physicians’ Reports on Availability of Data on Clinical Outcomes or Performance, 2006

Percent of physicians reporting yes:


Patients’ clinical outcomes

36 24 71 37 54 78 43

Surveys of patient satisfaction and experiences

29 11 27 16 33 89 48


48Primary Care Doctor’s Practice Has Documented Process for Follow-Up/Analysis of Adverse Events,

2006


Yes, for all adverse events

35 20 32 7 41 79 37

Yes, for adverse drug reactions only

21 19 26 10 19 8 19

Do Not have a process

44 58 42 82 40 13 41


49Primary Care Doctors’ Reports of Financial Incentives For Quality of Care Improvement, 2006

Percent of physicians who receive financial incentive:*


Achieving certain clinical care targets

33 10 9 6 43 92 23

High ratings for patient satisfaction

5 - 5 1 2 52 20

Managing patients with chronic disease/ complex needs

62 37 24 47 68 79 8

Enhanced preventive care activities

53 13 28 18 42 72 12

Participating in quality improvement activities

35 7 21 28 47 82 19

*Receive or have the potential to receive


50

95

7972

58

43 41

30

0

25

50

75

100

UK NZ AUS NET GER CAN US

Percent of physicians reporting any financial incentive*

Primary Care Doctors’ Reports of Any Financial Incentives for Quality of Care Improvement, 2006

*Receive of have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activities


51

Access to Care

52Cost-Related Access Problems, Sicker Adults, 2005

Percent in past year due to cost:


Did not fill prescription or skipped doses

22 20 14 19 8 40

Had a medical problem but did not visit doctor

18 7 15 29 4 34

Skipped test, treatment or follow-up

20 12 14 21 5 33

Percent who said yes to at leastone of the above

34 26 28 38 13 51


53Americans Spend More Out-of-Pocket on Health Care Expenses, 2004

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$0 $100 $200 $300 $400 $500 $600 $700 $800 $900

a2003b2003 Total Health Care Spending, 2002 OOP Spending

ba

United States

OECD Median

New Zealand

Netherlands

Japan

GermanyFrance CanadaAustralia

a

Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

Total health care spending per capita

Out-of-pocket spending per capita

54Out-of-Pocket Medical Costs in the Past Year, Sicker Adults, 2005

Percent with out of pocket expenses for medical bills more than $1000, US In the past year


48 8

14 14

34

0

25

50

75

UK NZ GER AUS CAN US

55


713 15

23 24 27

51

0

25

50

75

NET UK AUS GER CAN NZ US


Physicians’ Perception of Patient Access: Patients Often Have Difficulty Paying for Medications,

2006

56

58 5649 45

3023

2313

1716

17

13

0

50

100

NZ GER AUS UK US CAN

Next day

Same day

Percent of adults

310 13 15

23

36

NZ AUS GER UK US CAN

Waiting Time to See Doctor When Sick or Need Medical Attention, Sicker Adults in Six Countries, 2005

Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).

Last time you were sick or needed medical attention,how quickly could you get an appointment to see a doctor?


Percent of adults reporting 6 days or more

57Difficulty Getting Care on Nights, Weekends, Holidays WithoutGoing to the ER, Among Sicker Adults in Six Countries, 2005

2528

38

5459 61

0

50

100

GER NZ UK CAN AUS US

Percent of adults who sought care reporting “very” or “somewhat” difficult

GER=Germany; NZ=New Zealand; UK=United Kingdom; CAN=Canada; AUS=Australia; US=United States.Data: 2005 Commonwealth Fund International Health Policy Survey of Sicker Adults (Schoen et al. 2005a).


58Doctor’s Reports on Whether Practice Has Arrangement for Patients’

After-Hours Care to See Nurse/Doctor, 2006

9590 87

8176

4740

0

25

50

75

100

NET NZ UK AUS GER CAN US

Percent of physicians reporting “yes”


59

Help Line Use, Sicker Adults, 2005

Percent who reported: AUS CAN GER NZ UK US

Called help line for medical advice in the past 2 years

1028

5 10 32 13

Advice was definitely or somewhat helpful (Base: used help line)

90 86 75 86 88 80


60Waited More than Four Weeksto See a Specialist Doctor, Sicker Adults, 2005

22 23

4046

57 60

0

25

50

75

100

GER US NZ AUS CAN UK

Percent


Base: Saw or needed to see a specialist

61

Patients Often Experience Long Waits for Diagnostic Tests, 2006

6 8 9

26 28

5157

0

25

50

75

AUS GER US NET NZ CAN UK

Physicians’ Perception of Patient Access:



62Waiting Time for Elective or Non-Emergency Surgery, Sicker Adults, 2005

Percent experienced wait time of 4 month or more


Base: Needed non-emergency or elective surgery

6 8

19 20

33

41

0

25

50

75

GER US AUS NZ CAN UK

63

Efficiency

64

69

1215

21

26

0

25

50

GER NZ UK AUS CAN US

Went to ER for Condition That Could Have Been Treatedby Regular Doctor, Among Sicker Adults, 2005

Percent of adults who went to ER in past two years for condition that could have been treatedby regular doctor if available



65Readmitted to a Hospital or Went to ER asa Result of Complications After Discharge,

Sicker Adults, 2005

14171510

1620

0

25

50

75



Percent readmitted or ER visit due to complications


66

69 10 11

1820

0

25

50

UK NZ CAN AUS US GER

Duplicate Medical Tests, Sicker Adults, 2005

Percent reporting that doctor ordered test that had already been done in past two years



67

11 12

16 1619

23

0

25

50

GER AUS NZ UK CAN US

Percent reporting test results/records not available at time of appointment in past two years

Test Results or Medical Record Not Available atTime of Appointment, Among Sicker Adults, 2005



68Primary Care Doctors Use of Electronic Patient Medical Records, 2006

9892 89

79

42

2823

0

25

50

75

100

NET NZ UK AUS GER US CAN



69Primary Care Doctors’ Access to Electronic Medical Record System Access, 2006

Percent with capability to:


Share records electronically with clinicians outside your practice

10 6 9 45 17 15 12

Access records from outside the office

19 11 16 32 36 22 22

Provide patients with easy access to their records

36 6 15 8 32 50 10


70

Practice Use of Electronic Technology, 2006

Percent reporting routine use of:


Electronic ordering of tests

65 8 27 5 62 20 22

Electronic prescribing of medication

81 11 59 85 78 55 20

Electronic access to patients’ test results

76 27 34 78 90 84 48

Electronic access to patients’ hospital records

12 15 7 11 44 19 40


71Primary Care Practices with Advanced Information Capacity, 2006

*Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care.

Percent reporting 7 or more out of 14 functions*


8783

72

59

32

19

8

0

25

50

75

100

NZ UK AUS NET GER US CAN

72Public Investment per Capita in Health Information Technology (HIT) as of 2005

$192.79

$31.85$21.20

$4.93 $0.43$0

$50

$100

$150

$200

United K ingdom Canada Germany Australia United States

Source: The Commonwealth Fund, calculated from Anderson, G.F., Frogner, B., Johns, R.A., and Reinhardt, U. “Health Care Spending and Use of Information Technology in OECD Countries,” Health Affairs, 2006.

73

International Comparison of Spending on Health, 1980–2004

Data: OECD Health Data 2005 and 2006.

Average spending on healthper capita ($US PPP)

Total expenditures on healthas percent of GDP

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006

EFFICIENCY

73

0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

0

2

4

6

8

10

12

14

16

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

74Health Care Spending per Capita in 2004Adjusted for Differences in Cost of Living

$2,083$2,249

$2,546$2,571

$2,876$3,005$3,041$3,159$3,165

$6,102

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

United

States

Canada France Netherlands Germany Australia OECD

Median

United

K ingdom

J apan New

Zealand

aa

a2003

a


75Average Annual Growth Rate of Real Health Care Spending per Capita, 1994–2004

2.4%

2.8%2.8%

3.2%3.3%

3.4%

3.7%3.8%

4.2%4.3%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

Australia United

K ingdom

OECD

Median

United

States

New

Zealand

Netherlands France J apan Canada Germany

A1994–2003

a a a


76Percentage of Gross Domestic Product Spent on Health Care in 2004

8.0%8.3%8.4%8.7%

9.2%9.2%9.9%10.5%10.9%

16.0%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

United

States

Germany France Canada Netherlands Australia OECD

Median

New

Zealand

United

K ingdom

J apana a

a2003b2004c2004 number for US from C. Smith et al., “National Health Spending in 2004: Recent Slowdown Led by Prescription Drug Spending,” Health Affairs, Jan./Feb. 2006 25(1):186–96.

a b b b bbc


77Health Care Expenditure per Capitaby Source of Funding in 2004

Adjusted for Differences in Cost of Living

$803

$472 $313$582 $396 $389

$359

$2,572

$483 $342 $354

$1,611$1,832$1,917$2,176$1,940$2,350

$1,894$2,475$2,210

$2727

$238

$239$370 $28

$113

$444

$906$148

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

United

States

Canada France Netherlands Germany Australia United

K ingdom

OECD

Median

J apan New

Zealand

Private Spending

Out-of-Pocket Spending

Public Spending

a b

a2003b2002 (Out-of-Pocket)

aa

$6,102

$3,165 $3,158 $3,038 $3,005 $2,876$2,546 $2,461 $2,249

$2,083


78Inpatient Hospital Spending per Capita in 2004Adjusted for Differences in Cost of Living

$879$914$914

$1,015$1,043$1,044$1,069

$1,636

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

$1,800

United

States

France Germany Netherlands Australia OECD

Median

Canada J apana b

a2003b2002

b a


79Hospital Spending per Inpatient Acute Care Day in 2004


$419$549

$793$862

$1,015$1,069

$2,337

$0

$500

$1,000

$1,500

$2,000

$2,500

United

States

France Australia Canada OECD

Median

Germany J apan

a2003b2002

a a ab


80Average Annual Hospital Inpatient Acute Care Days per Capita in 2004

0.7

1.01.01.01.01.1

1.8

2.1

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

1.8

2.0

2.2

J apan Germany United

K ingdom

France Australia OECD

Median

Canada United

Statesa2003

a a


Days

81Number of Acute Care Hospital Beds per 1,000 Population in 2004

2.82.83.0

3.63.63.73.8

6.4

8.4

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

J apan Germany France OECD

Median

United

K ingdom

Australia Canada Netherlands United

Statesa2003

aa a


82Average Length of Stay for Acute Care in 2004

5.55.66.16.66.6

7.3

8.7

20.2

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

20.0

22.0

J apan Germany Canada OECD

Median

United

K ingdom

Australia United

States

France

Da

ys

a2003

aa

a


83

$88

$183

$310$313

$392$396$402$409

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

Canada Netherlands Germany United

States

OECD

Median

J apan Australia France

Long-Term Institutional Care Spendingper Capita in 2004


a

a2003b2002

ba


84Number of Long-Term Care Beds per 1,000 Population over Age 65 in 2004

2126

41

49

62

69

99

0

10

20

30

40

50

60

70

80

90

100

110

Canada France OECD

Median

United

States

Australia J apan United

K ingdomaa

a2003

a a a


85Home Health Care Spending per Capita in 2004Adjusted for Differences in Cost of Living

$10$14

$46

$60

$97

$147

$157

$0

$20

$40

$60

$80

$100

$120

$140

$160

Germany United

States

Netherlands Canada OECD

Median

France J apana

a2003b2002

a b


86Average Annual Growth Rate of Home Health Care Spending per Capita, 1994–2004

32.0%

13.4%

5.5%3.7%

2.1%

-5.0%

-10.0%

-5.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

J apan Germany France Canada United States Netherlands

a1995–2003 b1994–2003 c1994–2002

b ca


87Spending on Physician Services per Capita in 2004Adjusted for Differences in Cost of Living

$307$319$371$436

$482$563

$1,362

$0

$200

$400

$600

$800

$1,000

$1,200

$1,400

United

States

J apan OECD

Median

Australia France Canada Germanya

a2003b2002

ab


88Average Annual Growth Rate of Practicing Physicians per 1,000 Population, 1994–2004

3.1%

1.3% 1.3%1.3%

1.1% 1.1%0.9%

0.6%

0.0%0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

United

Kingdom

United

States

OECD

Median

Germany J apan New

Zealand

Australia France Canada

a1994–2003

a

a


89Number of Practicing Physicians per 1,000 Population in 2004

3.63.4 3.4

3.2

2.62.4

2.32.2

2.12.0

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Netherlands France Germany OECD

Median

Australia United

States

United

K ingdom

New

Zealand

Canada J apana

a2003

a


90Average Annual Number of Physician Visits per Capita in 2004

13.8

6.76.1 6.1 6.0

5.3 5.3

3.93.2

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

J apan France Canada OECD

Median

Australia Netherlands United

K ingdom

United

States

New

Zealand

a

a

aa

a2003

a


91Pharmaceutical Spending per Capita in 2004Adjusted for Differences in Cost of Living

$318

$377$383

$425$438

$559

$599

$752

$0

$100

$200

$300

$400

$500

$600

$700

$800

United

States

France Canada Germany J apan Australia OECD Median Netherlands

a2003b2002

aa b b


92Average Annual Growth Rate of Real Spendingper Capita on Pharmaceuticals, 1994–2004

1.6%

3.7%4.1%4.2%4.2%

5.9%

7.5%7.7%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

Australia United

States

Canada OECD

Median

Netherlands France Germany J apanb a

a1994–2003b1994–2002

b a


93Percentage of Total Health Care Spending on Health Administration and Insurance in 2004

7.6% 7.5%

5.6%

4.4%4.1%

3.0% 3.0%

2.3%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

United

States

France Germany Netherlands Canada Australia OECD Median J apan

a2003b2002

b aa


94

Equity

95Health Status by Income, 2004

Percent: AUS CAN NZ UK US

Fair/Poor Health:

Below Average 22* 19* 22* 24* 30*

Above Average 7 7 6 8 6

Any of 6 Chronic Illnesses:^

Below Average 63* 58* 62* 64* 62*

Above Average 41 42 40 39 42

^ Chronic illnesses include: hypertension, heart disease, diabetes, arthritis, lung problems, and depression.* Significant difference between below and above average income groups within country at p<.05.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

96Insurance and Cost-Sharing Policiesin Four Countries with Universal Public Coverage

AUS CAN NZ UK

Private insurancefor services covered by public

Permitted only for hospital services

Prohibited for core services in most provinces

Permitted Permitted

Percent with private coverage 49%

79.9%

(to cover benefits excluded from ‘free-of charge’ public

plan)

33% 12%

Public Plan Patient Cost-SharingVariable depending on

service type and providerNone for core services

Copayments for many services

None for basic services (except Rx and optical)

Prescription Drugs CoveredPublicly covered for social

assistance beneficiaries and in most provinces for seniors

Covered Covered

Source: B. K. Frogner and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2005(New York: The Commonwealth Fund, Apr. 2006).

97Private Insurance in Four Countrieswith Universal Coverage, 2004

3036

1911

63

81

57

35

0

25

50

75

100

Australia Canada New Zealand United

K ingdom

Below average income Above average income

Percent who have private insurance in addition to public

**

*

* Significant difference between below and above average income groups within country at p<.05.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

*

98Spent More than US$1,000 Out-of-Pocketfor Medical Care in Past Year, by Income, 2004

8 104 2

2421

126 5

32

0

25

50

75

Australia Canada New

Zealand

United

K ingdom

United

States


**

*

Percent


99

3526

44

12

57

25

6

29

12

24

0

25

50

75


Zealand

United

K ingdom

United

States


Cost-Related Access Problems, by Income, 2004

Percent reporting any of three access problems because of costs^

^ Access problems include: Had a medical problem but did not visit a doctor; skipped a medical test, treatment, or follow-up recommended by a doctor; or did not fill a prescription because of cost.* Significant difference between below and above average income groups within country at p<.05.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

*

*

*

*

*

100

73

14

24 25

5 3

12 13

24

0

25

50

75

Australia New

Zealand

United

K ingdom

United

States

Canada


Access to Doctor When Sick orNeed Medical Attention, by Income, 2004

Percent waited six days or more for appointment when sick


*

101

6 612

19 21

5 6 9 11 14

0

25

50

75

United

K ingdom

New

Zealand

Australia United

States

Canada


ER Visit for Condition a Primary CareDoctor Could Have Treated if Available, by Income, 2004

Percent

Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

102Difficulty Getting Care on Nights, Weekends, Holidays Without Going to ER, 2004

Percent saying “very” or “somewhat difficult”

5360

3242

70

56 59

3244

60

0

25

50

75

100


Zealand

United

K ingdom

United

States


•Significant difference between below and above average income groups within country at p<.05.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

*

103Care Coordination, by Income, 2004

26 29 27 26

3628 25 23 24 27

0

25

50

75


Zealand

United

K ingdom

United

States


^ Coordination problems include: Test results or medical records not available at time of appointment, received conflicting information from different doctors, or doctor ordered duplicate medical test.* Significant difference between below and above average income groups within country at p<.05.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

Percent reporting any of three care coordination problems^

Base: Have seen a doctor in past two years

*

104

9 11 9 12

22

7 84

117

0

25

50

75


Zealand

United

K ingdom

United

States


Percent of adults


Rated Doctor Fair or Poor, by Income, 2004

*

*

105Had Blood Pressure Check in Past Year,by Income, 2004

85

72777983

91

6170

8279

0

25

50

75

100


Zealand

United

K ingdom

United

States

Below average income Above average incomePercent of adults

**

*


106Had Pap Test in Past Three Years,by Income, 2004

8673716975

84 84 84 8293

0

25

50

75

100


Zealand

United

K ingdom

United

States


Base: Women ages 25–64


Percent

* * * **

107Under 65: ER Use—Comparisons with U.S. Insured and Uninsured, 2004

26 29 30

3934

27

46

0

25

50

75

NZ AUS UK CAN Total Insured Uninsured

Percent under 65 with ER visit in past two years

United States

* Significantly different from U.S. insured at p<.05.Uninsured = uninsured at time of survey or any time during the year.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

**

108Under 65: Coordination Problem— Comparisons with U.S. Insured and Uninsured, 2004

26 26 2630 33

28

44

0

25

50

75

CAN NZ UK AUS Total Insured Uninsured

Percent under 65 with at least one of three coordination problems^

United States

^ Coordination problems include: Test results or medical records not available at time of appointment, received conflicting information from different doctors, or doctor ordered duplicate medical test.* Significantly different from U.S. insured at p<.05.Uninsured = uninsured at time of survey or any time during the year.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

*

109Under 65: Lab Test Errors—Comparisons with U.S. Insured and Uninsured, 2004

9 9 12 15 16 13

27

0

25

50

75

AUS UK CAN NZ Total Insured Uninsured

Percent given wrong result or delay in receiving abnormal test result

United States

Base: Under 65 who have had lab tests in past two years

**

*

* Significantly different from U.S. insured at p<.05.Uninsured = uninsured at time of survey or any time during the year.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).

110

Long, Healthy, and Productive Lives

111Mortality Amenable to Health Care

97 97 99106 107 109 109

115 115

129 130 132

7584 88 88 88

8192

0

50

100

150

Fran

ceJa

pan

Spain

Swed

en Italy

Aus

tral

iaC

anad

aN

orw

ayN

ethe

rland

sG

reec

eG

erm

any

Aus

tria

New

Zea

land

Den

mar

k

Uni

ted

State

sFi

nland

Irela

nd

Uni

ted

Kin

gdom

Portu

gal

Deaths per 100,000 population*

110

8490

103

119

134

U.S.avg

10th 25th Med-ian

75th 90th

Percentiles

Internationalvariation, 1998

State variation,2002

* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.See Technical Appendix for list of conditions considered amenable to health care in the analysis.Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003);State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology.

Mortality from causes considered amenable to health care is deaths before age 75 that are potentially preventable with timely and appropriate medical care


112

7.0

5.3

6.0

7.1

8.1

9.1

U.S.avg

10th 25th Med-ian

75th 90th

Infant Mortality Rate, 2002

* 2001.Data: International estimates—OECD Health Data 2005;State estimates—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2005a).

2.2

3.0 3.03.3 3.5

4.1 4.1 4.1 4.2 4.2 4.4 4.4 4.5 4.55.0 5.0 5.0 5.0 5.1 5.2 5.4 5.6

7.0

0

5

10

Icel

and

Japa

nFi

nlan

dSw

eden

Norw

aySpa

inFr

ance

Austri

a

Czech

Rep

ublic

Ger

man

yBel

gium

Denm

ark

Italy

Switz

erla

ndNet

herla

nds

Austra

liaPor

tuga

lIre

land

Gre

ece

Unite

d Kin

gdom

Canad

a

New Z

eala

nd*

Unite

d Sta

tes

Infant deaths per 1,000 live births

Percentiles

International variation State variation


113Healthy Life Expectancy at Age 60, 2002

2220 20 20 20 20 19 19 19 19 19 19 19 19 18 18 18 18 18 18 18 17 1718 17 17 16 17 17 16 16 16 16 16 16

1816 16 16 16 16 15 15 15 15

14

0

10

20

30

Japan

Switzer

land

France

Spain

Sweden

Austra

lia

Italy

Austri

a

Canad

a

Belgiu

m

Germ

any

Norway

Icel

and

Finla

nd

Nether

lands

New Z

eala

nd

Greec

e

Unite

d Kin

gdom

Unite

d Sta

tes

Portu

gal

Irela

nd

Denm

ark

Czech

Rep

ublic

Women Men

Years

Data: The World Health Report 2003 (WHO 2003, Annex Table 4).

Developed by the World Health Organization, healthy life expectancy is based on life expectancy adjusted for time spent in poor health due to disease and/or injury


114Acute Myocardial Infarction Deaths per 100,000 Population

58.8

53.0

48.3 48.1 47.9 46.343.9

25.7

19.9

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

United

K ingdom

Australia Germany OECD

Median

United

States

Canada Netherlands France J apan

a2003b2002

b b a

b

b

b

J. Cylus and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2006(New York: The Commonwealth Fund, Apr. 2007).

115Bronchitis, Asthma, and Emphysema Deaths per 100,000 Population

6.46.0

5.04.7

4.44.0

3.73.4

3.0

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

J apan United

States

Australia Netherlands OECD

Median

United

K ingdom

Germany France Canada

a2003b2002

b

b a

bb

b


116Potential Years of Life Lost Due to Malignant Neoplasms per 100,000 Population in 2004

1059

952 912 895 885 867 847800

725

0

200

400

600

800

1000

1200

France Netherlands United

K ingdom

United

States

OECD

Median

Germany Canada Australia J apan

a2003b2002

abb

bb

b


117Potential Years of Life Lost Due to Diseases of the Circulatory System per 100,000 Population in 2004

825

635

557 550

472 464 437419 411

0

100

200

300

400

500

600

700

800

900

United

States

United

K ingdom

Germany OECD

Median

Netherlands J apan Canada Australia Francea

a2003b2002

bbb

bb


118Potential Years of Life Lost Due to Diabetes per 100,000 Population in 2004

101

59

4239 39 39

30 2925

0

20

40

60

80

100

120

United

States

Canada Netherlands Australia Germany OECD

Median

United

K ingdom

France J apan

a2003b2002

ab

b

bb

b


119Potential Years of Life Lost Due to Diseases of the Respiratory System in 2004

190

172

119114

10594 93 89

80

0

20

40

60

80

100

120

140

160

180

200

United

States

United

K ingdom

J apan OECD

Median

Australia Netherlands Germany Canada France

a2003b2002

a

b b

b bb


120Percentage of Adults Who Reported Being Daily Smokers in 2004

30.0% 29.4%

25.5% 25.0%24.3% 23.0%

22.0%

17.7% 17.0%15.0%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

Netherlands J apan OECD

Median

United

K ingdom

Germany France New

Zealand

Australia United

States

Canada

a2003

a


121Obesity (BMI>30) Prevalence in 2004

30.6%

23.0%22.4%

20.9%

13.0% 12.9%10.9%

9.5%

3.2%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

United

States

United

K ingdom

Canada New

Zealand

OECD

Median

Germany Netherlands France J apana

a

a2003b2002

a

b


122

Health Care System Views

123Views of the Health Care System in Five Nations, 1998 to 2004

Percent saying: AUS CAN NZ UK US

Only Minor Changes Needed

2004 21 21 19 26 16

2001 25 21 18 21 18

199819 20 9 25 17

Rebuild Completely

2004 23 14 19 13 33

2001 19 18 20 18 28

1998 30 23 32 14 33

Source: 2004, 2001 and 1998 Commonwealth Fund International Health Policy Surveys

124Sicker Adults Views of the Health Care Systemin Six Nations, 2005

Percent saying: AUS CAN GER NZ UK US

Only minor changes needed

23 21 16 27 30 23

Fundamental changes needed

48 61 54 52 52 44

Rebuild completely 26 17 31 20 14 30


125Care Experiences Reported by Adultswith Positive or Negative System Views, Sicker Adults,

2005Percent


2016 18

11

36 35

47

24

0

25

50

75 Minor Change Rebuild

Any medical, medication,or lab error

Coordination problems

Access problem

due to cost

Waited 6 days or more for

appointment

126

Physician Views of the Health System, 2006

Percent saying: AUS CAN GER NET NZ UK US

Only Minor Changes Needed

38 23 4 52 34 23 13

Fundamental Changes Needed

56 71 54 42 62 68 69

Rebuild Completely

5 3 42 3 4 9 16


127Physician Dissatisfaction with Medical Practice, 2006

Percent very or somewhat dissatisfied with:


Freedom to make clinical decisions

8 12 74 10 26 24 31

Time to spend per patient

33 36 50 35 33 51 42

Income from medical practice

36 40 53 23 44 18 47

Overall experience with medical practice

14 16 19 9 23 14 23


128

A Six Country Ranking of Healthcare Quality, Access, Efficiency, Equity and Mortality

129

Overall Ranking

AUSTRALIA CANADA GERMANYNEW

ZEALANDUNITED

KINGDOMUNITEDSTATES

OVERALL RANKING (2007) 3.5 5 2 3.5 1 6

Quality Care 4 6 2.5 2.5 1 5

Right Care 5 6 3 4 2 1

Safe Care 4 5 1 3 2 6

Coordinated Care 3 6 4 2 1 5

Patient-Centered Care 3 6 2 1 4 5

Access 3 5 1 2 4 6

Efficiency 4 5 3 2 1 6

Equity 2 5 4 3 1 6

Long, Healthy, and Productive Lives 1 3 2 4.5 4.5 6

Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102

1.0-2.66

2.67-4.33

4.34-6.0

Country Rankings

* 2003 dataSource: Calculated by Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians, and the Commonwealth Fund Commission on a High Performance Health System National Scorecard.

130

A Three Year View of Overall Ranking

1.0-2.66

2.67-4.33

4.34-6.0

Country Rankings

* 2003 dataSource: Calculated by Commonwealth Fund based on the Commonwealth Fund 2004 International Health Policy Survey, the Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults, the 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians; the Commonwealth Fund Commission on a High Performance Health System National Scorecard; K. Davis, C. Schoen, S.C. Schoenbaum, A.J. Audet, M.M. Doty, and K. Tenney, Mirror, Mirror on the Wall: Looking at the Quality of American Health Care through the Patient's Lens (New York: The Commonwealth Fund, Jan. 2004); and K. Davis, C. Schoen, S. C. Schoenbaum, A. J. Audet, M. M. Doty, A. L. Holmgren, and J. L. Kriss, Mirror, Mirror on the Wall: An Update on the Quality of American Health Care Through the Patient's Lens (New York: The Commonwealth Fund, Apr. 2006).

AUSTRALIA CANADA GERMANYNEW

ZEALANDUNITED

KINGDOMUNITEDSTATES

OVERALL RANKING (2007 Edition) 3.5 5 2 3.5 1 6

OVERALL RANKING (2006 Edition) 4 5 1 2 3 6

OVERALL RANKING (2004 Edition) 2 4 n/a 1 3 6

Health Expenditures per Capita, 2004 $2,876* $3,165 $3,005* $2,083 $2,546 $6,102

Documents

1 Health System Performance in Selected Nations: A Chartpack Compiled by Katherine K. Shea, Alyssa L. Holmgren, Robin Osborn, and Cathy Schoen May 2007