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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, 2013
AUS 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
46
1013 13
15 1618
21 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
Uninsured
Insured 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
6 811 12
19 20 2125
2932 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
GE
R NZ
NE
TH
AU
SS
WE
FR
NO
R
UK
US
CA
N
0
25
50
75
100
76 7263
58 58 5752 52 48
41
Access to Doctor or Nurse When Sick or Needed Care
Percent
NZ
AU
SN
ETH
GE
R FR UK
SW
E
US
NO
R
CA
N
514 14 15 16 16
22 26 2833
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
NO
RG
ER
NE
TH NZ
SW
IZA
US
US
CA
N FRS
WE
0
20
40
60
80
100
6958 56 56 54
49 4639 38 36 35
Access to After-Hours Care
Percent
95 9590 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 2427 28 28 28
31 32
39 41
48
Used the Emergency Department in Past Two Years
Percent
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
US Uninsured
1515
SW
IZ UK
US
NE
THG
ER NZ
SW
EA
US
FRN
OR
CA
N
0
25
50
75
100
80 80 76 75 72
5954 51 51
4639
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
SW
E
UK NZ
NO
RC
AN
AU
SG
ER
NE
TH FRS
WIZ US
0
25
50
75
4 4 7 815 16 17 19
23 2532
Percent
UK
AU
SN
OR
SW
E
NZ
FRC
AN
SW
IZN
ETH
GE
R
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
1919
Overall Views of Health Care System, 2013
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
US
FR
CAN
GER
SWE
NOR
NZ
AUS
NETH
SWIZ
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
2020
Insights 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.
