THE COMMONWEALTH FUND The Commonwealth Fund 2007 International Health Policy Survey in Seven Countries Cathy Schoen, Robin Osborn, Meghan Bishop, and Sabrina

THE COMMONWEALTH

FUND

The Commonwealth Fund 2007 International Health Policy

Survey in Seven CountriesCathy Schoen, Robin Osborn,

Meghan Bishop, and Sabrina HowThe Commonwealth Fund

November 2007

THE COMMONWEALTH

FUND

2007 International Health Policy Survey

• Telephone survey: representative samples of adults ages 18 and older in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.

• Final samples: 1,009 Australia, 3,003 Canada, 1,407 Germany, 1,557 the Netherlands, 1,000 New Zealand, 1,434 United Kingdom, and 2,500 United States.

• Conducted by Harris Interactive, Inc., and subcontractors,and in the Netherlands by The Center for Quality of Care Research (WOK), Radboud University Nijmegen, from March 6 to May 7, 2007.

• Co-funded by the German Institute for Quality and Efficiencyin Health Care, the Dutch Ministry for Health, and the Health Council of Canada.

• Core topics: Access, Coordination, Patient-Centered Care, Chronic Care, and Safety.

• Medical home: analysis of experiences of adults with and without a primary care “medical home” with specified attributes.

THE COMMONWEALTH

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System Views:Access, Cost, and Waiting Times

THE COMMONWEALTH

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Figure 1. Overall Views of the Health Care Systemin Seven Countries, 2007

Percent reported: AUS CAN GER NETH NZ UK US

Only minor changes needed 24 26 20 42 26 26 16

Fundamental changes needed 55 60 51 49 56 57 48

Rebuild completely 18 12 27 9 17 15 34

Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

THE COMMONWEALTH

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Figure 2. Overall Views of the Health Care Systemin Seven Countries, 2007 and 1998

Percent reporting: AUS CAN GER NETH NZ UK US

Only minor changes needed

2007 24 26 20 42 26 26 161998 19 20 * * 9 25 17

Fundamentalchanges needed

2007 55 60 51 49 56 57 481998 49 56 * * 57 58 46

Rebuild completely

2007 18 12 27 9 17 15 341998 30 23 * * 32 14 33

* Germany and the Netherlands did not participate in the 1998 survey.Sources: 1998 and 2007 Commonwealth Fund International Health Policy Surveys.Data collection: Harris Interactive, Inc.

THE COMMONWEALTH

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Figure 3. Confidence in Health Care System


Percent reporting“very confident”that they will:

AUS CAN GER NETH NZ UK US

Get quality and safe care 34 28 24 59 30 28 35

Receive the most effective drugs 36 32 23 45 20 25 33

Receive the best medical technology

39 28 24 46 25 27 38

THE COMMONWEALTH

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Figure 4. Cost-Related Access Problems

Percent in past year due to cost: AUS CAN GER NETH NZ UK US

Did not fill prescription or skipped doses

13 8 11 2 10 5 23

Had a medical problem but did not visit doctor

13 4 12 1 19 2 25

Skipped test, treatment, or follow-up

17 5 8 2 13 3 23

Percent who said yes to at least one of the above

26 12 21 5 25 8 37


THE COMMONWEALTH

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Figure 5. Out-of-Pocket Medical Costs in the Past Year

131921

129 10

38

512 10

52

410

30

0

25

50

75

No out-of-pocket cost More than US $1,000 AUS CAN GER NETH NZ UK US AUS CAN GER NETH NZ UK US

Percent


THE COMMONWEALTH

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Figure 6. Serious Problems Paying or Unable to Pay Medical Bills in the Past Year

84 4 5

8

1

19

0

25

50


Percent


THE COMMONWEALTH

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Figure 7. Spent Any Time on Paperwork or Disputes Related to Medical Bills or Insurance

Percent

10 12 14

31

13

3

24

0

25

50



THE COMMONWEALTH

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Figure 8. Access to Doctor When Sickor Need Medical Attention

42

10

2230

55

20

49

5 4

41

12

3020

53

0

25

50

75

Same-day appointment Wait of 6 days or more

Percent

AUS CAN GER NETH NZ UK US AUS CAN GER NETH NZ UK US


THE COMMONWEALTH

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Figure 9. E-mail Communication with Doctor and Electronic Access to Medical Records

Base: Have regular doctor/place

Percent: AUS CAN GER NETH NZ UK US

Currently can e-mail doctor 15 9 16 15 22 11 20No e-mail: Would liketo be able to communicate by e-mail 34 40 18 38 40 32 43

Have electronic access to medical records 12 5 18 7 11 9 10

No current access: would like electronic access to medical records

35 43 30 49 44 36 37


THE COMMONWEALTH

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Figure 10. Difficulty Getting Care on Nights, Weekends, Holidays Without Going to the Emergency Room

35 3825

12 2029

38

28

2534

2826

2829

0

25

50

75


Somewhat difficultVery difficult

Percent reported very or somewhat difficult


THE COMMONWEALTH

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Figure 11. Emergency Room Use in the Past Two Years

3339

2118

28 28

36

5 6911

16

8

15

0

25

50


Any visits Visited ER for condition doctor could have treated if availablePercent


THE COMMONWEALTH

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Figure 12. Waited Two or More Hours in Emergency Room Before Being Treated

32 31

9

25

11

46

34

0

25

50

75


PercentBase: Used emergency room at least once


THE COMMONWEALTH

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Figure 13. Waiting Time for Elective or Nonemergency Surgery

Percent of adults who needed elective or nonemergency surgery

55

9

32

14

72

3

47

2

55

4

40

15

62

40

25

50

75

100

Less than 1 Month More than 6 months AUS CAN GER NETH NZ UK US AUS CAN GER NETH NZ UK US


THE COMMONWEALTH

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Figure 14. Doctor-Recommended TreatmentHad Little or No Benefit in Past Two Years

1712

2015

10

20

13

0

25

50


Percent


THE COMMONWEALTH

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Primary Care Doctorand Medical Home

THE COMMONWEALTH

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Creation of “Medical Home”Composite Variable

• Analysis of 2007 Survey used positive responses to four questions to create an indicator of having a source of primary care with key characteristics of a “medical home”

• Medical Home criteria includes:– Adult has regular doctor or place of care– Doctor/staff know important information about patient’s history– Place is easy to contact by phone during regular office hours– Doctor/staff help coordinate care received from other

doctors/sources of care

THE COMMONWEALTH

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80 78 78 74 78 84 80

15 17 18 20 16 12 15

0

25

50

75

100


Somewhat importantVery important

Percent saying very or somewhat important

Figure 15. Adults Across Countries Place High Value on Having a “Medical Home”—Accessible, Personal, Coordinated Care

When you need care, how important is it that you have one practice/clinic wheredoctors and nurses know you, provide and coordinate the care that you need?


THE COMMONWEALTH

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84 92 10089 89 80

6 810

88

378

0

25

50

75

100


Regular place of careRegular doctorPercent

Figure 16. Have a Regular Doctor or Place of Care


THE COMMONWEALTH

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69 6778 71 69 63 62

19 1816 20

151716

0

25

50

75

100


OftenAlways

Figure 17. Does Doctor Know Important Information About Your Medical History?

PercentBase: Have regular doctor/place


THE COMMONWEALTH

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6044

22 27

6244 46

48

2636 35

44

3426

0

25

50

75

100


Somewhat easyVery easy

Figure 18. How Easy Is It to Contact Doctor by Phone During Regular Hours?



THE COMMONWEALTH

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Figure 19. Regular Doctor Coordinates Care Received from Other Doctors/Places

51 47 4531

4938 47

20 22 2120

22

24

19

0

25

50

75

100


OftenAlways



THE COMMONWEALTH

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Figure 20. Adults with a Medical Home

59

48 45 47

61

47 50

0

25

50

75

AUS CAN GER NET NZ UK US

Note: Medical home includes having a regular provider that knows you,is easy to contact, and coordinates your care.Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

Percent

THE COMMONWEALTH

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Coordination of Care

THE COMMONWEALTH

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Figure 21. Care Coordination

Percent reported inpast two years: AUS CAN GER NETH NZ UK US

Test results or records not available at time of appointment

11 11 8 7 9 10 15

Duplicate tests:doctor ordered test that had already been done

10 5 15 4 6 5 14

Percent with either coordination problem 18 15 19 9 12 13 23


THE COMMONWEALTH

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Figure 22. Coordination Problems: Medical Records Not Available During Visit or Duplicative Tests, by Medical Home

11 1016

8 8 7

16

29

1918

11

2319

27

0

25

50


Has medical home No medical home

Percent with coordination problems


THE COMMONWEALTH

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Figure 23. Saw Two or More Specialists in the Past Year

2920

44

2520 19

27

0

25

50

75


Percent


THE COMMONWEALTH

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Figure 24. Specialist Care Coordination

Percent who reported regular doctor: AUS CAN GER NETH NZ UK US

Helped you decide who to see 63 63 57 35 55 45 63

Provided specialist with information about your condition or problem

81 76 57 65 73 70 72

Base: Saw a specialist in the past year


THE COMMONWEALTH

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Figure 25. Regular Doctor Helped You Decide on Specialist, by Medical Home

67 69 65

43

5851

70

55

39

51

29

495657

0

25

50

75

100

AUS CAN GER NE NZ UK US

Has medical home No medical homePercent


THE COMMONWEALTH

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Figure 26. After Emergency Room Use, Did Regular Doctor Seem Informed About Care Received? by Medical Home

70 6964 67 69 68

73

58

4346

6655

4442

0

25

50

75

100



Note: Medical home includes having a regular provider that knows you, is easy to contact,and coordinates your care. Average for all respondents: AUS=57%, CAN=57%, GER=60%, NETH=66%, NZ=60%, UK=54%, US=66%.Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

Percent “yes”

THE COMMONWEALTH

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Patient-Centered Care

THE COMMONWEALTH

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Figure 27. Doctor-Patient Communication

Percent reported doctor: AUS CAN GER NETH NZ UK US

Always knows important information about your medical history

69 67 78 71 69 63 62

Always explains things so you can understand 79 75 71 71 80 71 70

Always spends enough time with you 73 59 70 71 69 59 56

Always tells you about your treatment options and involves you in decisions about your treatment

66 62 62 60 67 54 61


THE COMMONWEALTH

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Figure 28. Doctor Always Explains Things, Spends Enough Timewith You, and Involves You in Decisions, by Medical Home

83 79 78 78 8375 77

4547515857

5156

0

25

50

75

100



Average percent of adults with a regular doctor or place of care reporting “always” across three indicators of doctor-patient communication


THE COMMONWEALTH

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Figure 29. Quality of Care from Doctor, by Medical Home

87 88

65

89 8682

70

514959

4740

5760

0

25

50

75

100



Percent rated care received “excellent” or “very good”


THE COMMONWEALTH

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Care for Chronic Conditions

THE COMMONWEALTH

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Figure 30. Demographics: Adults withTwo or More Chronic Conditions

3026

21 19 19 20

30

0

25

50


Note: Chronic conditions include hypertension or high blood pressure,heart disease, diabetes, arthritis, lung problems, depression, or cancer.Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

Percent

THE COMMONWEALTH

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Figure 31. Care Management and Coordinationfor Chronic Conditions

Adults with a chronic condition reported: AUS CAN GER NETH NZ UK US

Doctor gives you awritten plan for managing care at home

40 33 22 31 35 30 51

Receive reminder for preventive/follow-up care 44 40 57 58 48 58 70

Often/sometimes receive conflicting information from different health professionals

14 16 19 13 19 18 22


THE COMMONWEALTH

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Figure 32. Doctor Gives You Written Plan forManaging Care at Home, by Medical Home

4538

24

36 3934

5547

253027

1928

32

0

25

50

75


Has medical home No medical homePercent with care planBase: Adults with a chronic condition


THE COMMONWEALTH

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Figure 33. Receive Reminder for Preventive/Follow-Up Care, by Medical Home

50 49

67 6351

6476

6350

4454

48

2935

0

25

50

75

100


Has medical home No medical homePercent with reminderBase: Adults with a chronic condition


THE COMMONWEALTH

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Figure 34. Receive Conflicting Information, by Medical Home

11 1114

7

15 13 15

2924

27

1824

2018

0

25

50



Percent often/sometimes received conflicting informationBase: Adults with a chronic condition


THE COMMONWEALTH

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Safety: Medication, Medical,and Diagnostic Test Errors

THE COMMONWEALTH

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Figure 35. Medical, Medication, and Lab Errors

Percent reported in past two years: AUS CAN GER NETH NZ UK US

Experienced medical or medication error 15 10 9 9 11 9 13

Experienced lab or diagnostic test error 11 12 4 8 9 10 14

Experienced any medical, medication, or lab error 20 17 12 14 16 13 20


THE COMMONWEALTH

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15 137 9

139

17

30

16

27

3429

3327

0

25

50


One doctor Three doctors or more

Figure 36. Any Error, by Number of Doctors Seen

Percent any error

Note: Errors include medical mistake, wrong dose/medication, or lab test error.Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

THE COMMONWEALTH

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2017

12 14 1613

20

28

16

2522 24

3226

0

25

50


All adults 2 or more chronic conditions

Figure 37. Any Error in Past Two Years

Percent any error

Note: Errors include medical mistake, wrong dose/medication, or lab test error.Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

THE COMMONWEALTH

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Figure 38. Chronically Ill: Any Error, by Medical Home

Percent any error

18 1711

17 1511

21

29

1922

3026

3430

0

25

50



Base: Has a chronic condition

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care. Errors include medical mistake, wrong dose/medication or lab test error.Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

THE COMMONWEALTH

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Figure 39. Views of the Health System inSeven Countries, by Medical Home

1610

23

7

1711

27

15

31

11

18 20

40

21

0

25

50



Note: Medical home includes having a regular provider that knows you,is easy to contact, and coordinates your care. Source: 2007 Commonwealth Fund International Health Policy Survey.Data collection: Harris Interactive, Inc.

Percent reported health system needs to be completely rebuilt

THE COMMONWEALTH

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Summary of Findings

• Country patterns reflect underlying insurance design and strategic policy choices– Universal coverage and benefit design matters– The U.S. stands out for financial barriers that undermine care and

often for symptoms of inefficiency• Experiences in all countries indicate the need for more integrated,

patient-centered care “systems”• In each country, having a “Medical Home” that is accessible and

coordinates care improves patient experiences– Patient safety– Coordination: with specialists/across sites of care; duplication and

delays– Patient-centeredness and satisfaction– Managing chronically ill patients

THE COMMONWEALTH

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Conclusions

• No country systematically leads in performance

• Variations in health system performance offer opportunities for cross-national learning

• Three major challenges:- Better coordination of care- New approaches to managing patients with complex

chronic illnesses- Primary care redesign and workforce strategy

• Amenable to policy action and changes in practice and essential to achieving a high performance health care system

THE COMMONWEALTH

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Acknowledgments

• C. Schoen, R. Osborn, M. Doty, M. Bishop, J. Peugh,N. Murukutla, “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007,” Health Affairs Web Exclusive (Oct. 31, 2007).

With appreciation to:

• Develop and conduct survey: Harris Interactive, Inc.

• Conduct survey in the Netherlands: The Center for Quality of Care Research (WOK), Radboud University Nijmegen

• Co-funders: The German Institute for Quality and Efficiencyin Health Care, the Dutch Ministry for Health, and the Health Council of Canada

Documents

THE COMMONWEALTH FUND The Commonwealth Fund 2007 International Health Policy Survey in Seven Countries Cathy Schoen, Robin Osborn, Meghan Bishop, and Sabrina