THE COMMONWEALTH FUND The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries Cathy Schoen and Robin Osborn The Commonwealth

THE COMMONWEALTH

FUND

The Commonwealth Fund

2010 International Health Policy Survey

in Eleven Countries

Cathy Schoen and Robin Osborn

The Commonwealth Fund

November 2010

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2010 Commonwealth Fund International Health Policy Survey• Telephone survey, conducted from March to June 2010, of

adults ages 18 and older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States.

• Final samples: 3,552 Australia, 3,302 Canada, 1,402 France, 1,005 Germany, 1,001 Netherlands, 1,000 New Zealand, 1,058 Norway, 2,100 Sweden, 1,306 Switzerland, 1,511 United Kingdom, and 2,501 United States.

• Conducted by Harris Interactive subcontractors, and Dutch Scientific Institute for Quality of Healthcare, Haute Authorité de Santé (HAS), Swedish Ministry of Health, Swiss Federal Office of Public Health, and Norwegian Knowledge for the Health Services.

• Core topics: Affordability, access, insurance complexity, equity, and system views.

• Examined differences between above- and below-average (median) income respondents, controlling for age and health status.

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International Comparison of Spending on Health, 1980–2008

0

1000

2000

3000

4000

5000

6000

7000

8000

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

United StatesNorwaySwitzerlandCanadaNetherlandsGermanyFranceDenmarkAustraliaSwedenUnited KingdomNew Zealand

Average spending on healthper capita ($US PPP)

0

2

4

6

8

10

12

14

16

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

United StatesFranceSwitzerlandGermanyCanadaNetherlandsNew ZealandDenmarkSwedenUnited KingdomNorwayAustralia

Total expenditures on healthas percent of GDP

Source: OECD Health Data 2010 (June 2010).

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Confidence, Affordability, and Access

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in the Past Year

Percent AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Did not fill prescription or skipped doses

12 10 7 6 3 7 6 7 4 2 21

Had a medical problem but did not visit doctor

13 4 6 16 2 9 6 5 6 2 22

Skipped test, treatment, or follow-up

14 5 6 10 3 8 5 4 4 3 22

Yes to at least one of the above

22 15 13 25 6 14 11 10 10 5 33

Source: 2010 Commonwealth Fund International Health Policy Survey in Eleven Countries.

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6

35

5147

41 39

61

33

50

20

76

31

0

25

50

75

100

AU

S

CA

N

FR

GE

RN

ETH N

Z

NO

R

SW

E

SW

IZ UK

US

Out-of-Pocket Medical Costs in the Past Year, in U.S. Dollars

Percent

2112

48 9 7

16

2

25

1

35

AU

S

CA

N

FR

GE

R

NE

T

NZ

NO

R

SW

E

SW

IZ UK

US

$200 or less $1,000 or more


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86

9

3 46 5 5 6

2

20

0

10

20

30

40

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

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

Percent


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76 7685 82

88 84

70 67

89 92

70

0

25

50

75

100


Confident Will Receive Most-Effective Treatment if Sick

Percent responded, if they became seriously ill, confident/very confident they would get most-effective treatment, including drugs and diagnostic tests


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64 6873 70

8175

69 7078

90

58

0

25

50

75

100


Confident Will Be Able to Afford Needed Care

Percent responded, if they became seriously ill, confident/very confident they would be able to afford the care they needed


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Primary Care, Specialist, and After-Hours Access

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65

45

6266

7278

45

57

93

70

57

0

25

50

75

100

AU

S

CA

N

FR

GE

RN

ETH N

Z

NO

R

SW

E

SW

IZ UK

US

Access to Doctor or Nurse When Sick or Needed Care

Percent*

14

33

17 16

5 5

28 25

28

19A

US

CA

N

FR

GE

R

NE

TH NZ

NO

R

SW

E

SW

IZ UK

US

Same- or next-day appointment

Waited six days or more


* Base: Answered question.

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12Difficulty Getting After-Hours Care

Without Going to the Emergency Room

* Base: Needed care and answered question.

5965 63

57

3338

45

68

4338

63

0

25

50

75

100


Percent reported very/somewhat difficult getting care on nights, weekends, or holidays without going to ER*


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Emergency Room Use in the Past Two Years

33

44

2722

2629

26

35

2225

37

0

20

40

60


Percent


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1414Wait Times for Elective Surgery and

Specialist Appointments


Specialist appointment*

Less than 4 weeks 54 41 53 83 70 61 50 45 82 72 80

2 months or more 28 41 28 7 16 22 34 31 5 19 9

Elective surgery**

Less than 1 month 53 35 46 78 59 54 44 34 55 59 68

4 months or more 18 25 7 0 5 8 21 22 7 21 7

* Base: Needed to see specialist in past 2 years.** Base: Needed elective surgery in past 2 years.


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Coordination and Insurance Complexity

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Coordination Problems in the Past Two Years


Test results/ records not available at time of appointment

11 11 7 8 8 9 10 9 7 9 15

Received conflicting information from different health professionals

20 20 16 17 15 18 24 18 16 10 23

Duplicate tests: doctors ordered test that had already been done

10 8 14 20 4 5 9 5 11 7 17

Yes to at least one of the above 28 28 28 29 21 23 31 23 24 19 37


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2623

2823

19 19

27

1719

13

3129 31 29

42

25 26

38

2932 32

42

0

25

50


No chronic conditions2 or more chronic conditions

Percent experienced any of three coordination problems*

* Test results/records not available at time of appointment, received conflicting information from different health professionals, and/or doctors ordered test that had already been done.

Coordination Problems in the Past Two Years, by Number of Chronic Conditions


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Problems with Health Insurance

Percent reported in the past year:


Spent a lot of time on paperwork or disputes over medical bills

6 6 11 16 8 4 8 3 6 3 17

Health insurance denied payment or did not pay as much as expected

11 12 18 11 15 4 2 2 10 2 25

Yes to either 14 15 23 23 20 6 9 4 13 5 31


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1319

16

34

1016 17

106

48

0

25

50

75

AUS CAN FR GER NETH NZ NOR SWE UK US

2009 Survey: Primary Care Doctors Say Insurance Restrictions on Care Are a Major Time Concern

Percent saying amount of time physician or staff spend getting patients needed medications or treatment because of coverage restrictions is a major problem


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Experiences by Income

Slides 21 to 26: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—insurance status.

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21Confident Will Receive Most-Effective Treatment if Sick,

by Income

79 8088

8288 87

72 70

91 95

8273 71

8578 81 78

6358

8692

65

0

25

50

75

100

AUS* CAN* FR GER NETH* NZ* NOR* SWE* SWIZ* UK US*

Above-average income Below-average income(Adjusted) percent confident/very confident


Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—insurance status.

* Indicates significant within-country differences with below-average income (p < 0.05).

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22Cost-Related Access Problems

in the Past Year, by Income

126 8

17

38

4 5 7 4

202218 17

27

13 1521

14 12

4

39

0

25

50

75

AUS* CAN* FR* GER* NETH* NZ* NOR* SWE* SWIZ* UK US*

Above-average income Below-average income


(Adjusted) percent experienced at least one of three problems**

** Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.



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23Out-of-Pocket Spending of $1,000 or More

in the Past Year, by Income



31

17

510 11 11

16

2

34

0

45

1612

5 5 7 6

15

2

20

0

29

0

15

30

45

60

AUS* CAN* FR GER* NETH NZ* NOR SWE SWIZ* UK US*



(Adjusted) percent

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52 2 1 2 2 1 2 2 2

910 9

13

711

610 9 9

3

24

0

10

20

30

40

AUS* CAN* FR* GER* NETH* NZ* NOR* SWE* SWIZ* UK US*


Serious Problems Paying or Unable to Pay Medical Bills in the Past Year, by Income


(Adjusted) percent



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25

60 6459 56

31 3440

67

43

31

5563

7267

55

4437

52

70

4247

68

0

25

50

75

100

AUS CAN* FR* GER NETH* NZ NOR* SWE SWIZ UK* US*


Difficulty Getting After-Hours Care, by Income

(Adjusted) percent reported somewhat/very difficult


Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—insurance status. Base: Needed care and answered question.


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Waited Two Months or Longer for Specialist Appointment, by Income

26

40

29

815 14

3532

7

18

7

31

45

30

9

24 26

3531

3

28

10

0

25

50

75

AUS* CAN FR GER NETH* NZ* NOR SWE SWIZ* UK US

Above-average income Below-average income(Adjusted) percent


Note: Percentages adjusted based on logistic regression to control for health status, age, and—in the U.S.—insurance status. Base: Needed to see specialist in past two years.


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2727

19

46

7

32

46

33

31

36

69

35

47

0 25 50 75 100

Insured all year,above-averageincome

Insured all year,below-averageincome

Uninsured

Percent

U.S. Adults Under Age 65, by Insurance and Income

Went without care because of cost

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

Serious problem or unable to pay bill

Insurance difficulty


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Overall Views of Health Care System, 2010


Only minor changes needed

24 38 42 38 51 37 40 44 46 62 29

Fundamental changes needed

55 51 47 48 41 51 46 45 44 34 41

Rebuild completely 20 10 11 14 7 11 12 8 8 3 27


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29Cross-Cutting Themes and Implications for U.S. Reform

• United States stands out

– Access problems because of costs, difficulty paying medical bills, insurance complexity, and disparities by income

• Insurance benefit design matters for access, protection, and simplicity

– Income-related cost-sharing and limits on out-of-pocket spending promote access and enable ability to pay

– Special provisions necessary to protect low- and modest-income people who are often sicker and least able to afford care if not well-insured

• Symptoms of weaker primary care in U.S., Canada, and Sweden

• German, Swiss, U.S., Dutch, and U.K. rapid access to specialists

– Swiss notable for rapid access to primary and specialized care

• U.S. health reforms will make a difference—include many elements seen internationally

– Medicaid expansion and premium assistance, limits on out-of-pocket spending

– Insurance exchanges, benefit standards, and rules to reduce complexity

– Health care delivery system change to improve access and integration

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Acknowledgments and Cofunders

• Australia: Commission on Safety and Quality in Health Care, Bureau of Health Information

• Canada: Health Council of Canada, Ontario Quality Council, Quebec Health Commission

• France: Haute Authorité de Santé (HAS), Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés (CNAMTS)

• Germany: Institute for Quality and Efficiency in Health Care (IQWiG)

• Netherlands: Dutch Ministry of Health, Welfare and Sport, and IQ Health, Radboud University Nijmegen

• Norway: Norwegian Knowledge Centre for the Health Services

• Sweden: Swedish Ministry of Health

• Switzerland: Federal Office of Public Health

• United Kingdom: Health Foundation

Thanks to coauthors David Squires, Michelle M. Doty, Roz Pierson, and Sandra Applebaum, and to Harris Interactive, Inc., and contractors for conducting the survey. Published by Health Affairs as: “How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries,” Web First, November 18, 2010.

Documents

THE COMMONWEALTH FUND The Commonwealth Fund 2010 International Health Policy Survey in Eleven Countries Cathy Schoen and Robin Osborn The Commonwealth