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THE COMMONWEALTH
FUND
The Commonwealth Fund 2013 International Health Policy Survey
in Eleven Countries
Robin Osborn and Cathy Schoen
The Commonwealth Fund
November 2013
THE COMMONWEALTH
FUND
The Commonwealth Fund 2013 International Health Policy Survey in Eleven Countries
• Survey of adults age 18 and older in eleven countries.
• Sample sizes: 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), United States (2,002).
• Survey in the field February to June 2013.
• Conducted by Social Science Research Solutions and country contractors (by landline and cell phone).
• Presentation topics: affordability and cost-related access barriers; access to primary care, emergency department, and specialist care; complexity; and system views.
2
THE COMMONWEALTH
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33
Affordability and Cost-Related Access Barriers
THE COMMONWEALTH
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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
4
THE COMMONWEALTH
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55Key National Insurance Design and
Cost-Sharing Policies, 2013
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US*
Deductible No No No No Yes No No No Yes No Yes
Caps on out-of-pocket spending
Yes No No Yes No No Yes Yes Yes No No
Core benefit
Drugs ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔
Dental (adults) ✔ ✔ ✔ ✔
* Before insurance market reforms take effect in 2014.Source: S. Thomson, R. Osborn, D. Squires, and M. Jun, International Profiles of Health Care Systems, 2013, The Commonwealth Fund, Nov. 2013.
THE COMMONWEALTH
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66
UK
SW
EN
OR
CA
NS
WIZ
GE
RA
US
FR NZ
NE
TH US
0
10
20
30
40
50
60
4 610
13 13 15 16 1821 22
37
Cost-Related Access Barriers and Out-of-Pocket Costs in the Past Year
Percent
SW
E
UK FR
NE
TH NZ
GE
R
CA
NN
OR
SW
IZA
US
US
2 37 7 9 11
1417
24 25
41
Experienced cost-related access problem*
Spent US$1,000 or more out-of-pocket
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.
THE COMMONWEALTH
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77
UK SWE NOR CAN GER AUS NETH NZ SWIZ FR US0
10
20
30
40
14
6 7 7 8 9 10 1013
23
Serious Problems Paying or Unable to Pay Medical Bills in the Past Year
Percent
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
THE COMMONWEALTH
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8
GER SWE NOR NETH SWIZ CAN UK FR US AUS NZ0
15
30
45
60
75
10 10 11
1922 23
26 27 27 28
41
812
2519
11
21
6
20
3329
32
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.
THE COMMONWEALTH
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99Cost and Access Problems in the Past Year for U.S. Adults,
by Insurance Status
Spent $1,000 or more out-of-pocket
Serious problems/ unable to pay medical bills
Experienced cost-related access
problem
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.
THE COMMONWEALTH
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1010
Access: Primary Care, Emergency Department Use, and Specialist Care
THE COMMONWEALTH
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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.
THE COMMONWEALTH
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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 with a Question, Always or Often Hear Back on the Same Day
Percent
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
THE COMMONWEALTH
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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.
THE COMMONWEALTH
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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
THE COMMONWEALTH
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1515Patients’ Email Access to Regular Practice
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Adults, 2013 Can email practice with questions
24 10 9 19 32 16 22 20 29 25 28
Have emailed practice in past two years
9 2 2 3 20 5 6 9 15 13 6
Primary care doctors, 2012
Patients can email practices with questions
21 11 39 45 47 39 27 44 68 35 35
Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.
THE COMMONWEALTH
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1616
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.
THE COMMONWEALTH
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1717
Complexity
THE COMMONWEALTH
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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
* 2010.Source: OECD Health Data 2013.
$US
18
THE COMMONWEALTH
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Adults, 2013Insurance did not cover as
expected/spent a lot of time on paperwork 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.
19
THE COMMONWEALTH
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2020Overall 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
THE COMMONWEALTH
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2121Insights from Global and Domestic Perspectives
• Insurance coverage and insurance design matter for ensuring access and affordability
• Insurance and payment policies targeted at primary care can strengthen access, including after-hours care
• Complexity can pose significant health system costs o U.S. provides a cautionary example
• Controlling costs while safeguarding access will require vigilance regarding the impact of insurance design changeso Especially for those vulnerable because of chronic disease or
limited incomes
• Varying country insurance approaches provide rich insights looking forward
THE COMMONWEALTH
FUND
22
Cofunded by:• Australia: New South Wales Bureau of Health Information• Canada: Health Council of Canada, Health Quality Ontario, Commissaire à
la Santé et au Bien–être du Québec, Health Quality Council of Alberta• France: Haute Autorité de Santé (HAS), Caisse Nationale de l’Assurance
Maladie des Travailleurs Salariés (CNAMTS)• Germany: Federal Ministry of Health, BQS Institute for Quality and
Patient Safety• Netherlands: Dutch Ministry of Health, Welfare and Sport, and Scientific
Institute for Quality of Healthcare (IQ Healthcare)• Norway: Norwegian Knowledge Centre for the Health Services • Sweden: Swedish Ministry of Health and Social Affairs• Switzerland: Federal Office of Public Health
Thanks to coauthors David Squires and Michelle M. Doty, and to Robyn Rapoport, Eran Ben-Porath, Social Science Research Solutions, and country contractors for conducting the survey.
Acknowledgments and Country Partners
