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1
International Health Policy and Practice: Comparing the U.S. and Canada on
Access and Equity
Eric Schneider, MD, MScSenior Vice President for Policy and Research
2
Outline• Why compare countries’ health care systems?• The Commonwealth Fund International Health
Policy Survey(s)• Are we as good as our neighbors to the
north/south?
3
Why Compare Countries’ Health Care Systems?
“Americans have the best health care system
in the world” - 2004
President Delivers State of the Union Speech
4
International Trends in Health SpendingHealth spending per capita
($US PPP)Total health spending as
percent of GDP
Note: PPP = Purchasing power parity.Source: OECD Health Data 2014; U.S. National Health Expenditure Accounts.
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000US
SWIZ
GER
CAN
FR
JPN
UK
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0 US
FR
SWIZ
GER
CAN
JPN
UK
$9,077
$4,602
10.9%
16.9%
5
Adults’ 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
6
• 17th year of an 11-country survey (began in 1998) Initially: Australia, Canada, New Zealand, U.K., and U.S. Recent years: France, Germany, Netherlands, Norway,
Sweden, Switzerland
Commonwealth Fund Annual International Surveys
• 3-year survey cycle: General population:
1998, 2001, 2004, 2007, 2010, 2013 Sicker/Older population:
1999, 2002, 2005, 2008, 2011, 2014 Physicians:
2000, 2006, 2009, 2012, 2015 (in field)
7
What do we hope to learn?
• Identify shared goals and strategies– Inform US policy reform efforts – Identify potentially transferable innovations
• Measurement – To expand the portfolio of internationally-
comparable metrics used to compare country performance and track the impact of reforms
– “What works” and “what doesn’t”
8
Areas Studied
Quality improvement Chronic illness/management Use of the ED Hospital care Medication use System complexity Health care coverage Demographics
Views of the health system Access and affordability Primary care Doctor-patient relationship Prevention/health promotion Care coordination Health information
technology Patient safety
• Focus on respondent observations (less on opinions)
• General themes:
9
Survey SampleTotal Sample
Minimum Maximum United States
Canada
2011 Survey of Sicker Adults
18,667 750 4,804 1,200 3,958
2012, Survey of Primary Care Providers
9,776 500 2,124 1,012 2,124
2013, Survey of Adults
20,045 1,000 5,412 2,002 5,412
10
Survey Administration Protocol• Sicker Adults (2011)
– Mode: Computer-assisted telephone interviews – Field period: March – June 2011
• Primary Care Physicians (2012)– Mode: Mail and phone survey of primary care
physicians – Field period: March – July 2012
• General Population (2013)– Mode: Computer-assisted telephone interviews – Field period: February- June 2013
11“Mirror, Mirror” Ranking of Health Care System Performance
12
Mirror, Mirror: Dimensions and Indicators
QUALITY(44 indicators)
ACCESS(12 indicators)
EFFICIENCY(11 indicators)
EQUITY(High/low income comparison 10 indicators)
HEALTHY LIVES(WHO and OECD data, 3 indicators)
Effective Care (13) Cost-Related Access (5)
Expenditures (2)
Access to care (10)
Mortality amenable to health care (1)
Safe Care (7) Timeliness of Care (7)
Administrative Burden (4)
Infant Mortality (1)
Coordinated Care (13)
Duplication (3) Healthy Life Expectancy (1)
Patient-Centered Care (11)
Tech usage (2)
13
Media Coverage of Mirror, Mirror
Mirror, Mirror is the most frequently viewed
publication on the Fund’s website
Mirror, Mirror 2010 Mirror, Mirror 20140
50,000
100,000
150,000
200,000
250,000
134,000
233,608
Page Views*
*Views since June 2014 for 2014 edition; views from 2010-2013 for 2010 edition.
Findings published annually in Health Affairs.
14
Ranking of Canada and US Health Care System Performance: Access and Equity
CANADA USA
ACCESS 9 9
COST-RELATED PROBLEM 5 11
TIMELINESS OF CARE 11 5
EQUITY 9 11
15
Percent of adults who(se):
Cost-Related Access Problems 15
Source: (1) 2013 Commonwealth Fund International Health Policy Survey; (2) 2012 International Survey of Primary Care Doctors
Didn’t fill prescription; skipped medical test, treatment or follow-up; or had medical problem but did not visit doctor in past year due to cost1
Insurance denied payment for medical care or did not pay as much as expected1
Had serious problems paying or was unable to pay medical bills1
Physicians think their patients often have difficulty paying for medications or out-of-pocket costs2
0 25 50 75 100
13
14
7
26
14
37
28
23
59
41
USCanada
Out-of-pocket expenses for medical bills > $1,000 in past year, = to USD1
Timeliness of Care
0 25 50 75 100
51
62
48
29
18
59
61
28
6
7
US Canada
Last time needed medical attention, was able to see doctor or nurse the same or next day3
Very or somewhat difficult to get medical care in the evening, weekend, or on a holiday without going to the emergency room1*
Waiting time for emergency care was 2 hours or more1**
Percent of patients reported:
Source: (1) 2013 Commonwealth Fund International Health Policy Survey; (3) 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries; *base: sought after-hours care; **base: used an emergency room in past 2 years; ***base: saw or needed to see a specialist in past 2 years; ****base: those needing elective surgery in past year
16
Waiting time to see a specialist was 2 months or more1***
Waiting time of 4 months or more for elective/ nonemergency surgery1****
17
Timeliness of Care Cont’d
Source: (2) 2012 International Survey of Primary Care Doctors
0 5 10 15 20 25 30 35 40 45 50
23
29
8
6
US Canada
Patients often experience difficulty getting specialized tests (e.g., CT, MRI)2
Patients often experience long wait times to receive treatment after diagnosis2
Percent of doctors who reported:
Equity Measures: U.S. and Canada
Source: (1) 2013 Commonwealth Fund International Health Policy Survey; (3) 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries
0 20 40 60 80 100
12
17
7
14
8
6
9
3
4
4
Canada - high income
Canada - low income
8
4
10
4
Rated doctor fair/poor1
Did not get recommended test, treatment, or follow-up because of cost in past year1
18
Percent of patients who:
Rated quality of care fair/poor3
Had medical problem but did not visit doctor because of cost in the past year1
Did not fill prescription or skipped doses because of cost in the past year1 0 20 40 60 80 100
15
27
39
31
30
6
7
17
11
12
US - high income
US - low income
9
20
22
20
18
6
19
Equity Measures: U.S. and Canada
0 20 40 60 80 100
55
67
29
48
10
47
59
30
43
9
Canada -high incomeCanada -low income
8
8
1
5
1
Last time needed medical attention not able to see doctor or nurse same or next day3
Somewhat or very difficult to get care on evenings, weekends, or holidays1*
Waited 2 months or longer for specialist appointment1**
Percent of Patients who report:
Source: (1) 2013 Commonwealth Fund International Health Policy Survey; (3) 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries; *base: sought after-hours care; **base: needed to see specialist in past 2 years; ***base: those going to ER
Waited 2 hours or more in ER1***
Unnecessary duplication of medical tests in past 2 years3 0 20 40 60 80 100
45
70
9
36
19
39
53
4
16
14
US -high incomeUS -low income
6
17
5
20
5
20
Other Dimension Rankings: Canada and US Health Care System Performance
CANADA USA
QUALITY CARE 9 5 EFFECTIVE CARE 7 3 SAFE CARE 10 7 COORDINATED CARE 8 6 PATIENT-CENTERED CARE 8 4
EFFICIENCY 10 11
HEALTHY LIVES 8 11
OVERALL RANKING 10 11
21
Conclusions
• Comparison of countries’ health systems with systematically-collected data can offer a useful antidote to conventional wisdom
• Tracking results can inform national policy discussions and research on policy and delivery system reforms, both in the U.S. and in other countries
22
Survey Co-funders in 2014
• Australia: New South Wales Bureau of Health Information.
• Canada: Canadian Institute for Health Information, Canadian Institutes of Health Research, Health Quality Ontario, Commissaire à la Santé et au Bien-être du Québec, and Health Quality Council of Alberta.
• France: Haute Autorité de Santé and Caisse Nationale d’Assurance Maladie des Travailleurs Salariés.
• Germany: Federal Ministry of Health and the National Institute for Quality Measurement in Health Care.
• Netherlands: Ministry of Health, Welfare, and Sport and the Scientific Institute for Quality of Healthcare at Radboud University Nijmegen Medical Centre.
• Norway: Norwegian Knowledge Centre for the Health Services.
• Sweden: Ministry of Health and Social Affairs.
• Switzerland: Federal Office of Public Health.
• United Kingdom: The Health Foundation.
23
Acknowledgements
CMWF IHP Survey Team
24
References1.Karen Davis, Kristof Stremikis, David Squires, and Cathy Schoen. Mirror, Mirror On The Wall. Online: The Commonwealth Fund 2014.2. Commonwealth Fund Commission, Why Not the Best? 2011. 3. Institute of Medicine, Crossing the Quality Chasm, 2001.
25
APPENDIX
26
Calculation of Ranks• Countries ranked by calculating means and
ranking scores from highest to lowest • Tied observations assigned the score that would
be assigned if no tie occurred• Summary ranking created for each Scorecard
domain of quality and access by averaging individual ranked scores within each country and ranking these averages from highest to lowest (1=highest; 11=lowest)