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:

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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

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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

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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)

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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.

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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

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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

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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

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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

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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.

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Acknowledgements

CMWF IHP Survey Team

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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.

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APPENDIX

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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)