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International Health Policy and Practice: Comparing the U.S. and Canada on
Effectiveness and Patient-centered Care
Eric Schneider, MD, MScSenior Vice President for Policy and Research
Outline• Why compare countries’ health care systems?• The Commonwealth Fund International Survey
Program• Are we as good as our neighbors to the
north/south?
Why Compare Countries’ Health Care Systems?
“Americans have the best health care system
in the world” - 2004
President Delivers State of the Union Speech
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%
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
• 17th year of an 11-country survey (Since 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)
What do we hope to learn?
• Shared goals and strategies: for reform and increasing transferability of innovations
• Measurement: expanding portfolio of internationally comparable metrics to compare country performance and track reforms, to know “what works” and “what doesn’t”
Areas Studied
Quality improvement Chronic illness/management Use of the ED Hospital care Medications 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 objective measures rather than opinions.
• General themes:
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
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
“Mirror, Mirror” Ranking of Health Care System Performance
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)
Media Coverage of IHP Survey Findings
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.
Ranking of Canada and US Health Care System Performance: Effectiveness
CANADA USAQUALITY CARE 9 5 EFFECTIVE CARE 7 3 SAFE CARE 10 7 COORDINATED CARE 8 6 PATIENT-CENTERED CARE 8 4
Percent of adults who had a chronic condition and:
Managing Patients with Chronic Conditions:U.S. and Canada Older Adults
15
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Health care professional discussed goals and gave instructions on symptoms
Had a treatment plan for their condition they could carry out in their daily life
Had a health care professional that contacted them between visits
Had a health care professional they could contact to ask questions
0 25 50 75 100
46
76
16
67
58
83
30
84
US Canada
Prevention: U.S. and Canada
0 25 50 75 100
23
39
35
51
54
69
30
49
52
67
70
77
US Canada
Physicians reporting it is easy to print out list of patients due or overdue for tests/preventive care
Patients receive reminders for preventive care
Patients sent computerized reminder notices for preventive or follow-up care
Doctor talked with patient about exercise or physical activity
Doctor talked with patient about healthy diet and healthy eating
Doctor talked with patient about health risks and ways to quit smoking
Percent reported:
Source: The Commonwealth Fund: 2014 Update “ Mirror, Mirror on the Wall”
Safe Care Measures: US and Canada
*Base: had a lab test ordered
Source: The Commonwealth Fund: 2014 Update “Mirror, Mirror on the Wall”
0 5 10 15 20 25 30 35 40 45 50
11
5
5
11
11
11
8
5
10
5
US CanadaPercent of Patients who reported:
Believed a medical mistake was made in treatment or care in past 2 years
Given wrong medication or wrong dose at pharmacy or while hospitalized in past 2 years
Given incorrect results for a diagnostic or lab test in past 2 years*
Experienced delays in being notified about abnormal test results in past 2 years*
Hospitalized patients reporting infection in hospital or shortly after
Safe Care Measures: US and Canada Cont’d
Source: The Commonwealth Fund: 2014 Update “ Mirror, Mirror on the Wall”
0 20 40 60 80 100
30
34
58
49
US CanadaPercent of Physicians who report
Doctor routinely receives a computerized alert or prompt about a potential problem with drug dose or interaction
Doctor routinely receives reminders for guideline-based interventions and/or tests
Patient-Centered Care: US and Canada, Communication
0 20 40 60 80 100
67
88
83
73
88
92
US CanadaPercent of Patients who report:
*Base: have a regular doctor and tried to contact by phone; **Base: those who had surgery or been hospitalized
Source: The Commonwealth Fund: 2014 Update :Mirror, Mirror on the Wall
Always or often getting telephone answer from doctor the same day*
Doctor always or often explains things in a way that is easy to understand
Received clear instructions about symptoms to watch for and when to seek further care after surgery or when leaving the hospital**
Patient-Centered Care: US and Canada, Continuity and Feedback
0 20 40 60 80 100
64
15
80
57
60
84
US CanadaPercent of Patients who report
Source: The Commonwealth Fund: 2014 Update “ Mirror, Mirror on the Wall
With same doctor 5 years or more
Doctor routinely receives and reviews data on patient satisfaction and experiences with care
Regular doctor always or often knows important information about patient’s medical history
Patient-Centered Care: U.S. and Canada, Engagement and Patient Preferences
0 25 50 75 100
77
67
72
62
66
71
76
80
75
75
US CanadaSpecialist always or often involves patient as much as they want in decisions re: care and RX*
Doctor discussed patient’s main goals or priorities caring for condition**
*Base: saw or needed to see specialist in past 2 years; **Base: has chronic conditionSource: The Commonwealth Fund: 2014 Update “ Mirror, Mirror on the Wall”
Specialist always or often tells you about treatment choices*
Percent of Patients that Reported:
Regular doctor always or often encouraged you to ask questions
Doctor gives clear instructions about symptoms/when to seek further care**
Other Dimension Rankings: Canada and US Health Care System Performance
CANADA USAACCESS 9 9 COST-RELATED PROBLEM 5 11 TIMELINESS OF CARE 11 5EFFICIENCY 10 11EQUITY 9 11HEALTHY LIVES 8 11OVERALL RANKING 10 11
Conclusions
• Comparison of countries’ health systems with systematically-collected data can offer a useful antidote to conventional wisdom
• We expect the results to inform national policy discussions about delivery system reform, especially in the U.S.
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.
Acknowledgements
CMWF IHP Survey Team
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.
APPENDIX
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)
