Transcript Cathy Schoen - The Commonwealth Fund

Learning by Comparing: Experiences of
Adults in Eleven Countries
Findings from the Commonwealth Fund 2013 International
Health Policy Survey and Health Affairs article, Dec. 2013
MAY 7, 2014 WEBINAR
Cathy Schoen, Senior Vice President
Commonwealth Fund
2
Key National Insurance Design and
Cost-Sharing Policies, 2013
AUS
CAN
FR
GER
NETH
NZ
NOR
SWE
SWIZ
UK
US*
Universal
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Deductible
No
No
No
No
Yes
No
No
No
Yes
No
Yes
Limit on
out-ofpocket
spending
Yes
No
No
Yes
No
No
Yes
Yes
Yes
No
No
✔
✔
✔
✔
✔
✔
✔
✔
✔
✔
Core benefits include:
Drugs
Dental
(adults)
✔
✔
* US: Before insurance market reforms take effect in 2014.
Source: Thomson, Osborn, Squires, and Jun, International Profiles of Health Care Systems, 2013,
The Commonwealth Fund, Nov. 2013. Swiss, Dutch, German 1-3% uninsured
✔
3
Health Spending per Capita, 2011
Adjusted for Differences in Cost of Living
$US
$9,000
$8,508
$8,000
$7,000
$6,000
$5,669 $5,643
$5,099
$5,000
$4,522 $4,495
$4,000
$4,118 $3,925
$3,800
$3,405 $3,182
$3,000
$2,000
$1,000
$0
% GDP
US
NOR
SWIZ NETH
CAN
GER
FR
SWE
AUS
UK
NZ
(17.7%) (9.3%) (11.0%) (11.9%) (11.2%) (11.3%) (11.6%) (9.5%) (8.9%)* (9.4%) (10.3%)
* 2010.
Source: OECD Health Data 2013.
Key Findings
• Coverage and benefit design matter for access and affordability
 US adults stand out for forgoing care because of costs, and
trouble paying medical bills, even when insured
 Wide country variation in out-of-pocket costs
• Access to primary care and specialists vary significantly
 US and Canada long waits for primary care and high ER use
 Swiss, UK, US, Dutch and German rapid access to specialists;
Norway and Canada longer waits
• Insurance complexity can pose significant health system costs
 Consumes time and resources for patients and clinicians
• Experiences influence views of the country health systems
• US adults the most likely to call for fundamental reform
• International perspective provides insights looking forward
4
5
Cost-Related Access Barriers in the Past Year
Percent*
40
37
30
27
20
13
13
15
16
21
22
NZ
NETH
18
10
10
4
6
0
UK
SWE NOR
CAN SWIZ GER
AUS
FR
US
* Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
US
Insured
Serious Problems Paying or Unable to Pay Medical Bills
in the Past Year
Percent
40
30
23
20
15
13
10
4
6
7
7
CAN
GER
8
9
10
10
NZ
SWIZ
1
0
UK
SWE NOR
AUS NETH
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
FR
US
US
Insured
6
7
Spent $1,000 or More Out-of-Pocket on Medical Care
in the Past Year
Percent
60
50
41
42
US
US
Insured
40
30
24
20
10
2
3
SWE
UK
7
7
FR
NETH
9
11
14
25
17
0
NZ
GER
CAN
NOR SWIZ AUS
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
8
U.S. Adults’ Access and Cost Concerns,
by Insurance Status
63
Went without care
because of costs
27
Serious problems/
unable to pay
medical bills
Uninsured
42
Insured all year
15
39
Spent $1,000 or more
out-of-pocket
42
0
20
40
60
Percent
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
80
100
9
Gaps in Dental Care
Percent
75
Did not visit dentist/hygenist/dental clinic in past two years
Skipped dental care because of cost in past year
60
45
30
41
27
26
22
15
6
10 8
UK
GER
19 19
20
25
23 21
11 10 12
28 29
33
32
27
11
0
SWIZ
SWE NETH
FR
CAN
NOR
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
AUS
NZ
US
10
Access
Primary Care, Emergency Department Use, and
Specialist Care
Access to Doctor or Nurse When Sick or Needed Care
Same-day or next-day
appointment
11
Waited six days or more
for appointment
Percent
100
76
75
72
63
58 58 57
52 52
50
48
41
25
14 14 15 16 16
5
0
Note: Question asked differently in Switzerland.
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
22
26 28
33
When Calling Regular Doctor or Practice with a Question,
Always or Often Hear Back on the Same Day
Percent
100
90
84
84
82
80
80
79
78
75
73
67
63
60
40
20
0
GER NETH SWE SWIZ
NZ
AUS
NOR
UK
Base: Has a regular doctor/place.
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
US
CAN
FR
12
13
Access to After-Hours Care
Adults, 2013
Easy getting after-hours care
without going to the ER
Primary care physicians, 2012
Practice has arrangement for
patients’ after-hours care
to see doctor or nurse
Percent
95 95
100
80
60
90 90
81 80 78
76
69
68
58 56 56 54
49 46
40
46
39 38 36 35
35
20
0
Base: Needed care after hours.
* In Norway, doctors asked whether their practice had
arrangements or there were regional arrangements.
Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.
14
Used the Emergency Department in Past Two Years
Percent
75
48
50
39
25
27
28
AUS GER NETH UK
NZ
22
22
24
28
28
31
32
FR
SWE
41
0
NOR SWIZ
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
US
CAN US
Uninsured
Wait Times for Specialist Appointment
Less than four weeks
15
Two months or more
Percent
100
80 80
75
76 75
72
59
50
54 51 51
46
39
26 29
17 18 18 19
25
3
3
6
7 10
0
Base: Needed to see specialist in the past two years.
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
16
Insurance Complexity
17
Spending on Health Insurance Administration per Capita, 2011
Adjusted for Differences in Cost of Living
$US
$700
$606
$600
$500
$400
$300
$199
$200
$100
$237
$266 $277
$128 $148
$35
$55
$70
SWE
AUS
$0
NOR
Source: OECD Health Data 2013.
NZ
CAN
NETH
GER
SWIZ
FR
US
Insurance Complexity and Restrictions Create Concerns
for Patients and Doctors
Adults, 2013
Spent a lot of time on paperwork or
insurance did not cover in past year*
18
Primary care physicians, 2012
Insurance coverage restrictions
pose major time concern**
Percent
75
54
50
41
32
25
19
15 16 17
8
4 4 7
23 25
10 11 12 12
23 24
20
18
0
* 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.
Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.
28
19
Overall Views of Health Care System, 2013
Works well, only minor changes
Fundamental changes
63
UK
33
54
51
48
47
46
44
42
42
40
SWIZ
NETH
AUS
NZ
NOR
SWE
GER
CAN
FR
0%
48
20%
4
7
5
9
8
12
10
10
8
11
40
44
43
45
42
46
48
50
49
25
US
Completely rebuild
40%
27
60%
Percent of adults
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
80%
100%
Insights from Global and Domestic Perspectives
• Coverage and benefit design matter for access and affordability
 Especially if vulnerable due to chronic disease or low incomes
• Insurance benefits and policies targeted at primary care can
improve access, including after-hours care
• Insurance complexity can pose significant health system costs
 Consumes time and resources for patients and clinicians
 United States provides a cautionary example
• Safeguarding access while confronting costs will require vigilance
and attention to consequences of insurance design changes
• International policy variations provide insights looking forward
 Opportunities to learn from internal and global experiences
20
21
2013 International Health Policy Survey: Description
• Landline and cell phone survey of adults age 18 or older in Australia,
Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden,
Switzerland, United Kingdom, and United States
• Final samples 20,045 in 11 countries
• 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), U.S. (2,002)
• Field from February to June 2013, conducted by Social Science
Research Solutions and country contractors.
• Published in Health Affairs: C. Schoen, R. Osborn, D. Squires, M.M. Doty,
“Access, Affordability, and Insurance Complexity are Often Worse in the
United States Compared to Ten Other Countries,” Dec. 2013.
• Also see 2012 Survey of Primary Care Physicians: Schoen, Osborn,
Squires et al. “Survey of Primary Care Doctors in Ten Countries Shows
Progress in Use of Health Information technology, Less in Other Areas,
Health Affairs, Dec. 2012.