THE COMMONWEALTH FUND

The Commonwealth Fund 2007 International Health Policy Survey in Seven Countries

Cathy Schoen, Robin Osborn, Meghan Bishop, and Sabrina How The Commonwealth Fund November 2007

2007 International Health Policy Survey • Telephone survey: representative samples of adults ages 18 and older in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States.

• Final samples: 1,009 Australia, 3,003 Canada, 1,407 Germany, 1,557 the Netherlands, 1,000 New Zealand, 1,434 United Kingdom, and 2,500 United States.

• Conducted by Harris Interactive, Inc., and subcontractors, and in the Netherlands by The Center for Quality of Care Research (WOK), Radboud University Nijmegen, from March 6 to May 7, 2007.

• Co-funded by the German Institute for Quality and Efficiency in Health Care, the Dutch Ministry for Health, and the Health Council of Canada.

• Core topics: Access, Coordination, Patient-Centered Care, Chronic Care, and Safety.

• Medical home: analysis of experiences of adults with and without a primary care “medical home” with specified attributes.

THE COMMONWEALTH FUND

THE COMMONWEALTH FUND

System Views: Access, Cost, and Waiting Times

Figure 1. Overall Views of the Health Care System in Seven Countries, 2007 Percent reported: Only minor changes needed Fundamental changes needed Rebuild completely AUS 24 55 18 CAN 26 60 12 GER 20 51 27 NETH 42 49 9 NZ 26 56 17 UK 26 57 15 US 16 48 34

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 2. Overall Views of the Health Care System in Seven Countries, 2007 and 1998 Percent reporting: Only minor changes needed 2007 1998 Fundamental changes needed 2007 1998 Rebuild completely 2007 1998 AUS 24 19 55 49 18 30 CAN GER NETH 26 20 60 56 12 23 20 * 51 * 27 *

* Germany and the Netherlands did not participate in the 1998 survey.

Sources: 1998 and 2007 Commonwealth Fund International Health Policy Surveys.

Data collection: Harris Interactive, Inc.

42 * 49 * 9 * NZ 26 9 56 57 17 32 UK 26 25 57 58 15 14 US 16 17 48 46 34 33 THE COMMONWEALTH FUND

Figure 3. Confidence in Health Care System Percent reporting “very confident” that they will: Get quality and safe care AUS 34 Receive the most effective drugs Receive the best medical technology 36 39 CAN GER 28 32 28 24 23 24 NETH NZ UK US 59 45 46 30 20 25 28 25 27 35 33 38

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 4. Cost-Related Access Problems Percent in past year due to cost: Did not fill prescription or skipped doses Had a medical problem but did not visit doctor Skipped test, treatment, or follow up Percent who said yes to at least one of the above AUS 13 13 17 26 CAN 8 4 5 12 GER NETH 11 12 8 21 2 1 2 5 NZ 10 19 13 25 UK 5 2 3 8 US 23 25 23 37

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 5. Out-of-Pocket Medical Costs in the Past Year Percent 75 52 50 38 25 0 13 21 9 12 No out-of-pocket cost 10 AUS CAN GER NETH NZ UK US

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

30 19 12 10 5 10 4 AUS CAN GER NETH NZ UK US More than US $1,000 THE COMMONWEALTH FUND

Figure 6. Serious Problems Paying or Unable to Pay Medical Bills in the Past Year Percent 50 25 8 0 AUS 4 4 5 CAN GER NETH 8 NZ

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

1 UK 19 US THE COMMONWEALTH FUND

Figure 7. Spent Any Time on Paperwork or Disputes Related to Medical Bills or Insurance Percent 50 31 25 10 12 14 13 0 AUS CAN GER NETH NZ 3 UK

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

24 US THE COMMONWEALTH FUND

Figure 8. Access to Doctor When Sick or Need Medical Attention Percent 75 50 25 0 42 22 55 49 53 41 30 AUS CAN GER NETH NZ UK US Same-day appointment

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

10 30 20 5 4 12 20 AUS CAN GER NETH NZ UK US Wait of 6 days or more THE COMMONWEALTH FUND

Figure 9. E-mail Communication with Doctor and Electronic Access to Medical Records Base: Have regular doctor/place Percent: Currently can e-mail doctor No e-mail: Would like to be able to communicate by e-mail Have electronic access to medical records No current access: would like electronic access to medical records AUS CAN GER NETH NZ UK 15 34 12 35 9 40 5 43 16 18 18 30 15 38 7 49 22 40 11 44 11 32 9 36 US 20 43 10 37

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 10. Difficulty Getting Care on Nights, Weekends, Holidays Without Going to the Emergency Room Percent reported very or somewhat difficult 75 Somewhat difficult Very difficult 50 29 28 28 26 25 28 34 25 35 38 25 20 29 38 0 AUS CAN GER 12 NETH

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 11. Emergency Room Use in the Past Two Years Percent Any visits 50 Visited ER for condition doctor could have treated if available 39 36 33 28 28 25 16 21 18 15 11 5 6 9 8 0 AUS CAN GER NETH

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 12. Waited Two or More Hours in Emergency Room Before Being Treated Base: Used emergency room at least once Percent 75 50 46 34 25 11 9 0 AUS CAN GER NETH

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

25 NZ 32 UK 31 US THE COMMONWEALTH FUND

Figure 13. Waiting Time for Elective or Nonemergency Surgery Percent of adults who needed elective or nonemergency surgery 100 75 50 55 32 72 47 55 40 62 25 0 AUS CAN GER NETH NZ UK US Less than 1 Month

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

9 14 3 2 4 15 4 AUS CAN GER NETH NZ UK US More than 6 months THE COMMONWEALTH FUND

Percent 50 Figure 14. Doctor-Recommended Treatment Had Little or No Benefit in Past Two Years 25 17 12 20 13 15 0 AUS CAN GER NETH NZ

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

10 UK 20 US THE COMMONWEALTH FUND

THE COMMONWEALTH FUND

Primary Care Doctor and Medical Home

Creation of “Medical Home” Composite Variable • Analysis of 2007 Survey used positive responses to four questions to create an indicator of having a source of primary care with key characteristics of a “medical home” • Medical Home criteria includes: – Adult has regular doctor or place of care – Doctor/staff know important information about patient’s history – Place is easy to contact by phone during regular office hours – Doctor/staff help coordinate care received from other doctors/sources of care THE COMMONWEALTH FUND

Figure 15. Adults Across Countries Place High Value on Having a “Medical Home”—Accessible, Personal, Coordinated Care When you need care, how important is it that you have one practice/clinic where doctors and nurses know you, provide and coordinate the care that you need?

Percent saying very or somewhat important Somewhat important Very important 100 15 17 18 20 16 12 15 75 50 80 78 78 74 78 84 80 25 0 AUS CAN GER NETH

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 16. Have a Regular Doctor or Place of Care Percent 100 8 75 50 25 0 88 AUS 7 84 CAN 3 92 Regular place of care Regular doctor 6 8 100 GER NETH 89 NZ 89 UK

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

10 80 US THE COMMONWEALTH FUND

Figure 17. Does Doctor Know Important Information About Your Medical History?

Base: Have regular doctor/place Percent 100 15 75 16 17 19 Often Always 18 16 20 50 69 67 78 71 69 63 62 25 0 AUS CAN GER NETH

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 18. How Easy Is It to Contact Doctor by Phone During Regular Hours?

Base: Have regular doctor/place Percent 100 Somewhat easy Very easy 75 26 34 50 44 48 25 60 44 22 27 0 AUS CAN GER NETH 26 62 NZ 36 44 UK 35 46 US

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 19. Regular Doctor Coordinates Care Received from Other Doctors/Places Base: Have regular doctor/place Percent 100 Often Always 75 19 20 22 21 22 50 20 24 25 51 47 45 31 49 38 47 0 AUS CAN GER NETH

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 20. Adults with a Medical Home Percent 75 59 50 48 45 47 61 47 50 25 0 AUS CAN GER NET

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

THE COMMONWEALTH FUND

Coordination of Care

Figure 21. Care Coordination Percent reported in past two years: Test results or records not available at time of appointment Duplicate tests: doctor ordered test that had already been done Percent with either coordination problem AUS CAN GER NETH NZ UK US 11 11 8 7 9 10 15 10 18 5 15 15 19 4 9 6 5 14 12 13 23

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 22. Coordination Problems: Medical Records Not Available During Visit or Duplicative Tests, by Medical Home Percent with coordination problems 50 Has medical home No medical home 25 11 27 10 19 16 23 8 11 8 18 7 19 16 29 0 AUS CAN GER NETH

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 23. Saw Two or More Specialists in the Past Year Percent 75 50 25 29 20 44 25 20 19 27 0 AUS CAN GER NETH NZ

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

UK US THE COMMONWEALTH FUND

Figure 24. Specialist Care Coordination Base: Saw a specialist in the past year Percent who reported regular doctor: Helped you decide who to see AUS 63 CAN 63 Provided specialist with information about your condition or problem 81 76 GER NETH NZ UK US 57 57 35 65 55 73 45 70 63 72

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Percent 100 Figure 25. Regular Doctor Helped You Decide on Specialist, by Medical Home Has medical home No medical home 75 67 57 50 69 56 65 49 43 29 58 51 51 39 70 55 25 0 AUS CAN GER NE

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 26. After Emergency Room Use, Did Regular Doctor Seem Informed About Care Received? by Medical Home Percent “yes” 100 Has medical home No medical home 75 70 69 64 55 67 66 69 68 73 58 50 42 44 46 43 25 0 AUS CAN GER NETH NZ UK

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care. Average for all respondents: AUS=57%, CAN=57%, GER=60%, NETH=66%, NZ=60%, UK=54%, US=66%.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

US THE COMMONWEALTH FUND

THE COMMONWEALTH FUND

Patient-Centered Care

Figure 27. Doctor-Patient Communication Percent reported doctor: Always knows important information about your medical history Always explains things so you can understand Always spends enough time with you Always tells you about your treatment options and involves you in decisions about your treatment AUS 69 79 73 66 CAN GER 67 75 59 62 78 71 70 62 NETH NZ 71 71 71 60 69 80 69 67 UK US 63 71 59 54 62 70 56 61

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 28. Doctor Always Explains Things, Spends Enough Time with You, and Involves You in Decisions, by Medical Home Average percent of adults with a regular doctor or place of care reporting “always” across three indicators of doctor-patient communication Has medical home No medical home 100 83 79 78 78 83 75 77 75 50 56 51 57 58 51 47 45 25 0 AUS CAN GER NETH

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 29. Quality of Care from Doctor, by Medical Home Percent rated care received “excellent” or “very good” Has medical home No medical home 100 87 88 89 82 75 60 57 65 70 59 50 40 47 49 86 51 25 0 AUS CAN GER NETH

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

THE COMMONWEALTH FUND

Care for Chronic Conditions

Figure 30. Demographics: Adults with Two or More Chronic Conditions Percent 50 25 30 26 21 19 19 20 30 0 AUS CAN GER NETH

Note: Chronic conditions include hypertension or high blood pressure, heart disease, diabetes, arthritis, lung problems, depression, or cancer.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 31. Care Management and Coordination for Chronic Conditions Adults with a chronic condition reported: Doctor gives you a written plan for managing care at home Receive reminder for preventive/follow-up care Often/sometimes receive conflicting information from different health professionals AUS 40 44 14 CAN GER 33 40 16 22 57 19 NETH NZ 31 58 13 35 48 19 UK US 30 58 18 51 70 22

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 32. Doctor Gives You Written Plan for Managing Care at Home, by Medical Home Base: Adults with a chronic condition Percent with care plan 75 Has medical home No medical home 50 45 32 25 38 28 24 19 36 27 39 30 34 25 55 47 0 AUS CAN GER NETH

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 33. Receive Reminder for Preventive/Follow-Up Care, by Medical Home Base: Adults with a chronic condition Percent with reminder 100 Has medical home No medical home 75 50 50 35 25 49 29 67 48 63 54 51 44 64 50 76 63 0 AUS CAN GER NETH

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 34. Receive Conflicting Information, by Medical Home Base: Adults with a chronic condition Percent often/sometimes received conflicting information 50 Has medical home No medical home 25 11 18 11 20 14 24 7 18 15 27 13 24 15 29 0 AUS CAN GER NETH

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

THE COMMONWEALTH FUND

Safety: Medication, Medical, and Diagnostic Test Errors

Figure 35. Medical, Medication, and Lab Errors Percent reported in past two years: Experienced medical or medication error Experienced lab or diagnostic test error AUS CAN 15 11 Experienced any medical, medication, or lab error 20 10 12 17 GER NETH 9 4 12 9 8 14 NZ UK US 11 9 16 9 10 13 13 14 20

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 36. Any Error, by Number of Doctors Seen Percent any error 50 One doctor Three doctors or more 34 25 15 27 13 30 7 16 0 AUS CAN GER 9 27 NETH 13 NZ 9 29 UK 17 33 US

Note: Errors include medical mistake, wrong dose/medication, or lab test error.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

THE COMMONWEALTH FUND

Figure 37. Any Error in Past Two Years Percent any error 50 All adults 2 or more chronic conditions 25 20 26 17 28 12 16 14 25 16 22 13 24 20 32 0 AUS CAN GER NETH

Note: Errors include medical mistake, wrong dose/medication, or lab test error.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK US THE COMMONWEALTH FUND

Figure 38. Chronically Ill: Any Error, by Medical Home Base: Has a chronic condition Percent any error 50 Has medical home No medical home 25 18 30 17 29 11 19 17 22 15 30 11 26 21 34 0 AUS CAN GER NETH NZ UK

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care. Errors include medical mistake, wrong dose/medication or lab test error.

Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

US THE COMMONWEALTH FUND

Figure 39. Views of the Health System in Seven Countries, by Medical Home Percent reported health system needs to be completely rebuilt 50 Has medical home No medical home 40 25 16 21 10 15 23 31 7 11 17 18 11 20 0 AUS CAN GER NETH

Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care. Source: 2007 Commonwealth Fund International Health Policy Survey.

Data collection: Harris Interactive, Inc.

NZ UK 27 US THE COMMONWEALTH FUND

Summary of Findings • Country patterns reflect underlying insurance design and strategic policy choices – Universal coverage and benefit design matters – The U.S. stands out for financial barriers that undermine care and often for symptoms of inefficiency • Experiences in all countries indicate the need for more integrated, patient-centered care “systems” • In each country, having a “Medical Home” that is accessible and coordinates care improves patient experiences – Patient safety – Coordination: with specialists/across sites of care; duplication and delays – Patient-centeredness and satisfaction – Managing chronically ill patients THE COMMONWEALTH FUND

Conclusions • No country systematically leads in performance • Variations in health system performance offer opportunities for cross-national learning • Three major challenges: - Better coordination of care - New approaches to managing patients with complex chronic illnesses - Primary care redesign and workforce strategy • Amenable to policy action and changes in practice and essential to achieving a high performance health care system THE COMMONWEALTH FUND

Acknowledgments • C. Schoen, R. Osborn, M. Doty, M. Bishop, J. Peugh, N. Murukutla, “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007,” Health Affairs Web Exclusive (Oct. 31, 2007). With appreciation to: • Develop and conduct survey: Harris Interactive, Inc.

• Conduct survey in the Netherlands: The Center for Quality of Care Research (WOK), Radboud University Nijmegen • Co-funders: The German Institute for Quality and Efficiency in Health Care, the Dutch Ministry for Health, and the Health Council of Canada THE COMMONWEALTH FUND