Figure 1. Percent of Patients Seen by 10 or More Physicians Varies Across Academic Medical Centers Average percentage of patients seeing 10+ different physicians in first year of care within AMC hospitals 40 30 20 Lowest quintile 35 16 20 Middle quintiles 15 17 25 Highest quintile 32 25 18 10 0 Hip Fracture Colorectal Cancer

Note: Quintiles of practice intensity (“treatment groups”) corresponded closely to regional differences in price and to illness-adjusted Medicare spending.

Source: E.S. Fisher et al., “Variations in the Longitudinal Efficiency of Academic Medical Centers,”

Health Affairs

Web Exclusive, October 7, 2004.

Acute Myocardial Infarction THE COMMONWEALTH FUND

Figure 2. Private-Public Collaboration Needed to Improve Availability of Quality and Cost Information Comprehensive HDHP/CDHP Health plan provides information on quality of care provided by: Doctors Hospitals Health plan provides information on cost of care provided by: Doctors Hospitals Of those whose plans provide info on quality, how many tried to use it for: Doctors Hospitals Of those whose plans provide info on cost, how many tried to use it for: Doctors Hospitals 14% 14 16 15 42 25 15 14 16% 15 12 12 54 45 36 ( n = 76) 32 ( n = 76)

Source: P. Fronstin, S.R. Collins,

Early Experience with High-Deductible and Consumer-Driven Health Plans: Findings From the EBRI/Commonwealth Fund Consumerism in Health Care Survey

, EBRI Issue Brief, December 2005.

THE COMMONWEALTH FUND

Figure 3. Physicians’ Access to Quality-of-Care or Performance Data on Their Own Care Percent receiving data on the following aspects of patient care 100 50 20 18 25 0 Process of Care Data Clinical Outcomes Data Patient Survey Data 33 Any Data THE COMMONWEALTH FUND

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

Figure 4. Availability of Quality-of-Care Data When Making Referrals Percent indicating how often they have any data about a physician’s quality of care when making referrals Sometimes 16% Rarely 32% 64% Often 14% Always 5% Never 32%

Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

THE COMMONWEALTH FUND

Dollars Figure 5. Hospital Charges for AMI–Medical Management Vary Eight-Fold Across Large Pennsylvania Hospitals $100,000 88,457 $80,000 $60,000 $40,000 $20,000 10,592 14,020 14,871 Lowest mortality hospital $21,846* 24,012 29,672 18,596 19,294 43,636 64,627 $0

*This hospital demonstrated significantly lower than expected in-hospital mortality rates. Note: Hospital charge equals patient total charge excluding professional fees; all hospitals shown provided advanced cardiac services (angioplasty/stent procedures), had >100 cases, and <5% of cases transferred to another acute care facility. Source: Pennsylvania Health Care Cost Containment Council, Hospital Performance Results, Hospital discharges between January 1, 2003 and December 31, 2003, www.phc4.org

.

THE COMMONWEALTH FUND

Figure 6. Top-Ranked and Bottom-Ranked Performances in Measures of Quality of Care for AMI, CHF, and Pneumonia Among the 40 Largest Hospital-Referral Regions* Hospital-Referral Region Top-ranked

Boston, MA Minneapolis, MN Kansas City, MO Albany, NY Indianapolis, IN

Bottom-ranked

Little Rock, AK Orlando, FL Miami, FL Memphis, TN San Bernardino, CA

AMI Score (%)

95 94 94 93 92 86 86 85 84 83

Hospital-Referral Region Top-ranked

Boston, MA Detroit, MI Baltimore, MD Camden, NJ Cleveland, OH

Bottom-ranked

San Diego, CA Nashville, TN Orlando, FL Little Rock, AK Lexington, KY

CHF Score (%) Hospital-Referral Region

89 88 87 87 86

Top-ranked

Oklahoma City, OK Indianapolis, IN Kansas City, MO Camden, NJ 77 76 74 Knoxville, TN

Bottom-ranked

Miami, FL Chicago, IL San Diego, CA 69 68 Los Angeles, CA San Bernardino, CA

Pneumonia Score (%)

82 79 78 78 77 63 61 60 60 59 *AMI denotes acute myocardial infarction, and CHF congestive heart failure.

Source: A K. Jha, Z. Li, E. J. Orav, and A. M. Epstein, “Care in U.S. Hospitals—The Hospital Quality Alliance Program,”

New England Journal of Medicine

353 (July 21, 2005): 265 –74.

THE COMMONWEALTH FUND

Figure 7. Physicians’ Willingness to Share Quality-of-Care Data Willingness to share data with:* Medical leadership Physicians’ own patients General public Other physicians Yes, Definitely/ Probably 71% 55% 29% 72% No, Definitely/ Probably Not 27% 44% 69% 26%

*Answers to survey question: “To improve high quality of care in the U.S., which of the following do you think should have access to ‘Quality of Care’ data about individual physicians?” Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.

THE COMMONWEALTH FUND

Figure 8. Hospital CEO Opposition to Disclosure of Quality Information to the Public Percent saying should NOT be released to the public: Mortality rates for specific conditions Frequency of specific procedures Medical error rate AUS 34% 16 31 Patient satisfaction ratings Average waiting times for elective procedures Nosocomial infection rates 5 6 25 CAN 26% 5 18 2 1 10 NZ 18% 4 25 0 0 25 UK 16% 13 15 1 1 9 US 31% 15 40 17 29 29 THE COMMONWEALTH FUND

Source: The Commonwealth Fund 2003 International Health Policy Survey of Hospital Executives.

Figure 9. Most Costs Are Concentrated in the Very Sick Distribution of Health Expenditures for the U.S. Population, 0% 10% 1% 5% 10% By Magnitude of Expenditure, 1997 Expenditure Threshold (1997 Dollars) 20% 30% 27% $27,914 40% 50% 60% 70% 80% 90% 100% 50% 55% 69% 97% $7,995 $4,115 $351 U.S. Population Health Expenditures THE COMMONWEALTH FUND

Source: A.C. Monheit, “Persistence in Health Expenditures in the Short Run: Prevalence and Consequences,”

Medical Care

41, supplement 7 (2003): III53 –III64.

Figure 10. Most Trusted Sources for Information on Health Care Providers, by Insurance Source Percent of adults 21-64 Your doctor 43 42 Consumer group Family member or friend Medical association 15 16 20 25 Comprehensive HDHP/CDHP Own health plan Government or other agency 2 2 4 6 8 10 0 20 40

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

60 THE COMMONWEALTH FUND

Figure 11. “Perception that Health Care Is Free”*Is Not the Problem National Health Expenditures per Capita, US$ 6000 United States 5000 4000 3000 2000 Netherlands Germany France New Zealand Canada OECD Median Japan a Australia 1000 0

a

0 100 200 300 400 500 600 700 800 900

a 2002

Out-of-Pocket Health Care Spending per Capita, US$

*Allan Hubbard, Director of the National Economic Council, February 14, 2006.

Note: Adjusted for Differences in the Cost of Living, 2003.

Source: Bianca K. Frogner and Gerard F. Anderson, “Multinational Comparisons of Health Systems Data, 2005,” The Commonwealth Fund, Forthcoming.

THE COMMONWEALTH FUND

Figure 12. Consumers Spending More Out-of-Pocket for Health Care Dollars spent per capita (in 2004 dollars) 900 800 700 600 500 400 300 200 100 0 $577 $583 $774 $667 $788 19701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004

Source: C. Smith et al., “National Health Spending in 2004: Recent Slowdown Led by Prescription Drug Spending,”

Health Affairs

25, no. 1 (January/February 2006); Centers for Medicare and Medicaid Services, National Health Expenditures Data; http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf

THE COMMONWEALTH FUND

Figure 13. Nearly One of Six Families Spent 10% or More of Income (or 5% or More if Low Income) on Out-of-Pocket Medical Costs, 2001–02 Percent of families with high out-of-pocket medical costs relative to income, not including premiums 20 Spent >10% of income Spent >10% of income, or >5% of income if low-income* 15 12 11 10 8 0 1996–97 2001–02

*Low-income includes families with incomes <200% of the federal poverty level.

Source: M. Merlis, D. Gould and B. Mahato,

Rising Out-of-Pocket Spending for Medical Care: A Growing Strain on Family Budgets

(New York: The Commonwealth Fund) February 2006.

THE COMMONWEALTH FUND

Figure 14. Cost-Sharing Reduces Use of Both Essential and Less Essential Drugs and Increases Risk of Adverse Events Percent reduction in drugs per day 25 Elderly Low Income 22 20 14 15 15 10 5 9 0 Essential Less Essential Percent increase in incidence per 10,000 140 120 100 80 60 40 20 0 Elderly 117 97 Low Income 43 78 Adverse Events ED Visits

Source: R. Tamblyn et al., “Adverse Events Associated With Prescription Drug Cost-Sharing Among Poor and Elderly Person,”

JAMA

285, no. 4 (2001): 421 –429.

THE COMMONWEALTH FUND

Figure 15. Distribution of Individuals Covered by Private Health Insurance, by Type of Health Plan CDHP HDHP 1% 9% Comprehensive 89%

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 16. FEHBP HDHP/HSAs Plans Enroll 7,500 out of 9 Million Covered Lives Percent 25 20 15 10 5 0 6.4

Percent of FEHBP plans that are HDHP/HSAs 0.1

Percent of FEHBP enrollees that are in HDHP/HSAs

Note: As of March 2005.

Source: Government Accountability Office,

Federal Employees Health Benefits Program First-Year Experience with High-Deductible Health Plans and Health Savings Accounts

, Washington, DC: GAO, January 2006; OPM, http://www.opm.gov/insure/handbook/FEHBhandbook.pdf

THE COMMONWEALTH FUND

Figure 17. Enrollees Who Chose HDHPs from the Federal Employees Health Benefits Program Are More Likely to Earn Higher Incomes Percent of FEHBP enrollees with incomes ≥ $75,000 75 50 25 43 23 0 HDHP All FEHBP plans

Source: Government Accountability Office,

Federal Employees Health Benefits Program First-Year Experience with High-Deductible Health Plans and Health Savings Accounts

, Washington, DC: GAO, January 2006.

THE COMMONWEALTH FUND

Figure 18. Age Distribution of HDHP and Other FEHBP Enrollees Percent FEHBP enrollees 35 HDHP enrollees 30 25 20 15 10 5 0 <23 23-34 35-44 45-54 All FEHBP enrollees 55-64 65-74 75-99 >99

Source: Government Accountability Office,

Federal Employees Health Benefits Program First-Year Experience with High-Deductible Health Plans and Health Savings Accounts

, Washington, DC: GAO, January 2006.

THE COMMONWEALTH FUND

Figure 19. Percentage of Individuals Covered by Employment-Based Health Benefits With No Choice of Health Plan, by Type of Health Plan 80 60 40 20 0 34 Comprehensive 51 HDHP 52 CDHP

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 20. Satisfaction with Quality of Health Care Received, by Type of Health Plan 80 60 40 20 0 Comprehensive 72 52 63 HDHP 23 34 28 CDHP 4 14 9 Extremely or very satisfied Somewhat satisfied Not satisfied

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

80 60 40 20 0 Figure 21. Satisfaction with Out-of-Pocket Costs for Health Care, by Type of Health Plan Comprehensive HDHP CDHP 42 12 18 36 31 28 21 57 54 Extremely or very satisfied Somewhat satisfied Not satisfied

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

80 60 40 20 0 Figure 22. Satisfaction with Choice of Doctors, by Type of Health Plan 73 60 Comprehensive 69 HDHP CDHP 21 29 21 6 11 10 Extremely or very satisfied Somewhat satisfied Not satisfied

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 23. Overall Satisfaction with Health Plan, by Type of Health Plan Comprehensive HDHP CDHP 80 60 40 20 0 63 33 42 Extremely or very satisfied 28 39 32 Somewhat satisfied 8 29 26 Not satisfied

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 24. Likelihood of Staying With Current Health Plan If Had the Opportunity to Change, by Type of Health Plan 80 60 40 20 0 61 Comprehensive 30 46 28 37 HDHP 21 CDHP 11 33 33 Extremely or very likely to stay Somewhat likely to stay Not likely to stay

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 25. Likelihood of Recommending Health Plan to Friend or Co-Worker, by Type of Health Plan 80 60 40 20 0 51 Comprehensive 22 34 26 34 HDHP CDHP 31 Extremely or very likely Somewhat likely 24 43 35 Not likely

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 26. Percent of Income Spent Annually on Out of-Pocket Medical Expenses, Including Premiums Percent of adults 21-64 spending ≥ 5% of income 100 10%+ of income 5-9% of income 92 80 60 40 20 0 3

Co mp reh en sive

12 9 42 29 13

HD HP CD HP

Total 31 23 9 66 (n = 61) 53 58 38 (n = 90) 34 44 35 4 17 13 18 26 12 25 10 33 21

Co mp reh en sive HD HP CD HP Co mp reh en sive

Health Problem**

HD HP CD HP

<$50,000 Annual Income

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

**Health problem defined as fair or poor health or one of eight chronic health conditions.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 27. Percent of Adults Who Have Delayed or Avoided Getting Health Care Due to Cost Percent of adults 21–64 60 40 20 17 31 Comprehensive 35 HDHP 31 40 (n = 90) 21 CDHP 42 48 (n = 61) 26 0 Total Health Problem** <$50,000 Annual Income

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

** Health problem defined as fair or poor health or one of eight chronic health conditions.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 28. Percent of Adults Who Have Skipped Doses to Make a Medication Last Longer Percent of adults 21-64 with prescriptions in last 12 months 60 40 20 Comprehensive 15 26 20 20 35 HDHP 29 (n = 85) CDHP 21 32 28 (n = 50) 0 Total Health Problem** <$50,000 Annual Income

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

** Health problem defined as fair or poor health or one of eight chronic health conditions.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 29. Percent of Adults Who Have Not Filled a Prescription Due to Cost Percent of adults 21–64 60 Comprehensive HDHP CDHP 40 20 16 26 20 21 33 26 (n = 90) 27 32 25 (n = 61) 0 Total Health Problem** <$50,000 Annual Income

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

**Health problem defined as fair or poor health or one of eight chronic health conditions.

Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.

THE COMMONWEALTH FUND

Figure 30. Medical Bill or Debt Problems in Past Year, by Size of Deductible Percent of adults ages 19–64 with any medical bill problem or outstanding debt* 60 54

^

46

^

40 39

^

24 20 0 $1,000 or more $500–$999 $1–$499 Size of deductible None

Note: Adjusted percentages based on logistic regression models; controlling for health status and income.

*Problems paying/not able to pay medical bills, contacted by a collection agency for medical bills, had to change way of life to pay bills, or has medical debt being paid off over time.

^Significant difference at p < .05 or better; referent category = no deductible.

THE COMMONWEALTH FUND

Source: The Commonwealth Fund Biennial Health Insurance Survey (2003).

Figure 31. HSAs Won’t Solve the Uninsured Problem: Income Tax Distribution of Uninsured 5% (27% tax bracket) 1% (30%-39% tax bracket) 23% (15% tax bracket) 55% (0% tax bracket) 16% (10% tax bracket)

Source: S.A. Glied,

The Effect of Health Savings Accounts on Health Insurance Coverage

, The Commonwealth Fund, April 2005.

THE COMMONWEALTH FUND

Figure 32. Medicare Physician Group Practice Demonstration • The Everett Clinic (WA) • Deaconess Billings Clinic • Park Nicollet Health Services (MN) • Marshfield Clinic (WI) • St. John’s Health System (MO) • Univ. of Michigan Faculty Group Practice • Geisinger Health System (PA) • Forsyth Medical (NC) • Middlesex Health (CN) • Dartmouth-Hitchcock Clinic • 10 physician group practices • 3-year project, began April 2005 • Bonus pool based on savings relative to local area • Practices expected to save 2%, keep up to 80% of additional savings • Actual bonuses depend on savings and quality targets THE COMMONWEALTH FUND

Source: “Medicare Physician Group Practice Demonstration,” www.cms.gov

, January 31, 2005.

Figure 33. Building Quality Into RIte Care Higher Quality and Improved Cost Trends Percent 160 140 120 100 80 60 40 20 0 Cumulative Health Insurance Rate Trend Comparison RI Commercial Trend RIte Care Trend • Quality targets and $ incentives • Improved access, medical home – One third reduction in hospital and ER – Tripled primary care doctors – Doubled clinic visits • Significant improvements in prenatal care, birth spacing, lead paint, infant mortality, preventive care 1995 1997 1999 2001 2003

Source: Silow-Carroll,

Building Quality into RIte Care,

Commonwealth Fund, 2003.

Tricia Leddy,

Outcome Update,

Presentation at Princeton Conference, May 20, 2005.

THE COMMONWEALTH FUND