THE COMMONWEALTH

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The Commonwealth Fund 2013 International Health Policy Survey

in Eleven Countries

Robin Osborn and Cathy Schoen The Commonwealth Fund

November 2013

THE COMMONWEALTH

FUND

The Commonwealth Fund 2013 International Health Policy Survey in Eleven Countries

•  Survey of adults age 18 and older in eleven countries.

•  Sample sizes: 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), United States (2,002).

•  Survey in the field February to June 2013.

•  Conducted by Social Science Research Solutions and country contractors (by landline and cell phone).

•  Presentation topics: affordability and cost-related access barriers; access to primary care, emergency department, and specialist care; complexity; and system views.

2

THE COMMONWEALTH

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3 3

Affordability and Cost-Related Access Barriers

THE COMMONWEALTH

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$8,508

$5,669 $5,643 $5,099

$4,522 $4,495 $4,118 $3,925 $3,800

$3,405 $3,182

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

$9,000

US (17.7%)

NOR (9.3%)

SWIZ (11.0%)

NETH (11.9%)

CAN (11.2%)

GER (11.3%)

FR (11.6%)

SWE (9.5%)

AUS (8.9%)*

UK (9.4%)

NZ (10.3%)

Health Spending per Capita, 2011 Adjusted for Differences in Cost of Living

* 2010. Source: OECD Health Data 2013.

% GDP

$US

4

THE COMMONWEALTH

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5 5 Key National Insurance Design and

Cost-Sharing Policies, 2013

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US*

Deductible No No No No Yes No No No Yes No Yes Caps on out-of-pocket spending

Yes No No Yes No No Yes Yes Yes No No

Core benefit

Drugs ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ Dental (adults) ✔ ✔ ✔ ✔

* Before insurance market reforms take effect in 2014. Source: S. Thomson, R. Osborn, D. Squires, and M. Jun, International Profiles of Health Care Systems, 2013, The Commonwealth Fund, Nov. 2013.

THE COMMONWEALTH

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6 6

4 6 10 13 13 15 16 18 21 22

37

0

10

20

30

40

50

60

Cost-Related Access Barriers and Out-of-Pocket Costs in the Past Year

Percent

2 3 7 7 9 11 14 17

24 25

41

Experienced cost-related access problem*

Spent US$1,000 or more out-of-pocket

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries. * Did not fill/skipped prescription, did not visit doctor with medical problem, and/or did not get recommended care.

THE COMMONWEALTH

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7 7

1 4 6 7 7 8 9 10 10

13

23

0

10

20

30

40

UK SWE NOR CAN GER AUS NETH NZ SWIZ FR US

Serious Problems Paying or Unable to Pay Medical Bills in the Past Year

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

THE COMMONWEALTH

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8

10 10 11

19 22 23 26 27 27 28

41

8 12

25 19

11

21

6

20

33 29 32

0

15

30

45

60

75

GER SWE NOR NETH SWIZ CAN UK FR US AUS NZ

Did not visit dentist/hygenist/dental clinic in past two years Skipped dental care because of cost in past year

Gaps in Dental Care

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

THE COMMONWEALTH

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9 9 Cost and Access Problems in the Past Year for U.S. Adults,

by Insurance Status

42

15

27

39

42

63

0 20 40 60 80 100

Spent $1,000 or more out-of-pocket

Serious problems/ unable to pay medical bills

Experienced cost- related access

problem

Uninsured Insured all year

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

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10 10

Access: Primary Care, Emergency Department Use, and Specialist Care

THE COMMONWEALTH

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11 11

76 72 63 58 58 57 52 52 48

41

0

25

50

75

100

Access to Doctor or Nurse When Sick or Needed Care

Percent

5 14 14 15 16 16

22 26 28 33

Same-day or next-day appointment

Waited six days or more for appointment

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

Note: Question asked differently in Switzerland.

THE COMMONWEALTH

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12

90 84 84 82 80 79 78 75 73

67 63

0

20

40

60

80

100

GER NETH SWE SWIZ NZ AUS NOR UK US CAN FR

When Calling Regular Doctor with a Question, Always or Often Hear Back on the Same Day

Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

THE COMMONWEALTH

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13

69 58 56 56 54 49 46

39 38 36 35

0

20

40

60

80

100

Access to After-Hours Care

Percent 95 95 90 90

81 80 78 76 68

46 35

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

Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.

Base: Needed care after hours. * In Norway, doctors asked whether their practice had arrangements or there were regional arrangements.

THE COMMONWEALTH

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14

22 22 24 27 28 28 28 31 32 39 41

48

0

25

50

75

AUS GER NETH UK NZ NOR SWIZ FR SWE US CAN

Used the Emergency Department in Past Two Years Percent

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

US Uninsured

THE COMMONWEALTH

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15 15 Patients’ Email Access to Regular Practice

AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US

Adults, 2013 Can email practice with questions

24 10 9 19 32 16 22 20 29 25 28

Have emailed practice in past two years

9 2 2 3 20 5 6 9 15 13 6

Primary care doctors, 2012 Patients can email practices with questions

21 11 39 45 47 39 27 44 68 35 35

Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.

THE COMMONWEALTH

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16 16

80 80 76 75 72 59 54 51 51 46

39

0

25

50

75

100

Wait Times for Specialist Appointment

Percent

3 3 6 7 10 17 18 18 19

26 29

Less than four weeks Two months or more

Base: Needed to see specialist in the past two years. Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

THE COMMONWEALTH

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Complexity

THE COMMONWEALTH

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$35 $55 $70 $128 $148

$199 $237 $266 $277

$606

$0

$100

$200

$300

$400

$500

$600

$700

NOR SWE AUS NZ CAN NETH GER SWIZ FR US

Spending on Health Insurance Administration per Capita, 2011 Adjusted for Differences in Cost of Living

* 2010. Source: OECD Health Data 2013.

$US

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THE COMMONWEALTH

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Adults, 2013 Insurance did not cover as expected/spent a lot of time on paperwork in

past year*

Insurance Complexity and Restrictions Create Concerns for Patients and Doctors

4 4 7 8 15 16 17 19 23 25

32

0

25

50

75 Percent

10 11 12 12 18 20 23 24 28

41

54

Primary care physicians, 2012 Insurance coverage restrictions

pose major time concern**

Source: 2012 and 2013 Commonwealth Fund International Health Policy Surveys.

* 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.

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THE COMMONWEALTH

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20 20 Overall Views of Health Care System, 2013

Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.

25 40 42 42 44 46 47 48 51 54

63

48 49

50 48 46 42

45 43

44 40

33

27 11

8 10 10

12 8 9

5 7 4

0% 20% 40% 60% 80% 100%

US FR

CAN GER SWE NOR

NZ AUS

NETH SWIZ

UK

Works well, only minor changes Fundamental changes Completely rebuild

Percent

THE COMMONWEALTH

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21 21 Insights from Global and Domestic Perspectives

•  Insurance coverage and insurance design matter for ensuring access and affordability

•  Insurance and payment policies targeted at primary care can strengthen access, including after-hours care

•  Complexity can pose significant health system costs o  U.S. provides a cautionary example

•  Controlling costs while safeguarding access will require vigilance regarding the impact of insurance design changes o  Especially for those vulnerable because of chronic disease or

limited incomes

•  Varying country insurance approaches provide rich insights looking forward

THE COMMONWEALTH

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Cofunded by: •  Australia: New South Wales Bureau of Health Information •  Canada: Health Council of Canada, Health Quality Ontario, Commissaire à

la Santé et au Bien–être du Québec, Health Quality Council of Alberta •  France: Haute Autorité de Santé (HAS), Caisse Nationale de l’Assurance

Maladie des Travailleurs Salariés (CNAMTS) •  Germany: Federal Ministry of Health, BQS Institute for Quality and

Patient Safety •  Netherlands: Dutch Ministry of Health, Welfare and Sport, and Scientific

Institute for Quality of Healthcare (IQ Healthcare) •  Norway: Norwegian Knowledge Centre for the Health Services •  Sweden: Swedish Ministry of Health and Social Affairs •  Switzerland: Federal Office of Public Health

Thanks to coauthors David Squires and Michelle M. Doty, and to Robyn Rapoport, Eran Ben-Porath, Social Science Research Solutions, and country contractors for conducting the survey.

Acknowledgments and Country Partners