Dr. Eric Schneider's presentation on international health policy and practice. This presentation was delivered at the 2015 AcademyHealth Annual Research Meeting on June 14, 2015.

1. International Health Policy and Practice:
Comparing the U.S. and Canada on
Access and Equity
Eric Schneider, MD, MSc
Senior Vice President for
Policy and Research
1

2. Outline
• Why compare countries’ health care systems?
• The Commonwealth Fund International Health
Policy Survey(s)
• Are we as good as our neighbors to the
north/south?
2

3. Why Compare Countries’ Health Care Systems?
“Americans have the best
health care system in the
world” - 2004
President Delivers State
of the Union Speech
3

4. International Trends in Health Spending
Health 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.
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
1980
1984
1988
1992
1996
2000
2004
2008
2012
US
SWIZ
GER
CAN
FR
JPN
UK
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
1980
1984
1988
1992
1996
2000
2004
2008
2012
US
FR
SWIZ
GER
CAN
JPN
UK
$9,077
$4,602
10.9%
16.9%
4

5. Adults’ 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 of adults
5

6. • 17th year of an 11-country survey (began in 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)
6

7. What do we hope to learn?
• Identify shared goals and strategies
– Inform US policy reform efforts
– Identify potentially transferable innovations
• Measurement
– To expand the portfolio of internationally-
comparable metrics used to compare country
performance and track the impact of reforms
– “What works” and “what doesn’t”
7

8. Areas Studied
 Quality improvement
 Chronic illness/management
 Use of the ED
 Hospital care
 Medication use
 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 respondent observations (less on opinions)
• General themes:
8

9. Survey Sample
Total
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
9

10. 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
10

11. “Mirror, Mirror” Ranking of
Health Care System Performance
11

12. 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)
12

13. Media Coverage of Mirror, Mirror
Mirror, Mirror is the
most frequently viewed
publication on the
Fund’s website
134,000
233,608
0
50,000
100,000
150,000
200,000
250,000
Mirror, Mirror 2010 Mirror, Mirror 2014
Page Views*
*Views since June 2014 for 2014 edition; views from 2010-2013 for 2010 edition.
Findings published annually in Health Affairs.
13

14. Ranking of Canada and US Health Care
System Performance: Access and Equity
CANADA USA
ACCESS 9 9
COST-RELATED PROBLEM 5 11
TIMELINESS OF CARE 11 5
EQUITY 9 11
14

15. Percent of adults who(se):
Cost-Related Access Problems
15
Source: (1) 2013 Commonwealth Fund International Health Policy Survey; (2) 2012
International Survey of Primary Care Doctors
Didn’t fill prescription;
skipped medical test,
treatment or follow-up; or
had medical problem but did
not visit doctor in past year
due to cost1
Insurance denied payment
for medical care or did not
pay as much as expected1
Had serious problems paying
or was unable to pay medical
bills1
Physicians think their
patients often have difficulty
paying for medications or
out-of-pocket costs2
13
14
7
26
14
37
28
23
59
41
0 25 50 75 100
Canada
US
15
Out-of-pocket expenses
for medical bills > $1,000
in past year, = to USD1

16. Timeliness of Care
51
62
48
29
18
59
61
28
6
7
0 25 50 75 100
Canada US
Last time needed medical
attention, was able to see
doctor or nurse the same or
next day3
Very or somewhat difficult
to get medical care in the
evening, weekend, or on a
holiday without going to
the emergency room1*
Waiting time for emergency
care was 2 hours or more1**
Percent of patients reported:
Source: (1) 2013 Commonwealth Fund International Health Policy Survey; (3) 2011 Commonwealth Fund International Health
Policy Survey of Sicker Adults in Eleven Countries; *base: sought after-hours care; **base: used an emergency room in past 2
years; ***base: saw or needed to see a specialist in past 2 years; ****base: those needing elective surgery in past year
16
Waiting time to see a
specialist was 2 months or
more1***
Waiting time of 4 months
or more for elective/
nonemergency
surgery1****

17. Timeliness of Care Cont’d
Source: (2) 2012 International Survey of Primary Care Doctors
23
29
8
6
0 5 10 15 20 25 30 35 40 45 50
Canada US
Patients often experience
difficulty getting
specialized tests (e.g., CT,
MRI)2
Patients often experience
long wait times to receive
treatment after diagnosis2
17
Percent of doctors who reported:

18. Equity Measures: U.S. and Canada
Source: (1) 2013 Commonwealth Fund International Health Policy Survey; (3) 2011 Commonwealth Fund International Health
Policy Survey of Sicker Adults in Eleven Countries
12
17
7
14
8
6
9
3
4
4
0 20 40 60 80 100
Canada - low income
Canada - high income
8
4
10
4
Rated doctor
fair/poor1
Did not get
recommended test,
treatment, or follow-
up because of cost in
past year1
18
Percent of patients who:
Rated quality of
care fair/poor3
Had medical problem
but did not visit
doctor because of
cost in the past year1
Did not fill prescription
or skipped doses
because of cost in the
past year1
15
27
39
31
30
6
7
17
11
12
0 20 40 60 80 100
US - low income
US - high income
9
20
22
20
18
6

19. Equity Measures: U.S. and Canada
55
67
29
48
10
47
59
30
43
9
0 20 40 60 80 100
Canada -low income
Canada -high income
8
8
1
5
1
Last time needed
medical attention
not able to see
doctor or nurse
same or next day3
Somewhat or very
difficult to get care
on evenings,
weekends, or
holidays1*
Waited 2 months
or longer for
specialist
appointment1**
19
Percent of Patients who report:
Source: (1) 2013 Commonwealth Fund International Health Policy Survey; (3) 2011 Commonwealth Fund International Health Policy Survey ofSicker
Adults in Eleven Countries; *base: sought after-hours care; **base: needed to see specialist in past 2 years; ***base: those going to ER
Waited 2 hours
or more in
ER1***
Unnecessary
duplication of
medical tests in
past 2 years3
45
70
9
36
19
39
53
4
16
14
0 20 40 60 80 100
US -low income
US -high income
6
17
5
20
5

20. Other Dimension Rankings: Canada and US Health
Care System Performance
CANADA USA
QUALITY CARE 9 5
EFFECTIVE CARE 7 3
SAFE CARE 10 7
COORDINATED CARE 8 6
PATIENT-CENTERED CARE 8 4
EFFICIENCY 10 11
HEALTHY LIVES 8 11
OVERALL RANKING 10 11
20

21. Conclusions
• Comparison of countries’ health systems with
systematically-collected data can offer a useful
antidote to conventional wisdom
• Tracking results can inform national policy
discussions and research on policy and
delivery system reforms, both in the U.S. and
in other countries
21

22. 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. 22

23. Acknowledgements
CMWF IHP Survey Team
23

24. References
1.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.
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25. APPENDIX
25

26. 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)
26