Aiming for a Higher Performing Health Care System: Learning from Cross-National Comparisons

Aiming for a Higher Performing Health Care System:
Learning from Cross-National Comparisons
Queen’s Health Policy Change Conference
May 6, 2015
Toronto, Canada
Robin Osborn
Vice President and Director
International Program in Health Policy and Practice Innovations
The Commonwealth Fund
1

What is a High Performing Health System?
• Goals of a High Performance Health System
• Best possible health outcomes for everyone
• Access to care for all
• Excellent patient experiences – patient-centered,
coordinated, high quality, safe care for all
• Lower cost – accountable for use of resources and
elimination of waste
• Encourages innovation
• Learning health care system
2

Why Do We Do Cross-National Comparisons?
• Benchmark performance
• Track policies and reforms
• Highlight best practices
• Identify variations
• Know what is possible
3

0
2
4
6
8
10
12
14
16
18
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010
US (16.9%)
NET (12.1%)*
FR (11.6%)
SWIZ (11.4%)
GER (11.3%)
DEN (11.0%)
CAN (10.9%)
JPN (10.3%)
NZ (10.0%)*
SWE (9.6%)
NOR (9.3%)
UK (9.3%)
AUS (9.1%)*
GDP refers to gross domestic product.
Source: OECD Health Data 2014.
Health Care Spending as a Percentage of GDP, 1980–2012
Percent
* 2011
4

Mortality Amenable to Health Care, 2006-07
55 57 60 61 61 64 66
76 79 80 83
96
0
20
40
60
80
100
120
140
FR AUS ITA JPN SWE NOR NETH GER NZ DEN UK US
5
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke,
and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S.
Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income
Nations,” Health Policy, published online Sept. 12, 2011.
Deaths per 100,000 population*

6
Overall Views of Health Care System, 2013
Source: 2013 Commonwealth Fund International Health Policy Survey in Eleven Countries.
Percent

Learning from International Surveys
7

Commonwealth Fund Annual International Surveys:
What We Track
8
– QI/Performance feedback
– Chronic illness
– Use of the ED
– Hospital care
– Medications
– Physician payment/Incentives
– System complexity
– Health care coverage
– Demographics
• General themes:
– Views of the health system
– Access and affordability
– Primary care/Medical home
– Doctor-patient relationship
– Prevention/health promotion
– Care coordination
– Electronic Health Record
– Patient safety
• Focus on objective measures rather than opinions.

Cost-Related Access Problems in the Past Year,
Among Adults Age 65 or Older
* Had a medical problem but did not visit doctor, skipped medical test or treatment recommended
by doctor, and/or did not fill prescription or skipped doses because of the cost.
3 4 4
5 6 6
7 8
9 10
19
0
10
20
30
FR SWE NOR UK NETH SWIZ GER AUS CAN NZ US
Percent*
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults
in Eleven Countries.
10

Could Get Same- or Next-Day Appointment with Doctor or Nurse
When Sick or Needed Care, Among Adults Age 65 or Older
11
83 83 81
76
71 69
65
57
54 53
45
0
20
40
60
80
100
FR NZ GER NETH AUS SWIZ UK US NOR SWE CAN
Percent

Waited Less Than Four Weeks for Specialist Appointment,
12
86
82
71
64 62 61 60 60
50
46 46
0
20
40
60
80
100
US SWIZ NETH AUS NZ GER FR UK SWE CAN NOR
* Base: Saw/Needed to see a specialist in the past two years.
Percent*

Access to After-Hours Care,
13
77
71 69 69 66 66
62
55 54
41
37
0
20
40
60
80
100
NETH UK FR NZ SWIZ NOR GER US AUS CAN SWE
Source: 2012 and 2014 Commonwealth Fund International Health Policy Surveys.
* Base: Needed after-hours care.
Percent who said it was somewhat or very easy to get after-hours care
without going to the emergency department*

Emergency Department Use in the Past Two Years,
14
15
19
21
27 27
29 30
33
35
39 39
0
10
20
30
40
50
FR UK GER NOR SWIZ NETH AUS NZ SWE CAN US
Percent

15
Care Coordination and Transitions

Experienced a Coordination Problem in the Past Two Years,
16
7
20 21 21
24 24
29
32
35
37
41
0
10
20
30
40
50
FR NZ NETH AUS UK SWE SWIZ CAN US NOR GER
* Test results/records not available at appointment or duplicate tests ordered; received
conflicting information from different doctors; and/or specialist lacked medical history or
regular doctor was not informed about specialist care.
Percent*

Experienced Gaps in Hospital Discharge Planning in the
Past Two Years, Among Adults Age 65 or Older
17
28
38
41 44
54 56 56 59
67
70
0
20
40
60
80
100
US UK AUS CAN FR SWIZ GER NETH SWE NOR
* When discharged from the hospital: you did not receive written information about what to do when you returned home and
symptoms to watch for; hospital did not make sure you had arrangements for follow-up care; someone did not discuss with
you the purpose of taking each medication; and/or you did not know who to contact if you had a question about your condition
or treatment. Base: hospitalized overnight in the past two years.
Percent*
Note: NZ omitted because of small N (fewer than 100 respondents).

Primary Care Doctors’ Receipt of Information from Specialists
18
Source: 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
47
44 44
41
30
24 22
16
13 12
5
0
20
40
60
80
FR NZ SWIZ UK AUS CAN NOR US SWE GER NETH
Percent who reported after their patient visits a specialist they always receive information
about changes to patient’s drugs or care plan

19
Chronic Care and Self-Management

Patient Engagement in Chronic Care Management,
20
83
80
76
73
64 62
53
47
41 41
30
0
20
40
60
80
100
Percent who have a chronic condition and had a treatment plan for their condition they
could carry out in their daily life

Support for Self-Management Between Doctor Visits,
21
47
30 28
24 24 23
17 16 15 14
9
0
20
40
60
80
100
Contacts them to check in They can contact to ask questions or
get advice
84 83
75 75
71
67 65
58
55 53
43
Percent who have a chronic condition and had a health care professional that between
doctor visits:

Patients with a Regular Doctor versus a Medical Home, 2011
Patients with a medical home have a regular practice who is accessible,
knows them, and helps coordinate their care
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
23

Medical, Medication, or Lab Test Errors in Past Two Years,
by Medical Home
Percent*
* Reported medical mistake, medication error, and/or lab test error or delay in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.
24

25
Primary Care Practice Infrastructure and
Capacity for Improvement

Doctors’ Use of Electronic Medical Records
in Their Practice, 2009 and 2012
26
Source: 2009 and 2012 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Percent

Doctor Can Electronically Exchange Patient Summaries
and Test Results with Doctors Outside their Practice
27
55
52
49 49
45
39 38
31
27
22
14
0
20
40
60
80
100
NZ SWE NETH SWIZ NOR FRA UK US AUS GER CAN
Percent

Doctor Routinely Receives Electronic Prompts About
Potential Problems with Rx Dose or Interaction
28
93
89 88
85
70
58
41
30
26 25
22
0
20
40
60
80
100
NETH NZ AUS UK SWE US FRA CAN GER SWIZ NOR
Percent

Practice Uses Nurse Case Managers or Navigators
for Patients with Serious Chronic Conditions
29
Percent
78
73
68 68
59
51
44 43 41
20
0
20
40
60
80
100
UK NETH NZ SWIZ AUS NOR CAN US SWE GER
Note: Question asked differently in France.

Practice Routinely Receives and Reviews Data on Clinical Outcomes
30
84
81
78
64
54
47
42
23
14 12
0
20
40
60
80
100
UK NETH SWE NZ GER US AUS CAN FR SWIZ
Percent

Financial Incentives and Targeted Support
31
Percent can
receive financial
incentives* for:
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK US
Managing patients
w/ chronic
disease or
complex needs
75 70 37 60 77 83 15 49 4 50 21
Enhanced
preventive care
activities**
42 42 12 23 28 40 17 55 5 37 14
Adding
nonphysician
clinicians to
practice
53 33 3 5 60 36 9 33 4 17 10
Making home
visits
57 53 16 51 50 36 45 49 32 20 9
* Including special payments, higher fees, or reimbursements.
** Including patient counseling or group visits.

Policy Implications
32
• Insurance design matters
• Having a “medical home” and after-hours care arrangements make a difference
• Innovations in payment and delivery system models are needed to encourage
care coordination and better management of complex patients
• Chronically ill patients need to be further empowered and supported in self-
management, including between scheduled visits
• Having electronic medical records is not enough – “meaningful use” matters
• More use of performance data and feedback are needed to help primary care
practices improve care and patient experiences
• And, as countries innovate and transform their health care systems, there is a
tremendous opportunity for cross-national learning

Limitations of Current Cross-National Comparisons
• Imperfect performance measures:
o Rely heavily on Commonwealth Fund surveys
o Outcome indicators are scarce
o Few measures of hospital quality
o Data does not always lead to a value judgment (e.g., are
more MRI machines good or bad?)
• Proliferation of country measures but not typically adopted
based on international comparability
• We need more patient-reported outcome measures
• Defining high performance requires subjective judgments
• Numbers don’t tell the full story
33

Monitoring & Tracking Performance:
U.S. Efforts
34

Overall Health System Performance, 2014
35
Source: The Commonwealth Fund State Scorecard
Ranking based on access & affordability, prevention & treatment,
avoidable hospital use and cost, healthy lives, and equity

Long Term Supports:
Overall Health System Performance, 2014
36
Source: The Commonwealth Fund Scorecard on Long Term Support Services
Ranking based on access & affordability, choice of setting and provider, quality of life and quality of
care, support for family caregivers, and effective transitions

Quality: Mortality Amenable to Health Care,
by Race and State, 2009-10
37
Source: Commonwealth Fund State Scorecard on State
Health System Performance, 2014

Access: Out-of-Pocket Mean Expenditures, by Race/Ethnicity
38
Source: Center for Financing, Access, and Cost Trends, AHRQ, Household
Component of the Medical Expenditure Panel Survey, 2012
Annual out-of-pocket mean expenditures by race/ethnicity

Quality: Preventable Hospitalizations in New York State,
by County
39
Age Adjusted Preventable Hospitalizations Rate per 10,000, Ages 18+ Years, 2008-10
Source: Health Data NY
The Prevention Quality Indicators (PQIs) are a set of measures developed by the federal Agency for Healthcare Research and Quality (AHRQ) for use
in assessing the quality of outpatient care for "ambulatory care sensitive conditions" (ACSCs). This indicator is defined as the combination of the 12
PQIs that pertain to adults: (1)Short-term complication of diabetes (2)Long-term complication of diabetes (3)Uncontrolled diabetes (4)Lower-extremity
amputation among patients with diabetes (5)Hypertension (6)Congestive heart failure (7)Angina (8)Chronic obstructive pulmonary disease (9)Asthma
(10)Dehydration (11)Bacterial pneumonia (12)Urinary tract infection.
1st & 2nd Quartiles
(<144 per 10,000)
3rd Quartile
(144-<162 per 10,000)
4th Quartile
(162+ per 10,000)

Quality: Readmission Rates, by Hospital
40
Heart Failure 30 Day Readmission Rate, by Hospital, 2010-13
Source: CMS Hospital Compare
Percent
High Performing Hospitals* Low Performing Hospitals**
* Examples from top 10% of hospitals
**Examples from bottom 10% of hospitals

Quality: Falls in Long Term Care Institutions,
by Nursing Home
41
Percent of Long-Stay Residents Experiencing One or More Falls with Major Injury, 2014
Source: CMS Nursing Home Compare
Percent
High Performing Nursing Homes* Low Performing Nursing Homes**
* Examples in top 10% of nursing homes
** Examples from bottom 10% of nursing homes

Acknowledgements
With appreciation to Dana Sarnak, David Squires, and Michelle Doty for their
contributions to this presentation.
And, to our International Survey Partners for their support and expertise:
• 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 German 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

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