The document compares the healthcare systems of the US and Canada based on data from the Commonwealth Fund's International Health Policy Survey. It finds that Canada outranks the US in several areas of healthcare system effectiveness, including quality of care, effective care, safe care, and coordinated care. Specifically, Canadians are more likely than Americans to report high quality experiences such as having their healthcare providers discuss treatment plans and contact them between visits. The US outperforms Canada in measures of timely access but lags in efficiency, equity, and healthy lives. Overall, the survey ranks Canada's healthcare system as 10th best globally and the US system as 11th.

1. International Health Policy and Practice:
Comparing the U.S. and Canada on
Effectiveness and Patient-centered Care
Eric Schneider, MD, MSc
Senior Vice President for Policy and Research

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

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

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%

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

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

7. What do we hope to learn?
• Shared goals and strategies: for reform and
increasing transferability of innovations
• Measurement: expanding portfolio of
internationally comparable metrics to
compare country performance and track
reforms, to know “what works” and “what
doesn’t”

8. Areas Studied
 Quality improvement
 Chronic illness/management
 Use of the ED
 Hospital care
 Medications
 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 objective measures rather than opinions.
• General themes:

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

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

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

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)

13. Media Coverage of IHP Survey Findings
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.

14. Ranking of Canada and US Health Care
System Performance: Effectiveness
CANADA USA
QUALITY CARE 9 5
EFFECTIVE CARE 7 3
SAFE CARE 10 7
COORDINATED CARE 8 6
PATIENT-CENTERED CARE 8 4

15. Percent of adults who had a chronic condition and:
Managing Patients with Chronic Conditions:
U.S. and Canada Older Adults
15
Source: 2014 Commonwealth Fund International Health Policy
Survey of Older Adults in Eleven Countries.
Health care professional
discussed goals and
gave instructions on
symptoms
Had a treatment plan
for their condition they
could carry out in their
daily life
Had a health care
professional that
contacted them
between visits
Had a health care
professional they
could contact to ask
questions
46
76
16
67
58
83
30
84
0 25 50 75 100
Canada US

16. Prevention: U.S. and Canada
23
39
35
51
54
69
30
49
52
67
70
77
0 25 50 75 100
Canada US
Physicians reporting it is
easy to print out list of
patients due or overdue for
tests/preventive care
Patients receive reminders
for preventive care
Patients sent computerized
reminder notices for
preventive or follow-up care
Doctor talked with patient
about exercise or physical
activity
Doctor talked with patient
about healthy diet and
healthy eating
Doctor talked with patient
about health risks and
ways to quit smoking
Percent reported:
Source: The Commonwealth Fund: 2014 Update “ Mirror, Mirror on the Wall”

17. Safe Care Measures: US and Canada
*Base: had a lab test ordered
Source: The Commonwealth Fund: 2014 Update “Mirror, Mirror on the Wall”
11
5
5
11
11
11
8
5
10
5
0 5 10 15 20 25 30 35 40 45 50
Canada USPercent of Patients who reported:
Believed a medical mistake
was made in treatment or
care in past 2 years
Given wrong medication or
wrong dose at pharmacy or
while hospitalized in past 2
years
Given incorrect results for
a diagnostic or lab test in
past 2 years*
Experienced delays in
being notified about
abnormal test results in
past 2 years*
Hospitalized patients
reporting infection in
hospital or shortly after

18. Safe Care Measures: US and Canada
Cont’d
Source: The Commonwealth Fund: 2014 Update “ Mirror, Mirror on the Wall”
30
34
58
49
0 20 40 60 80 100
Canada USPercent of Physicians who report
Doctor routinely
receives a
computerized alert or
prompt about a
potential problem with
drug dose or interaction
Doctor routinely
receives reminders
for guideline-based
interventions and/or
tests

19. Patient-Centered Care: US and Canada,
Communication
67
88
83
73
88
92
0 20 40 60 80 100
Canada USPercent of Patients who report:
*Base: have a regular doctor and tried to contact by phone; **Base: those who had surgery or been hospitalized
Source: The Commonwealth Fund: 2014 Update :Mirror, Mirror on the Wall
Always or often getting
telephone answer from
doctor the same day*
Doctor always or often
explains things in a
way that is easy to
understand
Received clear
instructions about
symptoms to watch for
and when to seek further
care after surgery or
when leaving the
hospital**

20. Patient-Centered Care: US and Canada,
Continuity and Feedback
64
15
80
57
60
84
0 20 40 60 80 100
Canada USPercent of Patients who report
Source: The Commonwealth Fund: 2014 Update “ Mirror, Mirror on the Wall
With same
doctor 5 years
or more
Doctor routinely
receives and reviews
data on patient
satisfaction and
experiences with care
Regular doctor always
or often knows
important information
about patient’s medical
history

21. Patient-Centered Care: U.S. and Canada, Engagement
and Patient Preferences
77
67
72
62
66
71
76
80
75
75
0 25 50 75 100
Canada US
Specialist always or often
involves patient as much as
they want in decisions re:
care and RX*
Doctor discussed patient’s
main goals or priorities
caring for condition**
*Base: saw or needed to see specialist in past 2 years; **Base: has chronic condition
Source: The Commonwealth Fund: 2014 Update “ Mirror, Mirror on the Wall”
Specialist always or often
tells you about treatment
choices*
Percent of Patients that Reported:
Regular doctor always or
often encouraged you to
ask questions
Doctor gives clear
instructions about
symptoms/when to seek
further care**

22. Other Dimension Rankings: Canada and
US Health Care System Performance
CANADA USA
ACCESS 9 9
COST-RELATED PROBLEM 5 11
TIMELINESS OF CARE 11 5
EFFICIENCY 10 11
EQUITY 9 11
HEALTHY LIVES 8 11
OVERALL RANKING 10 11

23. Conclusions
• Comparison of countries’ health systems with
systematically-collected data can offer a useful
antidote to conventional wisdom
• We expect the results to inform national
policy discussions about delivery system
reform, especially in the U.S.

24. 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.

25. Acknowledgements
CMWF IHP Survey Team

26. 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.

27. APPENDIX

28. 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)