Using International Comparisons to Guide Performance Improvement

Eric Schneider, MD, MSc, FACP
Senior Vice President for Policy and Research, The Commonwealth Fund
IGOPP Conference
October 27, 2017
Using International Comparisons to
Guide Performance Improvement
Implications for Governance

2
Origin of the Commonwealth Fund
International Health Policy Surveys
“Americans have the best health
care system in the world”
President George W. Bush
State of the Union Address - 2004
But is it the best?

3
GDP refers to gross domestic product.
Source: OECD Health Data 2016. Data are for current spending only, and exclude spending on capital formation of health care providers.
Health Care Spending as a Percentage of GDP,
1980–2014
0
2
4
6
8
10
12
14
16
18
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
United States (16.6%)
Switzerland (11.4%)
Sweden (11.2%)
France (11.1%)
Germany (11.0%)
Netherlands (10.9%)
Canada (10.0%)
United Kingdom (9.9%)
New Zealand (9.4%)
Norway (9.3%)
Australia (9.0%)
Percent

• Compare country health care systems in order to
learn about policies and care models that could
be used to achieve high-performing health care
in the U.S. and in other countries
• Motivate policymakers and providers to take
action on performance improvement
 Focus on legislators, regulators, payers, and
delivery system leaders
OBJECTIVES OF THE COMMONWEALTH FUND
INTERNATIONAL COMPARISON WORK

5
Traditional
Finance
Marketing
Operations
Performance
Quality
Patient experience
Safety
Innovation
Traditional
•Finance
•Marketing
• Populations
• Services
•Operations
• Management
• Staffing
More Recent
•Performance (metrics)
• Quality
• Patient experience
• Safety
•Innovation
Health Care Supervisory Board Focus Areas

6
Health Care System
Performance Measured Using 72
Indicators Across 5 Domains
• Care process
• Access
• Administrative efficiency
• Equity
• Health care outcomes
Mirror Mirror 2017 provides a broad evaluation of
health care system performance
POPULATIONS SURVEYED
• Elderly (2014)
• Primary Care Providers (2015)
• General Public (2016)
DATA SOURCES
• Annual International Health
Policy surveys of 11 high-income
countries
• Measures from OECD, WHO,
European Observatory

Annual International Survey: Public, Elderly, Primary Care Providers

8
Mirror, Mirror 2017: International
Comparison Reflects Flaws and
Opportunities for Better U.S Health Care
HOW DOES THE COMMONWEALTH FUND USE THE DATA?

9Source: Commonwealth Fund analysis
EXHIBIT 2
Health Care System Performance Rankings
AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US
OVERALL
RANKING
2 9 10 8 3 4 4 6 6 1 11
Care Process 2 6 9 8 4 3 10 11 7 1 5
Access 4 10 9 2 1 7 5 6 8 3 11
Administrative
Efficiency
1 6 11 6 9 2 4 5 8 3 10
Equity 7 9 10 6 2 8 5 3 4 1 11
Health Care
Outcomes
1 9 5 8 6 7 3 2 4 10 11

10
UK AUS
NETH
NZ NOR
SWIZ SWE GER
CAN
FRA
US
Note: See the methodology appendix for a description of how the performance score is calculated.
Health Care System Performance Scores of Eleven
High-Income Countries
Eleven-country average
Higher performing
Lower performing

11
-1.5
-1
-0.5
0
0.5
1
1.5
Note: “Performance Index” is based on the distance from the 11-country average, measured in
standard deviations
Source: Commonwealth Fund analysis
Performance Index
NETH
UK
AUS
NOR
NZ
SWE
SWIZ
GER
CAN
FR
US
Higher health system performance
Lower health system performance
International Health System Performance:
Health Care Outcomes

12
-1.5
-1
-0.5
0
0.5
1
1.5
Note: “Performance Index” is based on the distance from the 11-country average, measured in standard deviations
Performance Index
Eleven-country average NETH
UK
AUS
NOR
NZ
SWE
SWIZ GER
CAN
FR
US
Care Process

13
-1.5
-1
-0.5
0
0.5
1
1.5
Note: “Performance Index” is based on the distance from the 11-country average, measured in standard deviations
Performance Index
NETH
UK
AUS
NOR
NZ SWE
SWIZ
GER
CAN
FR
US
Access

14
Source: 2016 Commonwealth Fund International Health Policy Survey.
Definition: One or more of the following: problems: did not see a doctor when sick, skipped a medical
test or treatment recommended by a doctor, and did not fill a prescription or skipped doses because of
the cost in past year.
Percent reporting cost-related access barriers
in past year
7 7 8 8
10
14
16 17 18
22
33
0
10
20
30
40
50
GER UK SWE NETH NOR AUS CAN FRA NZ SWIZ US

15
Source: 2016 Commonwealth Fund International Health Policy Survey.
Percent Who Used Emergency Department in
the Past Two Years
11
20
22 23 24
26
30
33
35
37
41
0
10
20
30
40
50
GER NETH AUS NZ UK NOR SWIZ FRA US SWE CAN

16
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries.
Base: Saw/Needed to see a specialist in the past two years.
Percent Who Waited Less Than Four Weeks for
Specialist Appointment, Among Adults Age 65 or
Older*
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

17
Source: 2016 Commonwealth Fund International Health Policy Survey
Base: Needed elective surgery in past 2 years
Percent Who Reported that Wait Times For
Elective Surgery Was Less than 1 Month
60 59
52 51 49
43 43
39 37 37 35
0
20
40
60
80
100
US SWIZ AUS FRA NET UK NZ GER SWE NOR CAN

18
-1.5
-1
-0.5
0
0.5
1
1.5
Note: “Performance Index” is based on the distance from the 11-country average, measured in
standard deviations
Performance Index
NETH
UK
AUS
NORNZ
SWE
SWIZ
GER CAN
FR
US
Administrative Efficiency

19
Source: 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Definition: Amount of time practice spends on administrative issues related to insurance or claiming payments is a ‘major problem’.
Percent of Doctors Reporting that the Time Practice
Spends on Insurance Issues or Claiming Payments is a
MAJOR problem
9
20 20 21 21
27
50 52 54
60
63
0
10
20
30
40
50
60
70
NOR CAN NZ AUS UK SWE SWIZ GER US NETH FRA

20
Source: 2015 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
After Hospital Discharge, Percent of Doctors Reporting
That the Average Time it Takes to Receive Information
They Need to Continue Managing the Patient is < 48 h
68
62
52
42 40
34 32
22 22 19
15
0
20
40
60
80
100
GER NZ US NET SWIZ UK AUS CAN NOR SWE FRA

21
-1.5
-1
-0.5
0
0.5
1
1.5
Note: “Performance Index” is based on the distance from the 11-country average, measured in standard
deviations. Equity compares responses of individuals with above-average and below-average income
Performance Index
NETH
UK
AUS
NOR
NZ
SWE SWIZ
GER
CAN FR
US
Equity

22
100%
93%
80%
67%
67%
53%
53%
20%
Reports disseminated to the public
Benchmark performance with other countries
Provide Health Ministers with feedback
Benchmark performance regions/jurisdictions
Identify policymakers priorities
Research and scientific publications
Draw attention to issues for your organization
Track impact of specific reforms and policies
PART 2: HOW DO OUR PARTNERS USE THE DATA?
How Do Partners Use Commonwealth Fund
International Health Policy Survey Data?

23
• Expand insurance coverage
• Strengthen primary care
• Reduce administrative burdens for patients
and doctors
• Reduce income-related barriers and invest
in social services
Achieving a high performance health system: Lessons
for U.S. from high-performing countries
Source: Schneider EC and Squires D, New England Journal of Medicine

24
• England
• Decentralization and deregulation (2010) through local clinical commissioning groups
• Accountability: performance measurement, pay-for-performance
• Public participation: making results of accountability programs available to the public
• Netherlands
• Decentralization and deregulation (2006) through private, non-profit hospitals and GPs
• Accountability: Evolution to a uniform governance code, performance measurement
• Public participation: competition among insurers and private, non-profit hospitals
• Australia (i.e., New South Wales)
• Regionalization: 8 local area health administrations, private, non-profit hospitals
• Accountability: local health administrators accountable to director general (2004)
• Public participation: Area Health Advisory Councils (clinical and community members)
Governance Trends in High-Performing Countries

25
• Centralized control through accountability strategies including governance
codes, performance standards, standardized data collection, measurement
and reporting (public and private), incentives including competition
• Regional/local control over management decisions including financing,
organizational, services, and other processes that can produce expected
performance outcomes
• Increased public and patient participation in governance at many levels
• Role of boards to include review of performance measures on quality and
safety of care, performance improvement strategies, and use and impact of
financial and non-financial incentives
Observations about ‘shared-control’ models

26
Performance Measuremnt in Action
Journey for Excellence Dashboard 2015
Mar April May Jun July Aug Sep Oct Nov Dec
Regulatory
VBP
Lab
EOC
Patient Flow
Patient
Safety
Case
Management
Medical Staff
HCAHPS
Nursing
ED
Regulatory
VBP
Lab
EOC
Patient Flow
Patient Safety
Case
Management
Medical Staff
HCAHPS
Nursing
ED
December

27
Thank you
The first of what we now call
hospitals was established by
St. Basil of Caesarea (329-379
CE)
www.cmwf.org
es@cmwf.org
@ericschneidermd

Using International Comparisons to Guide Performance Improvement

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