1. Health System Performance: Challenges for the U.S. and Canada
Karen Davis
President, The Commonwealth Fund
Centre for Health Services and Policy
Research Conference
March 4, 2008

2. Goals for a High Performance Health System
HIGH QUALITY CARE
ACCESS AND EQUITY FOR ALL
LONG, HEALTHY, AND PRODUCTIVE LIVES
EFFICIENT
CARE
SYSTEM AND WORKFORCE INNOVATION AND IMPROVEMENT

3. US Scorecard: Why Not the Best
US Scorecard: Why Not the Best? Commonwealth Fund Commission National Scorecard
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 3

4. Mirror Mirror: US and Canada Fall Behind
Country Rankings
1-2.66
AUSTRALIA
CANADA
GERMANY
NEW
ZEALAND
UNITED
KINGDOM
STATES
OVERALL RANKING (2007)
3.5 5 2 1 6
Quality Care 4
2.5
Right Care 3
Safe Care
Coordinated Care
Patient-Centered Care
Access
Efficiency
Equity
Long, Healthy, and Productive Lives
4.5
Health Expenditures per Capita, 2004
$2,876*
$3,165
$3,005*
$2,083
$2,546
$6,102
* 2003 data
Source: K. Davis, C. Schoen, S. C. Schoenbaum, M. M. Doty, A. L. Holmgren, J. L. Kriss, and K. K. Shea, Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care, The Commonwealth Fund, May 2007

5. Mortality Amenable to Health Care
LONG, HEALTHY & PRODUCTIVE LIVES
Mortality Amenable to Health Care
Deaths per 100,000 population*
* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.
See Technical Appendix for list of conditions considered amenable to health care in the analysis.
Data: E. Nolte, London School of Hygiene and Tropical Medicine analysis of World Health Organization (WHO) mortality files.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 5

6. International Comparison of Spending on Health, 1980–2005
Average spending on health per capita ($US PPP)
Total expenditures on health as percent of GDP
Source: K. Davis, C. Schoen, S. Guterman, T. Shih, S. C. Schoenbaum, and I. Weinbaum, Slowing the Growth of U.S. Health Care Expenditures: What Are the Options?, The Commonwealth Fund, January 2007, updated with 2007 OECD data 6

7. Overall Views of the Health Care System in Seven Countries, 2007 and 1998
Percent reporting:
AUS
CAN
GER
NETH NZ UK US
Only Minor
Changes Needed
2007 24 26 20 42 16
1998 19 * 9 25 17
Fundamental Changes Needed 55 60 51 49 56 57 48 58 46
Rebuild
Completely 18 12 27 15 34 30 23 32 14 33
* Germany and the Netherlands did not participate in the 1998 survey.
Sources: 1998 and 2007 Commonwealth Fund International Health Policy Surveys

8. Improving Access Remove financial barriers to care
Enroll patients in a patient-centered primary care “home”
Standards for a primary care home
Accessibility
Care coordination
Prevention and health promotion
Chronic disease management
Patient-centered care
Monitoring performance
Aligning financial incentives
Organized system of “off hours” care coordinated with regular source of care

9. Fewer Canadians Face Cost-Related Access Problems Than Americans
Percent in past year due to cost:
AUS
CAN
GER
NETH NZ UK US
Did not fill prescription or skipped doses 13 8 11 2 10 5 23
Had a medical problem but did not visit doctor 4 12 1 19 25
Skipped test, treatment or follow-up 17 3
Percent who said yes to at least one of the above 26 21 37
Source: 2007 Commonwealth Fund International Health Policy Survey. (Schoen et al. Health Affairs 10/31/07)

10. Access to Doctor When Sick or Need Medical Attention
Percent
AUS GER NETH NZ UK CAN US
AUS GER NETH NZ UK CAN US
Source: 2007 Commonwealth Fund International Health Policy Survey

11. Over One-Third of Canadians and Americans Report Difficulty Getting Care on Nights, Weekends, Holidays Without Going to the Emergency Room
Percent reported very or somewhat difficult
Source: 2007 Commonwealth Fund International Health Policy Survey

12. Primary Care Doctors in Canada and U. S
Primary Care Doctors in Canada and U.S. Less Likely to Have Arrangement for Patients’ After-Hours Care to See Nurse/Doctor
Percent
Source Commonwealth Fund International Health Policy Survey of Primary Care Physicians. (Schoen et al. “On the Front Lines of Care…” Health Affairs, Nov. 2, 2006.

13. More Canadians and Americans Visited the Emergency Room For Condition Doctor Could Have Treated Than Other Countries
Percent
Source: 2007 Commonwealth Fund International Health Policy Survey

14. Only Half of Adults in Canada and U.S. Have a Medical Home
Percent
Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey

15. Canadians with Chronic Condition Less Likely to Receive a Reminder for Preventive Care, Even With a Medical Home
Base: Adults with a chronic condition
Percent with reminder
Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey

16. Less Than One in Three Canadians Without a Medical Home and a Chronic Condition Receive a Care Plan to Manage Condition at Home
Base: Adults with a chronic condition
Percent with care plan
Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey

17. Engaging Patients and Managing Care Chronic Care Model and Medical Home Fit Together
Chronic care model requires a team, patient-centered approach, IT support
Country initiatives around disease management or frail elderly have elements related to building medical homes

18. Canadian and American Patients Report High Rates of Any Medical, Medication, or Lab Error
Base: Adults with chronic condition
Percent any medical, medication, or lab error
Note: Errors include medical mistake, wrong medication/dose, or lab/diagnostic errors. Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey. (Schoen et al. Health Affairs 10/31/07)

19. Canadian and American Patients with a Medical Home More Likely to Receive Quality Care from Doctor
Percent rated care received “excellent” or “very good”
Note: Medical home includes having a regular provider that knows you, is easy to contact, and coordinates your care.
Source: 2007 Commonwealth Fund International Health Policy Survey

20. Physicians in Canada and U. S
Physicians in Canada and U.S. Less Likely to Participate in Activities to Improve Quality of Care
AUS
CAN
GER
NETH NZ UK US
Percent in past two years who:
Participated in collaborative QI efforts 58 48 76 70 78 49
Conducted clinical audit of patient care 45 69 46 82 96
Percent reporting their practice:
Sets formal targets for clinical performance 26 27 35 41 50
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

21. Coordination Problems: Medical Records Not Available During Visit or Duplicative Tests
Percent reported in past two years:
AUS
CAN
GER
NETH NZ UK US
Test results or records not available at time of appointment 11 8 7 9 10 15
Duplicate tests: doctor ordered test that had already been done 5 4 6 14
Percent with either coordination problem 18 19 12 13 23
Source: 2007 Commonwealth Fund International Health Policy Survey

22. Physicians in Canada and U. S
Physicians in Canada and U.S. Less Likely to Receive Incentives for Quality
Percent of physicians reporting any financial incentive for quality of care*
* Receive or have potential to receive payment for: clinical care targets, high patient ratings, managing chronic disease/complex needs, preventive care, or QI activities.
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.

23. Where are the U.S. and Canada on IT?
Percent reporting 7 or more out of 14 functions*
Percent reporting EMR
*Count of 14: EMR, EMR access other doctors, outside office, patient; routine use electronic ordering tests, prescriptions, access test results, access hospital records; computer for reminders, Rx alerts, prompt tests results; easy to list diagnosis, medications, patients due for care.
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians in Seven Nations: Australia, Canada, Germany, Netherlands, New Zealand, UK, and US.

24. Doctors Reporting Routinely Receiving Alerts about Potential Problem with Drug Dose/Interaction
Percent of physicians
Source: 2006 Commonwealth Fund International Health Policy Survey of Primary Care Physicians

25. Denmark Leads the Way In IT and Patient-centered Primary Care 2006: An Example of High Performance
Highest public satisfaction with health system among European countries
Blended primary care payment system: fee for service and medical home monthly fee per patient
Organized off-hours service
Physicians staff phone banks nights and weekends with computerized access to patient information; paid for telephone consultations
Physicians staff evening and weekend clinics, and
Off-hours service physicians do home visits
Health information technology and information exchange
98% of primary care physicians totally electronic health records and e-prescribing
Paid for with patients
All prescriptions, lab and imaging tests, specialist consult reports, hospital discharge letters flow through a single electronic portal accessible to patients, physicians, and home health nurses
Specialist payment depends upon filing information in the electronic portal

26. Take Away Messages
Country patterns reflect underlying strategic policy choices
Universal coverage matters
Having an integrated health care “system” matters
National leadership on health policy matters
Regardless of system characteristics, having a “Medical Home” that is accessible and coordinates care improves patient experiences
Patient safety
Coordination with specialists/across sites of care
Patient-centeredness and satisfaction
Managing Chronically Ill patients
Efficiency: duplication and delays
After-hours care arrangements
Health information technology has significant potential:
To enhance data availability on which to benchmark and improve performance
To improve quality by supporting providers and patients
To improve care coordination across providers of care
To improve accessibility of care
To improve physician satisfaction with practice

27. Conclusions No country systematically leads in performance
Variations in health system performance offer opportunities for cross-national learning
Managing patients with complex, chronic illnesses is a shared challenge
Primary Care “redesign” and Workforce Strategy
are critical to improving health system performance
Making rapid progress requires:
Learning from best practices within country and across countries
Aligning incentives for high value care
Accountable coordinated care for all patients
Implementation of electronic information systems
Accountable leadership

28. Thank You!
Robin Osborn, Vice President and Director, International Program in Health Policy and Practice
Stephen C. Schoenbaum, M.D., Executive Vice President and Executive Director, Commission on a High Performance Health System,
Cathy Schoen, Senior Vice President for Research and Evaluation
Katherine Shea, Research Associate
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