A Need to Transform the U.S. Health Care System: Improving A Chartbook

THE
COMMONWEALTH
FUND
A Need to Transform the U.S.
Health Care System: Improving
Access, Quality, and Efficiency
A Chartbook
Compiled by
Anne Gauthier, Senior Policy Director
Michelle Serber, Program Assistant
2
Contents
Acknowledgments
• 3
Overview
• 4
I. Need for Better Access
and Coverage
• 6
II. Need for Quality
Enhancements
• 28
III. Need for Greater
Efficiency
• 57
Conclusion. The Time Is
Ripe for Improvement
• 80
References
• 86
Commonwealth Fund pub. no. 867.
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3
Acknowledgments
This chartbook is a compilation of data that represents the work of many individuals
at The Commonwealth Fund. We wish to thank those who kindly provided data,
information, research, and assistance:
Anne-Marie J. Audet, M.D., Vice President, Quality Improvement
Sara R. Collins, Ph.D., Senior Program Officer
John E. Craig, Jr., Executive Vice President and Chief Operating Officer
Karen Davis, Ph.D., President
Michelle M. Doty, Ph.D., Senior Analyst
Paul D. Frame, Production Editor
Stuart Guterman, Senior Program Director
Alice Ho, former Research Associate
Christopher Hollander, Associate Communications Director
Alyssa L. Holmgren, Research Associate
Phuong Trang Huynh, Ph.D., Associate Director
Cathy Schoen, Senior Vice President, Research and Evaluation
Stephen C. Schoenbaum, M.D., Executive Vice President for Programs
Ilana Weinbaum, Program Associate
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Overview
The need for fundamental transformation of the U.S. health care system has
become increasingly apparent. Research reveals a fragmented system fraught
with waste and inefficiency. Among industrialized nations, the United States
spends well over twice the per capita average (Reinhardt et al. 2004). High
spending, however, has not translated into better health: Americans do not live
as long as citizens of several other industrialized countries, and disparities are
pervasive, with widespread differences in access to care based on insurance
status, income, race, and ethnicity.
Particularly problematic is the large number of individuals lacking ready access
to health services. Over a third of the population is uninsured, unstably insured,
or underinsured (Schoen et al. 2005). With health care costs on the rise,
affordability is a key concern for many working families. Gaps in insurance
coverage and high out-of-pocket spending hinder patients' access to care and
lead to skipped medical tests, treatments, and follow-up appointments. In turn,
these access problems produce preventable pain, suffering, and death—as well
as more expensive care.
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There are also significant issues with the safety and quality of care. As many
as 98,000 deaths result annually from medical errors (Kohn et al. 1999),
and U.S. adults receive only 55 percent of recommended care (McGlynn et
al. 2003). Inefficiencies, such as duplication and use of unnecessary
services, are costly and compromise the quality of care. High administrative
costs in health insurance and health care delivery are also problems.
The following sections further illustrate the need to improve coverage,
quality, and efficiency. The charts presented paint a stark picture of a health
system in need of reform. Clearly, moving the nation toward a high
performance health system will require collaboration. That is why The
Commonwealth Fund has formed the Commission on a High Performance
Health System: to identify public and private strategies, policies, and
practices that would lead to improvements in the delivery and financing of
health care for all Americans.
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6
I. Need for Better Access and Coverage
Number of uninsured individuals are on the rise.
In 2004, 45.8 million individuals in the United States were uninsured (U.S.
Census Bureau),* and projections indicate that the number of uninsured
individuals may exceed 50 million by the end of the decade (Chart I-1). The
following are findings pertaining to the uninsured:
– According to health care opinion leaders, the uninsured should be a top
priority for Congress (Chart I-2).
– Between 2000 and 2004, the number of uninsured individuals increased by
5.8 million. Adults ages 18 to 64 comprised all of the increase (Chart I-3).
– Between 1987 and 2003, the working middle class saw the greatest increase
in uninsured individuals (Chart I-4).
– Among the uninsured, low-income families and adults are disproportionately
represented (Chart I-5).
– Uninsured rates vary widely by state (Chart I-6).
* The CPS asks about insurance coverage in the previous year. An individual is considered
"uninsured" if he or she was not covered by any type of health insurance at any time in that year.
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Job-based premium increases, gaps in coverage, and underinsurance
contribute to access problems.
In 2003, 45 million U.S. adults were uninsured at some point during the year
(Schoen et al. 2005).** Contributing to problems with access are job-based
premium increases overtaking wage increases. The year 2004 saw
increases in premiums greatly outpace workers' earnings from the previous
year (Chart I-7). The Commonwealth Fund Biennial Health Insurance
Survey (2003) highlighted the growing problem of underinsurance:***
– 26 percent of U.S. adults 19 to 64 were either uninsured all year or part
of the year (Chart I-8).
– Another 9 percent of adults, or 16 million people, were underinsured
(Chart I-8).
– Added together, 61 million adults—one-third of adults under 65—were
either uninsured or underinsured during the year (Chart I-8).
** Schoen et al. used the term uninsured to refer to individuals who had been uninsured for
some time during the past year.
*** An underinsured person is defined as one who has insurance all year but has inadequate
protection, as indicated by one of three conditions: 1) annual out-of-pocket medical expenses
amount to 10 percent or more of income; 2) among low-income adults (with income below 200
percent of the federal poverty level), out-of-pocket expenses amount to 5 percent or more of
income; or 3) health plan deductibles equal or exceed 5 percent of income.
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Gaps in insurance coverage make it difficult for people to afford filling
prescriptions; seeing a specialist when warranted; undergoing a medical
test, treatment, or follow-up; or seeking advice for a medical problem. Of
adults who were uninsured at the time of the survey, 61 percent reported
encountering at least one of these access problems. Of those who were
currently insured but had been uninsured at some point during the past
year, a majority reported access problems. For those who had been insured
all year, the percentage was much lower but still large (Chart I-9). The
Institute of Medicine estimates that in 1999, being uninsured was the sixthleading cause of death (Chart I-10).
Underinsured adults are also at high risk of going without needed care
because of cost, as well as at high risk of experiencing financial stress.
Rates on both access and financial indicators for the underinsured
approach or equal those reported by the uninsured (Chart I-11). Even for
adults covered all year by private insurance, barriers to access exist in
several forms, including high out-of-pocket costs (Chart I-12).
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Disparities persist by income and race.
For low-income adults (with income below 200 percent of the poverty level),
unstable health coverage is a prevalent concern. Analysis of health insurance
coverage and employment patterns over the four years 1996-99 indicates that
at some point during this period, 68 percent of low-income adults were
uninsured, compared with 26 percent of adults with higher incomes (Chart I-13).
In addition to income, access also varies by race and ethnicity. In 2000, 50
percent of Hispanic adults were uninsured for all or part of the year, compared
with 35 percent of African Americans and 22 percent of whites (Chart I-14).
Inadequate access leads to reduced productivity and output.
Individuals with no insurance, only sporadic coverage, or insurance that exposes
them to catastrophic out-of-pocket costs are more likely to go without care.
Receipt of primary and preventive care is associated with job compensation, and
workers in the lowest-compensated positions are less likely to have a regular
physician and to receive preventive care screens (Chart I-15). The majority of
employers believe that health insurance positively affects employee health and
morale. In addition, more than one-third of employers link health benefits to
enhanced employee productivity (Chart I-16).
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The effects of inadequate access go beyond individual health consequences,
as gaps in coverage affect quality of care, health outcomes, and economic
productivity. The Institute of Medicine estimated that preventable morbidity and
mortality associated with being uninsured translates into a loss of $65 billion to
$130 billion annually (Institute of Medicine 2003). Providing all workers with
health insurance coverage would facilitate early treatment of acute illnesses
and the ongoing management of chronic conditions, increase use of preventive
care, and improve worker health and productivity (Davis et al. 2005).
The health of workers has economic implications.
More generally, substantial costs are incurred when workers are too sick to
work or function effectively. According to the 2003 Biennial Health Insurance
Survey, the majority of Americans experience reduced productivity, sick days, or
health problems (Chart I-17). Affordable and comprehensive health insurance
coverage and paid sick leave can improve the health of workers and their family
members, which in turn could yield economic payoffs for working families and
the economy as a whole (Davis et al. 2005). Since employers,
and society as a whole, benefit from workers having insurance, it is
important to strengthen employee coverage (Collins et al. 2005).
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Chart I-1. 46 Million Uninsured in 2004;
Projected to Increase Substantially
11
Millions uninsured
56
60
40
33
31 33
35 35
39 40 40
41
44
42 43
40 40 41
44 45
46
20
0
1987
1990
1993
1996
1999*
2002
2005
2008
2011 2013
Projected
* 1999–2004 estimates reflect the results of follow-up verification
questions and implementation of Census 2000-based population controls.
Note: Projected estimates for 2005–2013 are for nonelderly uninsured based on T. Gilmer and
R. Kronick, "It's the Premiums, Stupid: Projections of the Uninsured Through 2013," Health Affairs
Web Exclusive, April 5, 2005. Source: U.S. Census Bureau, March CPS Surveys 1988 to 2005.
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Chart I-2. Uninsured Top Priority for Congress
According to Health Care Opinion Leaders
12
"Which of the following health care issues should be the top
priorities for Congress to address in the next five years?"
Expand coverage to the uninsured
87%
Improve quality of medical care, inc. increased use of
IT
69%
Medicare reforms to ensure long-run solvency
50%
Enact reforms to moderate rising costs of medical
care
Medicare payment reform to reward performance on
quality and efficiency
48%
38%
Control rising cost of prescription drugs
35%
31%
Address racial/ethnic disparities in care
Malpractice reform
30%
27%
Administrative simplification and standardization
Medicaid reforms to improve coverage
24%
Improve quality of nursing homes and LTC
Control Medicaid costs
21%
6%
Source: The Commonwealth Fund Health Care Opinion Leaders Survey, November–December 2004.
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Chart I-3. Number Uninsured Rose 5.8 Million
from 2000 to 2004, with Adults Accounting
for All of the Increase
Under age 18
2004
8.3
2000
8.6
0
Ages 18–64
45.8
million
37.5
40
million
30.9
10
20
13
30
40
50
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Source: U.S. Census, March 2001 and March 2005 Current Population Surveys.
Chart I-4. Uninsured Rates Increasing
Most Sharply for Working Middle Class
14
Percent of working adults uninsured, by household income quintile 1987-2003
60%
52%
48%
50%
47%
44%
48%
Second
39%
40%
Lowest
quintile
33%
35%
25%
Third
21%
20%
Fourth
15%
18%
9%
6%
8%
5%
5%
2%
4%
0%
1987
11%
1989
1991
1993
1995
1997
1999*
* In 1999, CPS added a follow-up verification question for health coverage.
Source: Analysis of the March 1988–2004 Current Population Surveys by
Danielle Ferry, Columbia University, for The Commonwealth Fund.
2001
Highest
quintile
2003
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Chart I-5. Two-Thirds of Nonelderly
Uninsured Are Low-Income, 2003
Low-income
children
15%
15
Low-income
parents
17%
Other children
5%
Other parents
7%
Other adults
without
children
22%
Low-income
adults without
children
34%
Total = 44.7 million
Note: Low-income is defined as below 200% of the federal poverty level
($29,360 for a family of three in 2003).
Source: Kaiser Commission on Medicaid and Uninsured and Urban Institute
analysis of the March 2004 Current Population Survey.
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Chart I-6. Percent of Nonelderly Uninsured
Population Varies Widely by State, 2001–2003
16
WA
VT
MT
ND
WI
SD
NY
RI
PA
IA
IL
UT
CO
KS
MO
CT
NJ
OH
NE
CA
MA
MI
WY
NV
ME
MN
OR
ID
NH
DE
IN
MD
WV
VA
DC
KY
NC
TN
OK
AZ
NM
AR
SC
MS
TX
AL
GA
LA
FL
AK
HI
18% or more
15%–17.9%
12%–14.9%
Less than 12%
Source: Health Insurance Coverage in America: 2003 Data Update Highlights,
Kaiser Commission on Medicaid and Uninsured/Urban Institute, September 27, 2004.
Uninsured rates are two year averages, 2001–2003.
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Chart I-7. Job-Based Premium Increases
Greater than Wage Increases
17
Percent change from previous year
20%
Premiums
18%
18%
14%
Workers' earnings
14%
16%
13%
12%
14%
11%
12%
8%
9%
10%
11%
8%
5%
6%
4%
2%
1%
2%
0%
1988
1990
1992
1994
1996
1998
2000
Source: "Employer Health Benefits 2004 Annual Survey," Kaiser Family Foundation/
Health Research and Educational Trust, September 2004.
2002
2004
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Chart I-8. Significant Percentage of
Underinsured Adults Indicates Access to
Care Not Just Issue for Uninsured
18
Uninsured all year
13%
Insured all year,
not underinsured
65%
Uninsured part year
13%
Underinsured
9%
Uninsured is defined as uninsured for some time during the past year.
Source: C. Schoen et al., "Insured But Not Protected: How Many Adults Are Underinsured?" Health
Affairs, June 2005, based on The Commonwealth Fund 2003 Biennial Health Insurance Survey.
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Chart I-9. Gaps in Insurance Coverage
Hinder Access to Care
19
Percent of adults ages 19–64 reporting the following problems
because of cost:
Insured all year
Insured now, time uninsured in past year
Uninsured now
75
57
51
50
25
40 37
18
9
18
35
27
40
12
39
61
29
13
0
Did not fill a
Did not see
Skipped medical
Had medical
Any of the four
prescription
specialist when
test, treatment, or
problem, did not
access problems
needed
follow-up
see doctor or
clinic
Source: S. R. Collins, M. M. Doty, K. Davis et al., The Affordability Crisis in
U.S. Health Care: Findings From The Commonwealth Fund Biennial Health
Insurance Survey, The Commonwealth Fund, March 2004.
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Chart I-10. Being Uninsured Is a
Leading Cause of Death
20
Deaths of Adults Ages 25–64, 1999
1.
Cancer — 156,485
2.
Heart disease — 115,827
3.
Injuries — 46,045
4.
Suicide — 19,549
5.
Cerebrovascular disease — 18,369
6.
Uninsured — 18,000
7.
Diabetes — 16,156
8.
Respiratory disease — 15,809
9.
Chronic liver disease and cirrhosis — 15,714
10. HIV/AIDS — 14,017
Sources: U.S. Department of Health and Human Services, National Center for Health Statistics,
Health, United States, 2002, Table 33, p. 132 — deaths for causes other than uninsured; Institute
of Medicine, Care Without Coverage, Appendix D, p. 162, deaths attributable to higher risks of
uninsured adults 25–54.
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Chart I-11. Underinsured and Uninsured
Adults at High Risk of Access Problems
and Financial Stress
21
Percent of adults ages 19–64
75
Insured, not underinsured
54
Underinsured
59
46 44
50
25
Uninsured during year
35
25
11
28
7
0
Went without care
Contacted by collection
Changed way of life
because of costs*
agency about medical bills
significantly to pay
medical bills
* Did not fill a prescription; did not see a specialist; skipped
recommended care; or did not see doctor when sick because of costs.
Source: C. Schoen et al., "Insured But Not Protected: How Many
Adults Are Underinsured?" Health Affairs Web Exclusive, June 14, 2005.
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Chart I-12. Adults with Low and Moderate
Incomes Spend Greatest Share of Income
on Out-of-Pocket Costs
22
Percent of adults ages 19–64 insured all year with private insurance
who spent 5 percent or more of income on out-of-pocket costs
40
29
30
20
23
11
10
10
2
0
Total
Less than
$20,000–
$35,000–
$60,000 or
$20,000
$34,999
$59,999
more
Note: Income groups based on 2002 household income.
Source: S. R. Collins, M. M. Doty, K. Davis et al., The Affordability Crisis in
U.S. Health Care: Findings From The Commonwealth Fund Biennial Health
Insurance Survey, The Commonwealth Fund, March 2004.
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Chart I-13. Low-Income Adults, Especially
Hispanics, Have High Uninsured Rates over Four
Years; Disparities Persist Across Income Levels
23
Percent of population 19–64 uninsured, 1996–1999
Any time uninsured
100
Uninsured more than one year
80
75
50
68
66
63
47
42
64
46
41
26
25
31
23
12
10
23
16
0
Total
White
African
Hispanic
Total
White
American
Under 200% poverty
African
Hispanic
American
200% or more of poverty
Source: M. M. Doty and A. L. Holmgren, Unequal Access: Insurance Instability
Among Low-Income Workers and Minorities, The Commonwealth Fund, April 2004.
Data: 1996 panel of the Survey of Income and Program Participation.
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Chart I-14. Percent of Population
Uninsured All Year or Part-Year Varies
by Race and Ethnicity, 2000
24
Percent of population uninsured all year or part-year, 2000
75
Uninsured part year
Uninsured all year
50
50
37
25
23
14
0
20
13
23
20
14
9
7
9
Total
White
African
28
13
17
15
Hispanic
Total
American
Children ages 0–18
16
35
14
22
34
11
21
11
White
African
Hispanic
American
Adults ages 19–64
Source: M. M. Doty. Insurance, Access, and Quality of Care Among Hispanic Populations:
2003 Chartpack, The Commonwealth Fund, October 2003. Data: MEPS 2000.
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Chart I-15. Preventive and Primary Care Varies
by Workers' Job Compensation Levels
Lowest
compensated
100
74
80
Higher
compensated
91
89
90
70
Midcompensated
25
85
84
74
66
64
54
60
50
40
30
20
10
0
Regular doctor (ages 19–64)
Blood pressure check in
Cholesterol check in past
past year (ages 19–64)
five years (ages 19–64)
Note: Lowest compensated are all workers with wage rate <$10/hr; mid-compensated are
workers with wage rate $10-$15/hour and those >$15/hour but no employer-sponsored insurance;
higher compensated are workers with wage rate >$15/hour and employer-sponsored insurance.
Source: The Commonwealth Fund Biennial Health Insurance Survey (2003).
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Chart I-16. Majority of Employers Believe That
Health Benefits Improve Employee Health and Morale
26
Employers who say health benefits contribute
a great deal or quite a bit
Percent of firms offering coverage
80
67
60
60
39
40
20
0
Improves employee
Improves employee
Increases employee
health
morale
productivity
Source: S. R. Collins et al., Job-Based Health Insurance in the Balance: Employer Views of
Coverage in the Workplace, The Commonwealth Fund, March 2004; Commonwealth Fund
Supplement to the 2003 National Organization Study.
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Chart I-17. Majority of Americans Experience
Health Problems, Sick Loss, or Reduced
Productivity (all adults ages 19–64)
27
Working with no sick days or
reduced-productivity days
Working with 6 or more
sick days or reducedproductivity days
27%
18%
Working with 1 to 5
sick days or reducedproductivity days
21%
Not working for other
non-health reasons
21%
Not working because of
disability or other health reasons
12%
Note: Numbers may not sum to 100% because of rounding. Excludes self-employed adults and
workers with undesignated wage rate. Sick-loss days are days of work missed because self or
family member was sick. Reduced-productivity days are days unable to concentrate fully at work
because not feeling well or worried about sick family member.
Source: K. Davis et al., Health and Productivity Among U.S. Workers, The Commonwealth Fund,
August 2005; The Commonwealth Fund Biennial Health Insurance Survey (2003).
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II. Need for Quality Enhancements
Quality and cost of health care vary widely across the United States.
There are significant variations in the quality and cost of health care, both
within the United States and internationally (Davis et al. 2004; Fisher et al.
2003). U.S. adults often do not receive the level of care that is
recommended for a particular condition. One study indicates that overall,
individuals received only 55 percent of recommended care, a proportion that
varies based on the condition, as detailed below (McGlynn et al. 2003).
– Individuals being treated for breast cancer went without nearly onefourth of recommended care, while those undergoing treatment for
hypertension went without more than one-third of recommended care
(Chart II-1).
– The figures for individuals being treated for asthma reflect even lower
quality, with individuals receiving approximately half of the
recommended care (Chart II-1).
– For those undergoing treatment for diabetes, pneumonia, or a
hip fracture, the percentages of recommended care attained
were even lower (Chart II-1).
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The provision of appropriate care varies across the United States
(Chart II-2). In a study examining the quality of care provided to Medicare
beneficiaries, the authors ranked the states on 22 quality indicators.
Substantial discrepancies exist among states ranked in the first quartile and
those ranked in the fourth quartile, with northern states and less-populous
states performing better (Jencks, Huff, and Cuerdon 2003).
Preventive care is often overlooked.
The 2004 Commonwealth Fund International Health Policy Survey indicates
that 49 percent of respondents in the United States do not receive
reminders for preventive care (Chart II-3). The proportions of young children
and their families who receive preventive and developmental services are
relatively low: only 30 to 40 percent of parents of young children reported
receiving services such as anticipatory guidance, parental education,
psychosocial assessment, or screening for tobacco and substance use
(Chart II-4).
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Medication errors and medical mistakes compromise quality of care.
Medication errors and medical mistakes also compromise quality of care.
A 2002 Commonwealth Fund survey indicates that nearly one-fifth of sicker
adults in the United States reported a serious medical mistake or medication
error in the past two years (Chart II-5). A 2004 Fund survey found that 15
percent of contacted individuals had received incorrect test results or had
experienced delays in receiving notification about abnormal results (Chart II-6).
The United States compares unfavorably with other industrialized countries.
Communication affects quality of care.
Communication plays a critical role in quality of care. The 2004 Commonwealth
Fund International Health Survey reveals missed opportunities by physicians to
communicate effectively, involve patients in treatment decisions, and recognize
patients' concerns or preferences (Schoen et al. 2004). In the United States,
more than 50 percent of individuals did not feel that their doctor always spends
adequate time with them. Approximately 40 percent of U.S. respondents
indicated that their doctor does not always listen carefully and does not
always explain things clearly (Chart II-7).
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The 2002 International Health Policy Survey examined the views of sicker
adults and found that nearly one-third of those surveyed in the United States
had in the past two years left a doctor's office without getting an important
question answered. An even larger percentage of U.S respondents reported
not adhering to a doctor's advice (Chart II-8). Research indicates that
minorities face greater difficulty in communicating with physicians (Chart II-9).
Studies point to a link between patient-physician communication and a
patient's acceptance of advice, adherence to treatment regimens, and
satisfaction. Moreover, the quality of communication may also affect outcomes
of care (Stewart 1995; Stewart et al. 2000). In an examination of interpersonal
quality of care, middle-age adults gave lower rankings than seniors on the
following measures: health providers listened carefully, health providers
showed respect, and health providers spent enough time. When asked if the
health provider always explained things clearly, only about 60 percent of
seniors and middle-aged adults answered affirmatively (Chart II-10*).
* To access Leatherman and McCarthy's Chartbook on the Quality of Care for Medicare
Beneficiaries, please visit http://www.cmwf.org/usr_doc/MedicareChartbk.pdf.
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Expanding the use of information technology could facilitate communication
and benefit both patients and physicians. The health care sector, however,
has been slow to implement information technology, with the percentages of
physician groups using electronic medical records remaining low
(Chart II-11).
Physicians not as readily accessible as patients would hope.
In the 2004 Commonwealth Fund International Health Policy Survey, only a
third of U.S. adults reported they were able to schedule a same-day
appointment when sick or in need of medical attention (Chart II-12). Use of
the emergency department (ED) as a substitute for regular physician care is
a problem: 16 percent of U.S. respondents reported visiting the ED for a
nonemergent condition (Chart II-12). Overall ED use in the United States
was significant, with approximately one-third of respondents indicating they
had used it in the past two years (Chart II-13).
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Having a regular physician is important for quality.
When a patient builds a relationship with a physician, the result is enhanced
care, increased trust, and patient adherence to treatment regimens
(Parchman, M. and S. Burge 2004; Hall et al. 2001). Yet, only 37 percent of
individuals in the United States surveyed in a 2004 Commonwealth Fund
survey had a physician whom they had seen for more than five years
(Chart II-14).
Debates continue regarding disclosure of quality information.
Around the world, there is debate about whether and how to disclose
quality-of-care information to the public. The percentage of U.S. hospital
CEOs who do not wish to disseminate certain information to the public
varies according to the type of information under consideration (Chart II-15).
Among consumers, it is apparent that more information is desired. The
majority of Americans would like information pertaining to their health and
the care they receive (Chart II-16).
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Life expectancy and survival rates for certain medical conditions
indicate need for improvement.
The United States spends more on health care than most countries, but its
results lag behind.
– Five-year survival rates for kidney transplant and colorectal cancer in
the United States are relatively low (Charts II-17 and II-18).
– The five-year survival rate for patients diagnosed with cancer varies
based on race and ethnicity. Even greater variations exist based on
socioeconomic status (Charts II-19 and II-20).
– The United States ranks below a number of other industrialized nations
for life expectancy at birth and at age 65 (Charts II-21 and II-22).
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Chart II-1. U.S. Adults Receive Half of
Recommended Care, and Quality Varies
Significantly by Medical Condition
35
Percent of recommended care received
76
80
60
65
55
54
45
40
39
23
20
0
Overall
Breast
Hypertension
Asthma
Diabetes
Pneumonia
Hip fracture
cancer
Source: E. McGlynn et al., "The Quality of Health Care Delivered to Adults in the United States,"
The New England Journal of Medicine (June 26, 2003): 2635–2645.
THE
COMMONWEALTH
FUND
Chart II-2. Provision of Appropriate Care
Varies by State
36
Performance on Medicare Quality Indicators, 2000–2001
WA
VT
MT
ND
WI
SD
NY
RI
PA
IA
OH
NE
IL
UT
CA
CO
MA
MI
WY
NV
ME
MN
OR
ID
NH
KS
MO
CT
NJ
DE
IN
MD
WV
VA
DC
KY
NC
TN
OK
AZ
NM
AR
SC
MS
TX
AK
AL
GA
LA
Quartile Rank
FL
HI
First
Second
Third
Fourth
Note: State ranking based on 22 Medicare performance measures.
Source: S. F. Jencks, E. D. Huff, and T. Cuerdon, "Change in the Quality of Care
Delivered to Medicare Beneficiaries, 1998–1999 to 2000–2001," Journal of the
American Medical Association 289 (Jan. 15, 2003): 305–312.
THE
COMMONWEALTH
FUND
Chart II-3. U.S. Performs Relatively Well
But Emphasis on Prevention is Still Lacking
37
Percent who DID NOT receive reminders for preventive care
75
62
61
55
50
50
49
United
United States
25
0
Australia
Canada
New Zealand
Kingdom
THE
COMMONWEALTH
FUND
Source: 2004 Commonwealth Fund International Health Policy Survey.
Chart II-4. Gaps Exist in Provision of
Preventive and Developmental Services
38
Percent
100
69
80
60
50
71
60
48
40
20
0
Parental
anticipatory
guidance
Parental
Parental screen Family-centered Follow-up for
assessment for for tobacco and
care
children at risk
psychosocial
substance
issues
abuse
Source: C. Bethell et al., Analysis of FAACT Surveys PHDS-Plus of
Parents of Medicaid Children in Seven States. Unpublished data 2004.
THE
COMMONWEALTH
FUND
Chart II-5. Medication or Medical Mistake
Caused Serious Health Consequences
in Past Two Years
39
Percent of sicker adults reporting a serious error in past two years
30
20
13
15
18
14
9
10
0
Australia
Canada
New Zealand
United
United States
Kingdom
THE
COMMONWEALTH
FUND
Source: The Commonwealth Fund 2002 International Health Policy Survey of Sicker Adults.
Chart II-6. Incorrect Test Results and
Delays in Notification of Abnormal Results
Raise Safety Concerns
40
Percent of adults with test in past two years
30
20
10
9
12
15
14
8
0
Australia
Canada
New Zealand
United
United States
Kingdom
THE
COMMONWEALTH
FUND
Source: 2004 Commonwealth Fund International Health Policy Survey.
Chart II-7. Opportunities Exist
for Enhanced Doctor–Patient
Communication and Interactions
Percent saying doctor:
41
AUS
CAN
NZ
UK
US
Always listens carefully
71
66
74
68
58
Always explains things so
you can understand
73
70
73
69
58
Always spends enough time
with you
63
55
66
58
44
THE
COMMONWEALTH
FUND
Source: 2004 Commonwealth Fund International Health Policy Survey.
Chart II-8. Significant Share of Adults Report
Nonadherence, Questions Left Unanswered
42
Views of Sicker Adults*
In the past two years:
AUS
CAN
NZ
UK
US
Left a doctor's office
without getting
important questions
answered
21
25
20
19
31
Did not follow a
doctor's advice
31
31
27
21
39
* Sicker adults are individuals who met at least one of four criteria: reported their health as
fair or poor; or in the past two years had a serious illness that required intensive medical care,
major surgery, or hospitalization for something other than a normal birth.
Source: 2002 Commonwealth Fund International Health Policy Survey.
THE
COMMONWEALTH
FUND
Chart II-9. Minorities Face Greater Difficulty
in Communicating with Physicians
43
Percent of adults with one or more communication problems*
40%
20%
33%
19%
27%
23%
16%
0%
Total
White
African
American
Hispanic
Asian
American
Base: Adults with health care visit in past two years.
* Problems include understanding doctor, feeling doctor listened, had questions but did not ask.
Source: Commonwealth Fund 2001 Health Care Quality Survey.
THE
COMMONWEALTH
FUND
Chart II-10. Interpersonal Quality of Care
Lacking for a Number of Patients
44
Percent of community-dwelling adults in 2001
who visited doctor’s office in past year
Ages 45–64
100
80
60
56
65
59
59
Age 65+
59
66
46
54
40
20
0
Health providers
Health providers
Health providers
Health providers
always listened
always explained
always showed
always spent
carefully
things clearly
respect
enough time
Source: S. Leatherman and D. McCarthy, Quality of Health Care for Medicare Beneficiaries:
A Chartbook, 2005, The Commonwealth Fund. www.cmwf.org; Medical Expenditure Panel
Survey (AHRQ 2005).
THE
COMMONWEALTH
FUND
Chart II-11. Physician Use of Electronic
Technology Could Be Expanded
Percent indicating "routine/occasional" use
79%
All Physicians
1 Physician
87%
85% 84%
77%
45
2–9 Physicians
10–49 Physicians
68%
66%
50+ Physicians
61%
59%
57%
46%
37%
36%
27%
35%
27%
25%
13%
14%
Electronic billing*
Access to test results*
Ordering of tests*
23%
Electronic medical
records*
* p < .01, Cuzick's test for trend
Base: All respondents (N=1837)
Source: Commonwealth Fund 2003 National Survey of Physicians and Quality of Care.
THE
COMMONWEALTH
FUND
Chart II-12. Substituting Emergency Department (ED)
for Regular Care More Likely in U.S. and Canada
46
Percent of adults who were sick or needed medical attention
75
60
54
50
41
33
27
18
25
9
16
7
6
NZ
UK
0
AUS CAN
NZ
UK
US
Same-day appointment
available
AUS CAN
US
Went to ED for condition that could
have been treated by regular
physician if available
THE
COMMONWEALTH
FUND
Source: 2004 Commonwealth Fund International Health Policy Survey.
Chart II-13. Emergency Department Use
Rates Higher in the U.S. and Canada
47
Percent with any visits
50
38
29
29
27
34
25
0
Australia
Canada
New
Zealand
United
Kingdom
United
States
THE
COMMONWEALTH
FUND
Source: 2004 Commonwealth Fund International Health Policy Survey.
Chart II-14. Continuity of Care
with Same Physician Lacking
Percent:
48
AUS
CAN
NZ
UK
US
94
95
97
99
91
2 years or less
22
20
21
18
29
3 to 5 years
22
21
20
17
25
More than 5 years
50
53
56
63
37
5
5
3
1
9
Has regular
doctor/place
No regular
doctor/place
THE
COMMONWEALTH
FUND
Source: 2004 Commonwealth Fund International Health Policy Survey.
Chart II-15. Type of Information Influences Hospital
CEOs’ Opinions Regarding Public Dissemination
49
Percent saying should NOT
be released to the public:
AUS
CAN
NZ
UK
US
Mortality rates for specific
conditions
34%
26%
18%
16%
31%
Frequency of specific
procedures
16
5
4
13
15
Medical error rate
31
18
25
15
40
Patient satisfaction ratings
5
2
0
1
17
Average waiting times for
elective procedures
6
1
0
1
29
25
10
25
9
29
Nosocomial infection rates
THE
COMMONWEALTH
FUND
Source: 2003 Commonwealth Fund International Health Policy Survey of Hospital Executives.
Chart II-16. Majority of Americans Want
Information About Their Health and the
Care They Receive
50
Percent lacking access to own medical records but would like access
100
Percent with access to own medical records
80
82
80
75
40
50
25
48
40
34
Australia
Canada
88
70
35
37
42
45
51
28
0
New
United
United
Zealand
Kingdom
States
Source: 2004 Commonwealth Fund International Health Policy Survey.
THE
COMMONWEALTH
FUND
Chart II-17. U.S. Performs Poorly on Kidney
Transplant Five-Year Relative Survival Rate
51
Standardized performance on quality indicator
100 = Worst result; Higher score = Better results
120
100
104
104
106
United
United
New
Australia
States
Kingdom
Zealand
100
113
80
60
40
20
0
Source: P. S. Hussey, G. F. Anderson, R. Osborn et al., "How Does the Quality
of Care Compare in Five Countries?" Health Affairs 23 (May/June 2004): 89–99.
Canada
THE
COMMONWEALTH
FUND
Chart II-18. U.S. Lags on Colorectal Cancer
Five-Year Relative Survival Rate
52
Standardized performance on quality indicator
100 = Worst result; Higher score = Better results
140
120
100
100
108
113
116
Canada
Australia
123
80
60
40
20
0
United
United
Kingdom
States
Source: P. S. Hussey, G. F. Anderson, R. Osborn et al., "How Does the Quality
of Care Compare in Five Countries?" Health Affairs 23 (May/June 2004): 89–99.
New
Zealand
THE
COMMONWEALTH
FUND
Chart II-19. Five-Year Survival Rates for
Cancer Patients Vary by Race/Ethnicity
and Census Poverty Tract
53
Percent of male patients diagnosed with cancer, 1988–1994
Low poverty, <10%
80
62
61
49
52
High poverty, 20%+
60
58
54
46
40
0
All races
White
Black
Source: G. Singh et al., "Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality,
Stage, Treatment and Survival, 1975–1999," NCI, 2003. Figures 6.3 and 6.4.
Hispanic
THE
COMMONWEALTH
FUND
Chart II-20. Five-Year Survival Rates for
Cancer Patients Vary by Race/Ethnicity
and Census Poverty Tract
54
Percent of female patients diagnosed with cancer, 1988–1994
Low poverty, <10%
80
63
63
53
55
High poverty, 20%+
65
59
60
48
40
0
All races
White
Black
Source: G. Singh et al., "Area Socioeconomic Variations in U.S. Cancer Incidence, Mortality,
Stage, Treatment and Survival, 1975–1999," NCI, 2003. Figures 6.3 and 6.4.
Hispanic
THE
COMMONWEALTH
FUND
55
Chart II-21. Life Expectancy at Birth
Lower in the United States
Female
90
80
Male
85.3
82.9
82.8
82.1
81.3
78.4
77.8
75.8
77.2
75.5
81
75.5
81.1
80.7
79.9
76.2
76.3
74.5
70
60
50
40
30
20
10
0
d
te
ni
U
d
te
ni
U
S
00
(2
2)
)
02
)
3
00
(2
0
(2
2
00
(2
)
om
s
te
ta
gd
in
K
n
ia
3
00
(2
3)
)
02
nd
la
ea
y
0
(2
ed
M
Z
D
C
ew
N
E
O
an
m
er
G
a
ad
)
03
)
00
(2
0
(2
3
00
(2
ia
al
tr
an
C
us
A
n
ce
an
Fr
pa
Ja
)
THE
COMMONWEALTH
FUND
Source: OECD Health Data, 2005.
56
Chart II-22. United States Performs
Poorly on Life Expectancy at Age 65
Female
25
21.3
16.9
20.6
17.6
17.2
an
C
18
21
us
A
20
23
Male
19.6
20
16.7
19.6
19.5
16
16.1
19.1
16.6
16.1
15
10
5
0
d
te
ni
U
d
te
ni
U
2)
2
00
(2
00
(2
om
s
te
ta
)
)
)
02
2
00
(2
1
00
(2
n
ia
0
(2
3)
)
02
gd
in
K
S
y
ed
M
0
(2
nd
la
ea
an
D
C
Z
m
er
G
E
O
ew
N
a
ad
)
01
)
00
(2
0
(2
3
00
(2
ia
al
tr
n
ce
an
Fr
pa
Ja
)
THE
COMMONWEALTH
FUND
Source: OECD Health Data, 2005.
III. Need for Greater Efficiency
57
After a period of relatively stable growth in the 1990s, health care spending
has exploded in recent years. Health care costs are concentrated among the
sickest and most vulnerable Americans and are borne by those with private as
well as public coverage.
– In 2002, U.S. health expenditures totaled 14.6 percent of gross domestic
product, substantially higher than other developed nations. This
percentage is projected to rise in the next decade (Charts III-1 and III-2).
– Ten percent of patients account for 69 percent of health expenditures
(Chart III-3).
– Closer examination of the continued acceleration of health care spending
indicates that private insurance premiums have historically outpaced
Medicare spending per beneficiary (Chart III-4).
THE
COMMONWEALTH
FUND
58
The United States far outpaces other countries in health care spending per
capita (Chart III-5). Per capita out-of-pocket health spending in 2002 was
more than double the OECD median (Chart III-6). Yet, the United States
does not consistently use more services. In international comparisons of
hospital discharges and average annual physician visits per capita, the
United States sits on the lower end of the spectrum (Charts III-7 and III-8).
Still, U.S. hospital expenditures exceed those in France, Canada, and
Australia (Chart III-9), and use of expensive specialty services is much
higher (Chart III-10).
Administrative costs are rising rapidly.
Health care coordination and administration are two areas that may greatly
benefit from initiatives to raise efficiency. Growth in administrative costs has
exceeded growth in national health expenditures (Chart III-11).
THE
COMMONWEALTH
FUND
59
Enhancements in care coordination could foster cost savings.
A study examining elderly adults hospitalized for heart failure determined
that transitional care provided by an advanced practice nurse reduced
rehospitalization rates and lowered overall health care costs. Through
discharge planning and home follow-up visits, the advanced practice nurse
provided needs assessment, care planning, patient education, and
therapeutic support. The average cost of care for the intervention group was
39 percent lower than for the group receiving usual care (Chart III-12).
Lack of care coordination can lead to the unavailability of test results or
records at the time of the patient's appointment; duplication of testing; or
provision of conflicting information by the patient's various physicians. The
2004 Commonwealth Fund International Health Policy Survey found that 31
percent of those surveyed in the United States had experienced at least one
of the aforementioned issues (Chart III-13). Individuals lacking insurance
are more likely to experience a care coordination problem (Chart III-14).
THE
COMMONWEALTH
FUND
60
Substantial variations indicate a need for standardization of practices
based on individual patient characteristics and conditions, not on
geographic location.
Standardization of practices can create more effective care while
decreasing costs. Currently, there are substantial variations within the
health care system, including quantity of services and prices.
– Across large Pennsylvania hospitals, charges for medical management
of acute myocardial infarction vary eightfold (Chart III-15).
– Medicare spending varies across the states; higher Medicare spending
per beneficiary does not necessarily correlate with higher-quality care
(Chart III-16).
– Quality and cost vary greatly across hospitals (Chart III-17).
– Drug prices are between 34 to 59 percent lower in Canada, France, and
the United Kingdom than in the United States (Chart III-18).
– Doctors who practice more evidence-based medicine can be the ones
whose costs per case are lowest, but they can also be the highest
(Chart III-19). Strategies are needed to foster high-quality, highefficiency practices.
THE
COMMONWEALTH
FUND
Chart III-1. U.S. Spends Greater Percentage
of GDP on Health Care Than Other Nations
61
Percent of gross domestic product (GDP) spent on health care, 2002
16.0
14.6
14.0
10.9
12.0
10.0
9.7
9.6
9.1
8.5
8.5
Australia
OECD
(2001)
Median
7.8
7.7
New
Japan
United
Zealand
(2001)
Kingdom
8.0
6.0
4.0
2.0
0.0
United
States
Germany
France
Canada
Source: G. F. Anderson and P. S. Hussey, Multinational Comparisons of Health
Systems Data 2004, The Commonwealth Fund, October 2004. OECD data.
THE
COMMONWEALTH
FUND
Chart III-2. U.S. Health Expenditures
as Share of GDP Expected to Rise
Through Next Decade
62
Expenditures as percent of gross domestic product (GDP)
20
18 19
15
11 11
13 13 13 13 13 13 13 13 13
12 13
14
16 16
15 15
10
5
0
8
8
19
0
9
19
2
9
19
4
9
19
6
9
19
8
9
19
0
0
20
2
0
20
4
0
20
6
0
20
8
0
20
0
1
20
2
1
20
4
1
20
Projected
Source: Center for Medicare and Medicaid Services, Office of the Actuary, 1998–2003 from CMS
Health Accounts data file nhegdp03.zip available at http://www.cms.hhs.gov/statistics/nhe/default.asp;
2004–2014 published in Heffler et al., "U.S. Health Spending Projections for 2004–2014," Health
Affairs Web Exclusive (February 23, 2005): W5-74–W5-85.
THE
COMMONWEALTH
FUND
Chart III-3. Health Care Costs
Concentrated in Sick Few
63
Distribution of health expenditures for the U.S. population,
by magnitude of expenditure, 1997
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Expenditure
Threshold
(1997 Dollars)
1%
5%
10%
50%
U.S. population
27%
$27,914
55%
$7,995
69%
$4,115
97%
$351
Health expenditures
Source: A. C. Monheit, "Persistence in Health Expenditures in the Short Run:
Prevalence and Consequences," Medical Care 41, supplement 7 (2003): III53–III64.
THE
COMMONWEALTH
FUND
Chart III-4. Private Insurance Premiums
Have Historically Outpaced Medicare
Spending per Beneficiary
64
Percent annual growth in per-enrollee spending
Medicare
12
10
9.0
10.1
Private health insurance
10.7
9.6
8
FEHBP*
8.8
5.9
6
4
2
0
1969–2003
1999–2003
* FEHBP estimates are for 1969–2002 and 1999–2002 from Levit et al.,
“Health Spending Rebound Continues in 2002,” Health Affairs 23 (Jan/Feb 2004).
Source: Analysis by Office of the Actuary, Centers for Medicare and Medicaid Services, January 2005.
THE
COMMONWEALTH
FUND
Chart III-5. Health Care Spending Per Capita
in 2002 Illustrates Higher U.S. Spending
65
Adjusted for differences in cost of living
$6,000
5,267
$5,000
$4,000
$3,446
$2,931
$3,000
$2,817 $2,736
$2,643$2,517
$2,000
$2,504
$2,193 $2,160
$2,077
$1,857
$1,000
$553
$0
e
M
x
w
o
la
)
d
1
m
1)
do
n
00
g
an
di
0
s
0
(2
s
d
te
d
in
a
K
(2
e
Z
n
ic
a
ed
it
e
ap
n
a
li
n
e
M
ra
st
e
D
C
E
N
J
U
O
u
A
ed
y
an
rl
e
e
c
th
n
n
ta
an
rl
S
a
a
ad
rm
w
S
e
e
n
ze
it
ed
it
ra
N
F
G
a
C
n
w
S
U
Source: G. F. Anderson et al., "Health Spending in the United States and the Rest of the
Industrialized World," Health Affairs 24 (July/August 2005): 903. OECD Health Data.
THE
COMMONWEALTH
FUND
Chart III-6. Out-of-Pocket Health Care Spending
Per Capita in 2002 Highest in United States
66
Adjusted for differences in cost of living
$800
$737
$700
$600
$483
$500
$445
$400
$347
$342
$298
$300
$292
$288
$268
$266
$200
$100
$0
N
s
1)
1)
)
d
00
(2
y
n
la
d
an
rl
ce
he
et
an
Fr
an
a
Ze
1
00
(2
es
00
(2
t
ta
n
ia
ed
M
o
ic
ew
m
er
ex
M
G
N
n
D
EC
a
ad
pa
Ja
O
an
C
S
ia
al
tr
d
te
ni
us
A
U
Source: OECD Health Data.
THE
COMMONWEALTH
FUND
Chart III-7. United States on Lower End of Spectrum
for Hospital Discharges per 1,000 Population in 2002
67
300
252
250
247
206
201
200
159
156
150
112
100
98
91
50
0
France
United
New
Germany
OECD
(2001)
Kingdom
Zealand
(2001)
Median
Australia
Source: OECD Health Data, 2004, from G. F. Anderson et al., "Multinational
Comparisons of Health Systems Data, 2004" (forthcoming).
Japan
United
Canada
States
(2001)
THE
COMMONWEALTH
FUND
Chart III-8. United States on Lower End of
Spectrum for Average Annual Number of
Physician Visits Per Capita
16.0
68
14.5
14.0
12.0
10.0
7.3
8.0
6.9
6.2
6.2
6.0
6.2
4.9
4.4
3.6
4.0
2.9
2.5
2.0
)
xi
co
(2
00
2
1)
(2
00
M
e
S
w
e
de
n
(2
0
S
ta
te
s
(2
nd
ni
te
d
la
U
Z
ea
01
)
)
00
1
00
)
(2
0
ew
ni
te
d
U
Source: OECD Health Data.
N
K
in
gd
D
om
M
e
di
an
1)
E
C
O
an
C
us
tr
al
ia
ad
a
(2
(2
00
00
2
)
01
)
(2
0
A
Fr
an
ce
ny
a
er
m
G
Ja
pa
n
(2
00
(2
00
0
)
1)
0.0
THE
COMMONWEALTH
FUND
Chart III-9. Per-Day Hospital Expenditures
High in the United States
69
Adjusted for differences in cost of living
$3,000
$2,500
$2,434
$2,000
$1,500
$1,000
$902
$870
$848
France (2001)
Canada (2001)
Australia (2001)
$500
$0
United States
(2002)
THE
COMMONWEALTH
FUND
Source: OECD Health Data.
Chart III-10. United States Uses
More Expensive Specialty Services
70
Percutaneous transluminal coronary angioplasty (PTCA)
interventions per 100,000 population in 2002
500
416
400
300
158
200
157
130
100
94
86
73
OECD
New
United
Median
Zealand
Kingdom
0
United
Canada
France
States
(2001)
(2001)
Australia
Source: OECD Health Data 2004, from G. F. Anderson et al., "Multinational
Comparisons of Health Systems Data, 2004" (forthcoming).
THE
COMMONWEALTH
FUND
Chart III-11. Administrative Cost Growth
Outpaces Total Medical Expenditure Growth
Annual growth 1997–2000
Percent
Annual growth 2000–2001
20
Annual growth 2001–2002
16.3
Annual growth 2002–2003
15
10
71
12.5
8.5
6.2
9.3
7.7
13.2
9.7
5
0
National health expenditure
Administrative costs of private
and public insurance
* Administrative costs totaled $119.7 billion in 2003, nearly double that of 1997.
Source: Smith et al., "Health Spending Growth Slows in 2003," Health Affairs 24 (Jan/Feb 2005).
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Chart III-12. Transitional Care Reduces
Rehospitalization for Heart Failure Patients
72
Resource use among congestive heart failure patients ages 65+ treated at
six Philadelphia hospitals during 1997–2001 who were randomly assigned
to receive a three-month transitional care intervention or usual care
Usual care group
100
200
$16,000
162
80
$12,481
150
61
60
Intervention group
48
$12,000
104
100
$8,000
50
$4,000
0
$0
40
20
0
Percentage of patients who
were rehospitalized or died
Number of
hospital readmissions
$7,636
Average cost of care
Source: Medical records and patient interviews (N=239) (Naylor et al. 2004), S. Leatherman
and D. McCarthy, Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005,
The Commonwealth Fund. www.cmwf.org/usr_doc/MedicareChartbk.pdf.
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COMMONWEALTH
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Chart III-13. Care Coordination
Concerns Abound
73
Base: Have seen a doctor in past two years
Percent saying in the past
two years:
AUS
CAN
NZ
UK
US
Test results or records not
available at time of appointment
12
14
13
13
17
Duplicate tests: doctor ordered
test that had already been done
7
6
7
4
14
Received conflicting information
from different doctors
18
14
14
14
18
Percent who experienced at
least one of the above
28
26
25
24
31
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COMMONWEALTH
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Source: 2004 Commonwealth Fund International Health Policy Survey.
Chart III-14. Uninsured in U.S. at Highest Risk
for Care Coordination Problem
74
Percent ages 19–64 reporting any of three coordination problems*
60
44
40
30
33
26
26
26
Canada
New Zealand
United
Kingdom
28
20
0
Australia
Total
Insured all
year
Uninsured
anytime
United States
*Coordination problems include duplication of tests, conflicting views,
and medical record not available at time of appointment.
Source: 2004 Commonwealth Fund International Health Policy Survey.
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75
Chart III-15. Charges for Medical
Management of Acute Myocardial Infarction
Vary Eightfold Across Large Pennsylvania
Hospitals
$100,000
88,457
$80,000
$60,000
Lowest
mortality
hospital
$21,846*
$40,000
14,020 14,871
$20,000
10,592
18,596 19,294
24,012
64,627
43,636
29,672
$0
* This hospital demonstrated significantly lower than expected in-hospital mortality rates.
Note: Hospital charge equals patient total charge excluding professional fees; all hospitals shown
provided advanced cardiac services (angioplasty/stent procedures), had >100 cases, and <5% of
cases transferred to another acute care facility.
Source: Pennsylvania Health Care Cost Containment Council, Hospital Performance Results,
Hospital discharges between January 1, 2003 and December 31, 2003, www.phc4.org.
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COMMONWEALTH
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Chart III-16. Quality and Medicare Spending
Vary Across States, 2000–2001
76
Quality Expressed by Percent of Beneficiaries with Atrial Fibrillation
Sources: K. Baicker and A. Chandra, "Medicare Spending, The Physician Workforce, and
Beneficiaries' Quality of Care," Health Affairs Web Exclusive (April 7, 2004).
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Chart III-17. Cost and Quality Vary Widely
Across U.S. Hospitals
77
Coronary Artery Bypass Graft:
Observed/Expected Cost vs. Observed/Expected Quality
Outcomes by Hospital
2.0
Cost per Case - Observed/Expected
High Cost
1.5
1.0
0.5
Low Cost
Low Quality
High Quality
0.0
0.0
0.5
1.0
1.5
2.0
2.5
Poor Outcomes - Observed/Expected
Source: S. Grossbart, "The Business Case for Safety and Quality: What Can Our Databases
Tell Us," 5th Annual NPSF Patient Safety Congress, March 15, 2003.
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COMMONWEALTH
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Chart III-18. Pharmaceutical Prices in U.S.
Exceed Those in Other Countries
78
Relative Prices of Thirty Pharmaceuticals in Four Countries, 2003
Price index
120
20% U.S. discount
No U.S. discount
100 100
100
80
66
60
48
60
41
52
53
40
20
0
United States
Canada
France
Note: Analysis of IMS health data.
Source: G. F. Anderson, D. Shea, P. S. Hussey et al., "Doughnut Holes
and Price Controls," Health Affairs Web Exclusive (July 21, 2004).
United Kingdom
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COMMONWEALTH
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Chart III-19. High Longitudinal Efficiency
and Quality Are Compatible
79
(Applies to selections of providers and treatment options)
MD Quality Index
(outcomes or % adherence to EBM)
Lower
Higher
50th %ile
High Quality
Low TCO
(Dream Suppliers)
High Quality
High TCO
50th %ile
Low Quality
High TCO
(Nightmare
Suppliers)
Low Quality
Low TCO
Higher
Lower
MD Longitudinal Efficiency Index
(total cost per case mix-adjusted treatment episode)
TCO is total cost of ownership. It refers to the average stream of total health care spending over the course of a
longitudinal episode of care, adjusted for case mix/severity of illness incurred for a particular provider's patients.
Source: A. Milstein, "Restorers, Skin-grafters & Calibrators: A Five-Year Forecast for Large Employer Cost Sharing,"
data from Regence Blue Shield; Health System Change Patient Cost Sharing Conference, 12/3/2003.
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Conclusion. The Time Is Ripe
for Improvement
80
Although there are numerous challenges facing the U.S. health care
system, transformation is possible. In the minds of health care opinion
leaders,* enhanced performance is not unrealistic, and viable policies for
improving access, quality, and efficiency are attainable. Currently, 18
percent of the under-65 population is without health insurance. According to
a Commonwealth Fund Health Care Opinion Leaders survey released in
March 2005, the proportion of uninsured can and should be reduced by
more than half in 10 years (Chart IV-1).
Respondents to the survey believe that health expenditures will need to
increase somewhat as a percentage of GDP (Chart IV-1). But they also
believe that there are effective ways to cut health care costs. According to a
survey released in May 2005, these leaders consider pay-for-performance
to be the most effective means to reduce health care costs.
* Health care opinion leaders answering the Fund's survey include widely recognized
U.S. experts in health care policy, finance, and delivery with a variety of perspectives
and expertise.
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In addition, a majority of respondents believe enhanced disease
management and primary care case management would effectively reduce
unnecessary utilization of health care services. Respondents were also
enthusiastic about use of evidence-based guidelines, and nearly half rated
expanding the use of information technology as an extremely or very
effective means of controlling use of unnecessary services (Chart IV-2).
Promising strategies for improving affordability and achieving savings also
include the following:
– Management of high-cost care
– Selection of medical home and improved access to primary care and
preventive services
– Better information on provider quality and total costs of care
– Development of networks of high-performing providers under Medicare,
Medicaid, and private insurance
– Limits on family premium and out-of-pocket costs as a percent of
income (e.g., 5 percent of income for low-income individuals)
– Expanded group coverage and reinsurance
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Medicare, which comprised one-fifth of all personal health care spending in
2003 (MedPAC 2004), is a major payer and therefore an important driver of
change. The Centers for Medicare and Medicaid Services (CMS) conducts
and sponsors demonstration projects in order to evaluate the effect of new
interventions and to inform policy decisions. Large majorities of respondents
who participated in an online survey of U.S. health care experts favor
leveraging Medicare to speed the adoption of electronic medical records
and health information technology (Chart IV-3). Innovations in the private
sector are also important for promoting high-quality, high-efficiency, and
cost-effective care.
The Commission on a High Performance Health System will seek
opportunities to change the delivery and financing of health care to improve
system performance and will identify public and private policies and
practices that would lead to those improvements. It will explore mechanisms
for financing improved health insurance coverage and investments in the
nation's capacity for quality improvement, including reinvesting savings from
efficiency gains.
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Chart IV-1. Transformation Is Possible
83
"What you would see as both an achievable and
a desirable target or goal for policy action for the next 10 years?"
80%
Current
Goal
63%
65%
60%
Asked as a
current target,
not a ten-year
goal
40%
20%
18%
15%
16%
9%
8%
0%
Proportion of under-65 Total cost of health care
population that has no as a percentage of GDP
health insurance
Percent of under-65
population with
employer-provided
insurance
Note: Goal percentages represent median responses.
Source: Commonwealth Fund Health Care Opinion Leaders Survey, February 2005.
Maximum % of income a
consumer should spend
for out-of-pocket
expenses and
premiums
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COMMONWEALTH
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Chart IV-2. Health Care Leaders: Pay-for-Performance
Is Most Effective Way to Reduce Health Care Costs
84
"How effective do you think each of these possible actions
would be to reduce health care costs?"
(Percent saying extremely or very effective)
Reward more efficient and high-quality medical-care
providers
57%
Improve disease management and primary care case
management
56%
Use evidence-based guidelines to determine when a
test or procedure should be done
52%
Expand the use of information technology
46%
Have all payers, including private insurers, Medicare,
and Medicaid, adopt common payment methods and
rates
Have patients pay a substantially higher share of their
health care costs
Source: Commonwealth Fund Health Care Opinion Leaders Survey, April 2005.
44%
31%
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COMMONWEALTH
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Chart IV-3. Health Policy Experts Suggest
Various Changes to Medicare
85
"Do you favor or oppose changing Medicare in the following ways?"
(Percent who favor…)
Using Medicare leverage to accelerate adoption of
electronic medical records and health information
technology
89%
Using Medicare’s leverage to reward providers for
performance on quality and efficiency
87%
Allowing those under age 65 to contribute to a
Medicare savings account
67%
Raising taxes to ensure Medicare’s long-term
solvency
67%
Having Medicare offer its own comprehensive benefit
package as an alternative to Medigap or Medicare
Advantage
67%
Eliminating the two-year waiting period for coverage
of the disabled
67%
Source: Commonwealth Fund Health Care Opinion Leaders Survey, July 2005.
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COMMONWEALTH
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86
References
Baile, W. and J. Aaron. “Patient–Physician Communication in Oncology: Past, Present, and Future.”
Current Opinion in Oncology. 17(4). (July 2005): 331.
Collins, S. et al. “Opinion: Proposals for Health Policy.” Inquiry. 42. (Spring 2005): 6.
Cutler, D. and M. McClellan. “Is Technological Change in Medicine Worth It?” Health Affairs. 20(5). (Sept/Oct 2001): 11.
Davis, K. et al. Health and Productivity Among U.S. Workers. (New York, The Commonwealth Fund, August 2005).
Davis, K. et al. Mirror, Mirror on the Wall: Looking at the Quality of American Health Care Through the Patient’s Lens.
(New York, The Commonwealth Fund, Jan. 2004).
Fisher, E. et al. “The Implications of Regional Variations in Medicare Spending: Part I. The Context, Quality, and
Accessibility of Care.” Annals of Internal Medicine. 138. (Feb 18, 2003): 273.
Gilmer, T. and R. Kronick. “It's the Premiums, Stupid: Projections of the Uninsured Through 2013.” Health Affairs
Web Exclusive. April 5, 2005.
Glied, S. and S. Little. “The Uninsured and the Benefits of Medical Progress.” Health Affairs. 22(4). (July/Aug 2003): 210.
Hall, M. et al. “Trust in Physicians and Medical Institutions: What Is It, Can It Be Measured, and Does It Matter?”
The Milbank Quarterly. 79(4). (2001): 613.
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References (cont.)
Institute of Medicine. Hidden Costs, Value Lost: Uninsurance in America. (Washington, DC: National Academies
Press, 2003).
Jencks, S., Huff, E. and T. Cuerdon. "Change in the Quality of Care Delivered to Medicare Beneficiaries,
1998–1999 to 2000–2001. JAMA. 289(3). (January 15, 2005): 305.
Kohn, L., Corrigan, J. and M. Donaldson (eds). To Err Is Human: Building a Safer Health System. Washington, DC:
National Academy Press; 1999.
Leatherman, S. and D. McCarthy. Quality of Health Care for Medicare Beneficiaries: A Chartbook, 2005.
The Commonwealth Fund.
MedPAC. June 2004. "National Health Care and Medicare Spending." In A Data Book: Health Care Spending
and the Medicare Program. Washington, DC: MedPAC. www.medpac.gov.
McGlynn et al. "The Quality of Health Care Delivered to Adults in the United States." The New England Journal
of Medicine. (June 26, 2003): 2635.
Parchman, M. and S. Burge. "The Patient-Physician Relationship, Primary Care Attributes, and Preventive Services."
Family Medicine. 36(1). (January 2004): 22.
Reinhardt, U., Hussey, P. and G. Anderson. "U.S. Health Care Spending in an International Context." Health
Affairs. 23(3). (May/June 2004): 10.
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References (cont.)
Schoen, C. et al. "Insured But Not Protected: How Many Adults Are Underinsured?" Health Affairs Web Exclusive.
June 14, 2005.
Schoen, C. et al. "Primary Care and Health System Performance: Adults' Experiences in Five Countries." Health Affairs
Web Exclusive. October 28, 2004.
Stewart, M. et al. "The Influence of Older Patient-Physician Communication on Health and Health-Related Outcomes.
Clinical Geriatric Medicine. 16(1). (2000): 25.
Stewart, M. "Effective Physician-Patient Communication and Health Outcomes: A Review." CMAJ. 152(9):1,423.
U.S. Census Bureau. Income, Poverty, and Health Insurance Coverage in the United States: 2004. (Washington, DC:
U.S. Government Printing Office, 2005).
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Visit the Fund at
www.cmwf.org
89
Publications:
• Chartbooks on quality of care
• International surveys (annual)
• Other publications on coverage,
access, and quality
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COMMONWEALTH
FUND