US lags in access, cost and insurance problems due to insurance design

The Commonwealth Fund study on How Health Insurance Design Affects Access to Care and Costs, by Income, in Eleven Countries found that:

• "One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs, compared with as few as 5 percent of adults in the United Kingdom and 6 percent in the Netherlands.
• One-fifth (20%) of U.S. adults had major problems paying medical bills, compared with 9 percent or less in all other countries.
• Thirty-one percent of U.S. adults reported spending a lot of time dealing with insurance paperwork, disputes, having a claim denied by their insurer, or receiving less payment than expected. Only 13 percent of adults in Switzerland, 20 percent in the Netherlands, and 23 percent in Germany—all countries with competitive insurance markets that allow consumers a choice of health plan—reported these concerns.
• The study found persistent and wide disparities by income within the U.S.—even for those with insurance coverage. Nearly half (46%) of working-age U.S. adults with below-average incomes who were insured all year went without needed care, double the rate reported by above-average-income U.S. adults with insurance.
• The U.S. lags behind many countries in access to primary care when sick. Only 57 percent of adults in the U.S. saw their doctor the same or next day when they were sick, compared with 70 percent of U.K. adults, 72 percent of Dutch adults, 78 percent of New Zealand adults, and 93 percent of Swiss adults.
• U.S. , German, and Swiss adults reported the most rapid access to specialists. Eighty percent of U.S. adults, 83 percent of German adults, and 82 percent of Swiss adults waited less than four weeks for a specialist appointment. U.K. (72%) and Dutch (70%) adults also reported prompt specialist access."

Commonwealth Fund: US Health System Continues to Underperform

A new Commonwealth Fund study  reports that despite having the "most costly health system in the world, the United States consistently underperforms on most dimensions of performance... Compared with six other nations—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom — the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives."

"The most notable way the U.S. differs from other countries is the absence of universal health insurance coverage. Health reform legislation recently signed into law by President Barack Obama should begin to improve the affordability of insurance and access to care when fully implemented in 2014. Other nations ensure the accessibility of care through universal health insurance systems and through better ties between patients and the physician practices that serve as their long-term “medical homes.” Without reform, it is not surprising that the U.S. currently underperforms relative to other countries on measures of access to care and equity in health care between populations with above-average and below-average incomes.

But even when access and equity measures are not considered, the U.S. ranks behind most of the other countries on most measures. With the inclusion of primary care physician survey data in the analysis, it is apparent that the U.S. is lagging in adoption of national policies that promote primary care, quality improvement, and information technology. Health reform legislation addresses these deficiencies; for instance, the American Recovery and Reinvestment Act signed by President Obama in February 2009 included approximately $19 billion to expand the use of health information technology. The Patient Protection and Affordable Care Act of 2010 also will work toward realigning providers’ financial incentives, encouraging more efficient organization and delivery of health care, and investing in preventive and population health.

For all countries, responses indicate room for improvement. Yet, the other six countries spend considerably less on health care per person and as a percent of gross domestic product than does the United States. These findings indicate that, from the perspectives of both physicians and patients, the U.S. health care system could do much better in achieving value for the nation’s substantial investment in health.

Key Findings


Quality: The indicators of quality were grouped into four categories: effective care, safe care, coordinated care, and patient-centered care. Compared with the other six countries, the U.S. fares best on provision and receipt of preventive and patient-centered care. However, its low scores on chronic care management and safe, coordinated care pull its overall quality score down. Other countries are further along than the U.S. in using information technology and managing chronic conditions. Information systems in countries like Australia, New Zealand, and the U.K. enhance the ability of physicians to identify and monitor patients with chronic conditions.

Access: Not surprisingly—given the absence of universal coverage—people in the U.S. go without needed health care because of cost more often than people do in the other countries. Americans with health problems were the most likely to say they had access issues related to cost, but if insured, patients in the U.S. have rapid access to specialized health care services. In other countries, like the U.K. and Canada, patients have little to no financial burden, but experience wait times for such specialized services. There is a frequent misperception that such tradeoffs are inevitable; but patients in the Netherlands and Germany have quick access to specialty services and face little out-of-pocket costs. Canada, Australia, and the U.S. rank lowest on overall accessibility of appointments with primary care physicians.


Efficiency: On indicators of efficiency, the U.S. ranks last among the seven countries, with the U.K. and Australia ranking first and second, respectively. The U.S. has poor performance on measures of national health expenditures and administrative costs as well as on measures of the use of information technology, rehospitalization, and duplicative medical testing. Sicker survey respondents in Germany and the Netherlands are less likely to visit the emergency room for a condition that could have been treated by a regular doctor, had one been available.

Equity: The U.S. ranks a clear last on nearly all measures of equity. Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick, not getting a recommended test, treatment, or follow-up care, not filling a prescription, or not seeing a dentist when needed because of costs. On each of these indicators, nearly half of lower-income adults in the U.S. said they went without needed care because of costs in the past year.

Long, healthy, and productive lives:  The U.S. ranks last overall with poor scores on all three indicators of long, healthy, and productive lives. The U.S. and U.K. had much higher death rates in 2003 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Canada and Australia. Overall, Australia ranks highest on healthy lives, scoring in the top three on all of the indicators."

US Lags in Health IT for Primary Care

46% of U.S. primary care physicians report using electronic medical records (EMRs) significantly trailing other leading countries. EMRs are "nearly universal" in the Netherlands (99%), New Zealand (97%), the U.K. (96%), Australia (95%), Italy (94%), Norway (97%), and Sweden (94%).

The Commonwealth Fund report on A Survey of Primary Care Physicians in 11 Countries, 2009: Perspectives on Care Costs, and Experiences surveyed 10,000 primary care physicians in 11 countries. The findings: the United States lags far behind in terms of access to care, the use of financial incentives to improve the quality of care, and the use of health information technology.

The study's authors conclude that "the advanced health information technology and extensive use of quality incentives and care teams reported by Australian, Dutch, and New Zealand doctors reflect national payment and information system policies focused on primary care. Lacking such policies, the U.S. lags far behind its peers in these areas—even as it spends far more on health care overall. In addition, insurance coverage restrictions make it difficult for many U.S. physicians to provide their patients with timely access to care."

"We spend far more than any of the other countries in the survey, yet a majority of U.S. primary care doctors say their patients often can’t afford care, and a wide majority of primary care physicians don’t have advanced computer systems to access patient test results, anticipate and avoid medication errors, or support care for chronically ill patients," said Commonwealth Fund Senior Vice President Cathy Schoen, lead author of the article. "The patient-centered chronic care model originated in the U.S., yet other countries are moving forward faster to support care teams including nurses, spending time with patients, and assuring access to after-hours. The study underscores the pressing need for national reforms to close the performance gap to improve outcomes and reduce costs."

Seven of eleven countries surveyed had near universal deployment of EMRs and found EMRs with stronger functionality across all sizes of practices. By contrast in the US, more sophisticated EMR deployment was found primarily in larger practices and integrated care systems.

Clinical decision support is not that well developed across any of the countries surveyed. This included low scores for computerized reminders for treatment guidelines, tracking laboratory tests, and prompts to provide patients with test results.

The following are the comparative charts related to health information technology.


What are the salient differences in structure for primary care? "The United States is distinct in its reliance on internal medicine and pediatrics for primary care and its highly decentralized referral systems. The other countries rely extensively on general or family practice (GP/FP) physicians, often augmented by use of primary care nurses for preventive or chronic care and counseling. In Australia, Italy, the Netherlands, New Zealand, Norway, and the United Kingdom, patients register with primary care physicians, who typically serve as “gatekeepers” for referral for more specialized care. Other countries encourage registration through financial incentives for patients or providers, or both. Primary care practices, except in Sweden, generally operate as private practices. A majority of Swedish doctors work as public employees (local health centers), but reforms have been moving to private contracts and a mix of prepayment, or capitation, and fees. Australian, Canadian, French, German, and U.S. insurers generally pay fee-for-service (FFS). The other countries use a blend of capitation and fees for visits, targeted care, or performance incentives. The U.S. system includes examples of salary, mixed FFS and capitation, and integrated systems. Insurance systems differ across countries in patient cost sharing. In contrast to the United States, Canada, the Netherlands, and the United Kingdom have no or little cost sharing for medical care. France requires no cost sharing for specific chronic illnesses. Germany limits costs as a share of income. Norway and Sweden limit annual out-of-pocket costs. In Australia, primary care visits are often “bulkbilled” with no patient charge, and ceilings limit overall cost exposure. New Zealand has been reducing patient fees. Italy’s national benefits cover primary care in full, with copayments for outpatient drugs and specialists."

The study found that only the US had not pursued reform of primary care "including financial and information incentives... to provide a foundation for high-quality, efficient care."