By Cathy Schoen, Robin Osborn, David Squires, Michelle Doty, Petra Rasmussen, Roz Pierson and Sandra Applebaum
Health Affairs, November 15, 2012
To explore the experiences of physicians as health reform policies unfold, we surveyed primary care physicians in the following ten countries in 2012: Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, the United Kingdom, and the United States.
Swiss and US patients often face substantial deductibles as well as cost sharing, although Swiss health insurance standards reduce rates for low-income people and limit out-of-pocket liability to levels well below those in the United States.
The United States is alone among the study countries in segmenting the population by income and age for government-sponsored health insurance and in its lack of coordinated policies across multiple private and public insurers.
US and Canadian physicians’ responses to questions regarding after-hours arrangements mirror patients’ experiences: In the 2010 international population survey on patient experience with health care services, Canadian and US patients were more likely than those in other countries to have used emergency departments and among the most likely to say that it was difficult to obtain health care after hours.
In 2012, 59 percent of US physicians said that their patients often have difficulty paying out-of-pocket costs for medical care – a percentage well above that in any other country.
In the United States, physicians’ perceptions of affordability or difficulties getting specialized care varied by patient insurance mix. Doctors with high proportions of uninsured or Medicaid patients were the most likely to say that their patients often faced long waits for specialized care.
To gauge primary care physicians’ perspectives overall, the survey asked about their views of their country’s health system, their satisfaction with the practice of medicine, and their perceptions of change in recent years. Repeating a pattern observed in earlier surveys, US and German physicians were the most negative about their health care systems, with only 15 percent and 22 percent, respectively, saying that the system needs only minor changes versus fundamental change or rebuilding. German and US physicians were also the least likely to say that they were satisfied or very satisfied with practicing medicine.
As countries aim to reduce health care costs, some countries have looked to coverage restrictions on treatments or medications or to reviews of physician care decisions. Although such interventions may target the appropriateness of care, they can also have the unintended consequence of imposing time and administrative burdens on physicians. Among the study countries, US physicians were the most likely to say that such time concerns are a major problem: More than half of US respondents said that they or their staff spend too much time getting patients care because of coverage restrictions on treatment or medications.
Notably, the share of Dutch doctors expressing concern about this issue has more than doubled since the 2009 survey (increasing from 10 percent to 26 percent). This suggests that problems are emerging with the growing complexity of health insurance practices in the Netherlands.
Regarding after-hours access to primary health care services, all of the study countries except the United States and Canada have policies for after-hours coverage. The low rates of after-hours arrangements reported by Canadian and US physicians indicate that such arrangements are slow to develop if they must depend on the actions of individual practices.
Insurance design also matters. US physicians stand out, as they have in past surveys, for saying that their patients often have difficulty paying for care and that insurance restrictions on care decisions consume substantial doctor and staff time. The other countries in the study all provide universal coverage and, with the exception of Switzerland, have little or no cost sharing for primary care and essential medications. All of the other countries limit out-of-pocket expenses to levels well below those typical in US insurance.
In contrast to other countries with multiple insurers, US private insurers often use prior authorization and employ varying drug formularies and complex benefit designs, with little standardization. Recent studies confirm that the resulting insurance-related complexity adds substantially to US practice costs as a result of increased paperwork and time demands.
In patient surveys, the United States also stands out for insurance-related time concerns. US experiences provide a cautionary example for other countries regarding the time and resource costs of complexity.
In general, US primary care physicians’ views and experiences endorse the need for reform, including enhanced access. US physicians who reported that their patients often faced cost or other access barriers were the most likely to say that the system required major change.
By Don McCanne, MD
We spend by far the most money per capita on health care. Yet, compared to primary care physicians in other nations, U.S. physicians are by far the most negative about our health system, with only 15 percent saying that “the system needs only minor changes” (versus fundamental change or rebuilding).
The perspective provided by the excerpts posted above should drive the citizens of our nation to demand comprehensive reform. Are we up to it?