US Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures

By Lawrence P. Casalino, David Gans, Rachel Weber, Meagan Cea, Amber Tuchovsky, Tara F. Bishop, Yesenia Miranda, Brittany A. Frankel, Kristina B. Ziehler, Meghan M. Wong and Todd B. Evensong
Health Affairs, March 2016

Abstract

Each year US physician practices in four common specialties spend, on average, 785 hours per physician and more than $15.4 billion dealing with the reporting of quality measures. While much is to be gained from quality measurement, the current system is unnecessarily costly, and greater effort is needed to standardize measures and make them easier to report.

**

The number of quality measures directed at US health care providers by external entities such as Medicare, Medicaid, and private health insurance plans has increased rapidly during the past decade. These measures, such as rates of mammography screening for women or of testing for cholesterol or hemoglobin A1c levels for diabetes, are used to provide publicly reported information for patients and as a basis for financial “pay-for-performance” incentives to physicians. At least 159 measures of outpatient physician care are now publicly available. The movement toward accountable care organizations, the federal Sustainable Growth Rate “fix” legislation, and the private-sector Catalyst for Payment Reform coalition will further emphasize measurement of physician performance.

Anecdotally, dealing with these measures imposes a considerable burden on physician practices in terms of understanding the measures, providing performance data, and understanding performance reports from payers, but the extent of that burden has not been quantified. We present results from a national survey of practices representing three common physician specialty and multispecialty practices.

From the Study Results

On average, physicians and staff spent a total of 15.1 hours per physician per week dealing with quality measures, with the average physician spending 2.6 hours per week and other staff spending 12.5 hours.

By far the most time — 12.5 hours of physician and staff time per physician per week — was spent on “entering information into the medical record ONLY for the purpose of reporting for quality measures from external entities.”

The time spent by physicians and staff translates to an average cost to a practice of $40,069 per physician per year.

From the Discussion

There is much to gain from quality measurement, but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures. Improving the system rapidly will be difficult. Obstacles include the fragmented US health care system, lack of interoperability across EHRs, lack of EHR functionalities to facilitate retrieval of data for quality measures, the cost of change to external entities and to providers, and opposition from vested interests. Increasing efforts to reduce the number of measures and to standardize their use across external entities are being made by the National Quality Forum, the Institute of Medicine, and America’s Health Insurance Plans, as well as by federal agencies such as the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality. Our data suggest that US health care leaders should make these efforts a priority.

http://content.healthaffairs.org/content/35/3/401.abstract

***

Comment:

By Don McCanne, M.D.

Quality measures in health care have proven to be burdensome, consuming excess resources in both time and money. This study quantifies those costs.

Not only do these quality games waste resources, they have become a significant contributor to physician burnout.

Wouldn’t it be far better to devote these extra resources to improving access to actual health care for the uninsured and underinsured who are now being all too often left out? It would be automatic under a single payer Medicare for all program.

US Physician Practices Spend More Than $15.4 Billion Annually To Report Quality Measures

By Lawrence P. Casalino, David Gans, Rachel Weber, Meagan Cea, Amber Tuchovsky, Tara F. Bishop, Yesenia Miranda, Brittany A. Frankel, Kristina B. Ziehler, Meghan M. Wong and Todd B. Evensong
Health Affairs, March 2016

Abstract

Each year US physician practices in four common specialties spend, on average, 785 hours per physician and more than $15.4 billion dealing with the reporting of quality measures. While much is to be gained from quality measurement, the current system is unnecessarily costly, and greater effort is needed to standardize measures and make them easier to report.

**

The number of quality measures directed at US health care providers by external entities such as Medicare, Medicaid, and private health insurance plans has increased rapidly during the past decade. These measures, such as rates of mammography screening for women or of testing for cholesterol or hemoglobin A1c levels for diabetes, are used to provide publicly reported information for patients and as a basis for financial “pay-for-performance” incentives to physicians. At least 159 measures of outpatient physician care are now publicly available. The movement toward accountable care organizations, the federal Sustainable Growth Rate “fix” legislation, and the private-sector Catalyst for Payment Reform coalition will further emphasize measurement of physician performance.

Anecdotally, dealing with these measures imposes a considerable burden on physician practices in terms of understanding the measures, providing performance data, and understanding performance reports from payers, but the extent of that burden has not been quantified. We present results from a national survey of practices representing three common physician specialty and multispecialty practices.

From the Study Results

On average, physicians and staff spent a total of 15.1 hours per physician per week dealing with quality measures, with the average physician spending 2.6 hours per week and other staff spending 12.5 hours.

By far the most time — 12.5 hours of physician and staff time per physician per week — was spent on “entering information into the medical record ONLY for the purpose of reporting for quality measures from external entities.”

The time spent by physicians and staff translates to an average cost to a practice of $40,069 per physician per year.

From the Discussion

There is much to gain from quality measurement, but the current system is far from being efficient and contributes to negative physician attitudes toward quality measures. Improving the system rapidly will be difficult. Obstacles include the fragmented US health care system, lack of interoperability across EHRs, lack of EHR functionalities to facilitate retrieval of data for quality measures, the cost of change to external entities and to providers, and opposition from vested interests. Increasing efforts to reduce the number of measures and to standardize their use across external entities are being made by the National Quality Forum, the Institute of Medicine, and America’s Health Insurance Plans, as well as by federal agencies such as the Centers for Medicare and Medicaid Services and the Agency for Healthcare Research and Quality. Our data suggest that US health care leaders should make these efforts a priority.

http://content.healthaffairs.org/content/35/3/401.abstract

Quality measures in health care have proven to be burdensome, consuming excess resources in both time and money. This study quantifies those costs.Not only do these quality games waste resources, they have become a significant contributor to physician burnout.

Wouldn’t it be far better to devote these extra resources to improving access to actual health care for the uninsured and underinsured who are now being all too often left out? It would be automatic under a single payer Medicare for all program.

The “Cadillac Tax” on Health Benefits in the United States Will Hit the Middle Class Hardest

Refuting the Myth That Health Benefit Tax Subsidies Are Regressive

By Steffie Woolhandler, David U. Himmelstein
International Journal of Health Services, Online March 9, 2016

Abstract

U.S. employment-based health benefits are exempt from income and payroll taxes, an exemption that provided tax subsidies of $326.2 billion in 2015. Both liberal and conservative economists have denounced these subsidies as “regressive” and lauded a provision of the Affordable Care Act — the Cadillac Tax — that would curtail them. The claim that the subsidies are regressive rests on estimates showing that the affluent receive the largest subsidies in absolute dollars. But this claim ignores the standard definition of regressivity, which is based on the share of income paid by the wealthy versus the poor, rather than on dollar amounts. In this study, we calculate the value of tax subsidies in 2009 as a share of income for each income quintile and for the wealthiest Americans. In absolute dollars, tax subsidies were highest for families between the 80th and 95th percentiles of family income and lowest for the poorest 20%. However, as shares of income, subsidies were largest for the middle and fourth income quintiles and smallest for the wealthiest 0.5% of Americans. We conclude that the tax subsidy to employment-based insurance is neither markedly regressive, nor progressive. The Cadillac Tax will disproportionately harm families with (2009) incomes between $38,550 and $100,000, while sparing the wealthy.

http://joh.sagepub.com/content/early/2016/03/08/0020731416637163.abstract

PNHP press release:
https://www.pnhp.org/news/2016/march/‘cadillac-tax’-on-health-benefits-will-hit-middle-class-hardest-study

***

Comment:

By Don McCanne, M.D.

The “Cadillac tax” is an excise tax on premiums of more expensive employer-sponsored health plans. It was included in the Affordable Care Act partly as a revenue source to help pay for ACA, partly to offset the tax subsidies for employer-sponsored insurance that were more generous for higher income individuals, and partly to reduce the incentive to purchase more insurance than necessary under the theory that making patients more sensitive to health care costs will prevent spending on supposedly excessive health care services (certainly a contentious point).

Because of the high costs of health care, we do need funding mechanisms that result in a transfer to those less able to pay. The Cadillac tax is a problem because, instead of disproportionately assessing the very wealthy, it impacts primarily working families. Not only is the tax unfair, the health plans will likely have their benefits reduced in an effort to escape the taxes.

In a PNHP press release (link above), Steffie Woolhandler, one of the co-authors of the report, stated, “Taxpayers should be paying directly for health care through Medicare-for-All, not indirectly through tax subsidies to private insurance. However, removing the tax subsidies – as Obamacare will do – without setting Medicare-for-All in place is a step backwards. It’s shameful that economists have provided cover for this tax that will hit middle-class families and largely spare the wealthy.”

The Cadillac tax is just one more example of the flawed policy patches required simply because the architects of reform decided to build on our current dysfunctional, fragmented financing system instead of replacing it with a more efficient, effective and equitable single payer Medicare-for-all program. That doesn’t mean that we have to live with our highly flawed system. We can still change it.

The “Cadillac Tax” on Health Benefits in the United States Will Hit the Middle Class Hardest

Refuting the Myth That Health Benefit Tax Subsidies Are Regressive

By Steffie Woolhandler, David U. Himmelstein
International Journal of Health Services, Online March 9, 2016

Abstract

U.S. employment-based health benefits are exempt from income and payroll taxes, an exemption that provided tax subsidies of $326.2 billion in 2015. Both liberal and conservative economists have denounced these subsidies as “regressive” and lauded a provision of the Affordable Care Act — the Cadillac Tax — that would curtail them. The claim that the subsidies are regressive rests on estimates showing that the affluent receive the largest subsidies in absolute dollars. But this claim ignores the standard definition of regressivity, which is based on the share of income paid by the wealthy versus the poor, rather than on dollar amounts. In this study, we calculate the value of tax subsidies in 2009 as a share of income for each income quintile and for the wealthiest Americans. In absolute dollars, tax subsidies were highest for families between the 80th and 95th percentiles of family income and lowest for the poorest 20%. However, as shares of income, subsidies were largest for the middle and fourth income quintiles and smallest for the wealthiest 0.5% of Americans. We conclude that the tax subsidy to employment-based insurance is neither markedly regressive, nor progressive. The Cadillac Tax will disproportionately harm families with (2009) incomes between $38,550 and $100,000, while sparing the wealthy.

http://joh.sagepub.com/content/early/2016/03/08/0020731416637163.abstract

PNHP press release:
https://pnhp.org/news/2016/march/‘cadillac-tax’-on-health-benefits-will-hit-middle-class-hardest-study

The “Cadillac tax” is an excise tax on premiums of more expensive employer-sponsored health plans. It was included in the Affordable Care Act partly as a revenue source to help pay for ACA, partly to offset the tax subsidies for employer-sponsored insurance that were more generous for higher income individuals, and partly to reduce the incentive to purchase more insurance than necessary under the theory that making patients more sensitive to health care costs will prevent spending on supposedly excessive health care services (certainly a contentious point).

Because of the high costs of health care, we do need funding mechanisms that result in a transfer to those less able to pay. The Cadillac tax is a problem because, instead of disproportionately assessing the very wealthy, it impacts primarily working families. Not only is the tax unfair, the health plans will likely have their benefits reduced in an effort to escape the taxes.

In a PNHP press release (link above), Steffie Woolhandler, one of the co-authors of the report, stated, “Taxpayers should be paying directly for health care through Medicare-for-All, not indirectly through tax subsidies to private insurance. However, removing the tax subsidies – as Obamacare will do – without setting Medicare-for-All in place is a step backwards. It’s shameful that economists have provided cover for this tax that will hit middle-class families and largely spare the wealthy.”

The Cadillac tax is just one more example of the flawed policy patches required simply because the architects of reform decided to build on our current dysfunctional, fragmented financing system instead of replacing it with a more efficient, effective and equitable single payer Medicare-for-all program. That doesn’t mean that we have to live with our highly flawed system. We can still change it.

Transcript of the Democratic Presidential Debate in Miami

The New York Times, March 10, 2016

Excerpt:

HILLARY CLINTON: But let me say this. Senator Sanders has talked about free college for everybody. He’s talked about universal, single payer health care for everybody. And yet, when you ask questions, as many of us have and more importantly, independent experts, it’s very hard to get answers.

And a lot of the answers say that this is going to be much more expensive than anything Senator Sanders is admitting to. This is going to increase the federal government dramatically. And, you know, my dad used to say, if it sounds too good to be true, it probably is.

BERNIE SANDERS: All right. Let me respond to this.

(APPLAUSE)

CLINTON: And we deserve answers about how these programs will actually work and how they would be paid for.

SANDERS: I want you all to think. What Secretary Clinton is saying is that the United States should continue to be the only major country on earth that doesn’t guarantee health care to all of our people.

(APPLAUSE)

SANDERS: I think if the rest of the world can do it, we can. And by the way, not only are we being ripped off by the drug companies, we are spending far, far more per capita on health care than any other major country on earth.

You may not think the American people are prepared to stand up to the insurance companies or the drug companies. I think they are. And I think we can pass…

RAMOS: Thank you senator. (CROSSTALK)

(APPLAUSE)

CLINTON: This is a very important point in this debate, because I do believe in universal coverage. Remember, I fought for it 25 years ago. I believe in it. And I know that thanks the Affordable Care Act, we are now 90 percent of universal coverage. I will build on the Affordable Care Act. I will take it further. I will reduce the cost.

But I just respectfully disagree. Between the Republicans trying to repeal the first chance we’ve ever had to get to universal health care, and Senator Sanders wanting to throw us into a contentious debate over single-payer, I think the smart approach is build on and protect the Affordable Care Act. Make it work. Reduce the cost.

(APPLAUSE)

SANDERS: I’m on the committee, I know a little bit about this, I’m on the committee, Health, Education, Labor Committee that helped write the Affordable Care Act. And it has done a number of good things. But when Secretary Clinton says, well, 90 percent of the people have insurance, yes, not really.

Many of you may have insurance, but you have outrageously high deductibles and co-payments. One out of five Americans cannot afford the prescription drugs their doctors prescribe. Elderly people are cutting their pills in half.

I do believe that we should do what every other major country on earth does, and I think when the American people stand up and fight back, yes, we can have it, a Medicare for all health care system.

(APPLAUSE)

http://www.nytimes.com/2016/03/10/us/politics/transcript-democratic-presidential-debate.html

***

Hillary Clinton’s health care proposals:
https://www.hillaryclinton.com/issues/health-care/

Bernie Sanders’ health care proposals:
https://berniesanders.com/issues/medicare-for-all/

Donald Trump’s health care proposals:
https://www.donaldjtrump.com/positions/healthcare-reform

***

Comment:

By Don McCanne, M.D.

Although today’s message does not seem appropriate for this forum since it is political and our agenda is on policy, actually it is apropos since it represents a disagreement over single payer policy, even though framed as a political debate.

Of the three candidates for the presidential nomination who have mentioned single payer, Donald Trump has recently clarified his stance by releasing a health reform proposal that made no mention of single payer. So the debate over single payer is really between the two remaining Democratic candidates – Hillary Clinton and Bernie Sanders.

In this election season, single payer is a political issue. Bernie Sanders is the first leading presidential candidate to support a bona fide single payer Medicare for all. Hillary Clinton continues to support private health plans in a multi-payer system, originally as her managed competition model 25 years ago, and now as incremental expansion of the Affordable Care Act. She opposes single payer since it would eliminate the private insurers.

The politics have been somewhat bizarre. The Republicans have not had to take a high profile position against single payer since many in the progressive community have done their work for them. Although often presented as policy arguments, the substance of the opposing arguments by these progressives has been political. We can only speculate that their reasons have more to do with their support of a particular political candidate than they do with their position on single payer. In fact, the leading analysis being used to oppose single payer was written by an academic who has authored other single payer proposals. Fortunately, many others in the progressive community have stood up to insist that single payer be accurately portrayed.

Instead of trying to wade through the proxy arguments of these outside experts, it would be better to listen to the words of the two candidates themselves. What did they have to say in last night’s debate?

Sanders reiterated his views on a truly universal Medicare for all, whereas Clinton reiterated her views on rejecting single payer and building on the Affordable Care Act which she mentions has us at 90 percent coverage. These are policy issues.

When you look at their respective plans (links above), you can see that, from a policy perspective, Sanders’ proposal automatically covers everyone, whereas Clinton’s proposals barely nudge us in that direction but cannot come close to universal coverage. In addition, Sanders points out that the current private insurance products frequently do not meet the needs of those insured because of the exposure to high out-of-pocket costs. Again, regardless of the politics, these are fundamental policy issues that often determine whether or not people will receive the health care that they need.

We’ll continue to speak out on policy and leave it to others to get the politics right.

Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Transcript of the Democratic Presidential Debate in Miami

The New York Times, March 10, 2016

Excerpt:

HILLARY CLINTON: But let me say this. Senator Sanders has talked about free college for everybody. He’s talked about universal, single payer health care for everybody. And yet, when you ask questions, as many of us have and more importantly, independent experts, it’s very hard to get answers.

And a lot of the answers say that this is going to be much more expensive than anything Senator Sanders is admitting to. This is going to increase the federal government dramatically. And, you know, my dad used to say, if it sounds too good to be true, it probably is.

BERNIE SANDERS: All right. Let me respond to this.

(APPLAUSE)

CLINTON: And we deserve answers about how these programs will actually work and how they would be paid for.

SANDERS: I want you all to think. What Secretary Clinton is saying is that the United States should continue to be the only major country on earth that doesn’t guarantee health care to all of our people.

(APPLAUSE)

SANDERS: I think if the rest of the world can do it, we can. And by the way, not only are we being ripped off by the drug companies, we are spending far, far more per capita on health care than any other major country on earth.

You may not think the American people are prepared to stand up to the insurance companies or the drug companies. I think they are. And I think we can pass…

RAMOS: Thank you senator. (CROSSTALK)

(APPLAUSE)

CLINTON: This is a very important point in this debate, because I do believe in universal coverage. Remember, I fought for it 25 years ago. I believe in it. And I know that thanks the Affordable Care Act, we are now 90 percent of universal coverage. I will build on the Affordable Care Act. I will take it further. I will reduce the cost.

But I just respectfully disagree. Between the Republicans trying to repeal the first chance we’ve ever had to get to universal health care, and Senator Sanders wanting to throw us into a contentious debate over single-payer, I think the smart approach is build on and protect the Affordable Care Act. Make it work. Reduce the cost.

(APPLAUSE)

SANDERS: I’m on the committee, I know a little bit about this, I’m on the committee, Health, Education, Labor Committee that helped write the Affordable Care Act. And it has done a number of good things. But when Secretary Clinton says, well, 90 percent of the people have insurance, yes, not really.

Many of you may have insurance, but you have outrageously high deductibles and co-payments. One out of five Americans cannot afford the prescription drugs their doctors prescribe. Elderly people are cutting their pills in half.

I do believe that we should do what every other major country on earth does, and I think when the American people stand up and fight back, yes, we can have it, a Medicare for all health care system.

(APPLAUSE)

http://www.nytimes.com/2016/03/10/us/politics/transcript-democratic-presidential-debate.html

***

Hillary Clinton’s health care proposals:
https://www.hillaryclinton.com/issues/health-care/

Bernie Sanders’ health care proposals:
https://berniesanders.com/issues/medicare-for-all/

Donald Trump’s health care proposals:
https://www.donaldjtrump.com/positions/healthcare-reform

Although today’s message does not seem appropriate for this forum since it is political and our agenda is on policy, actually it is apropos since it represents a disagreement over single payer policy, even though framed as a political debate.

Of the three candidates for the presidential nomination who have mentioned single payer, Donald Trump has recently clarified his stance by releasing a health reform proposal that made no mention of single payer. So the debate over single payer is really between the two remaining Democratic candidates – Hillary Clinton and Bernie Sanders.

In this election season, single payer is a political issue. Bernie Sanders is the first leading presidential candidate to support a bona fide single payer Medicare for all. Hillary Clinton continues to support private health plans in a multi-payer system, originally as her managed competition model 25 years ago, and now as incremental expansion of the Affordable Care Act. She opposes single payer since it would eliminate the private insurers.

The politics have been somewhat bizarre. The Republicans have not had to take a high profile position against single payer since many in the progressive community have done their work for them. Although often presented as policy arguments, the substance of the opposing arguments by these progressives has been political. We can only speculate that their reasons have more to do with their support of a particular political candidate than they do with their position on single payer. In fact, the leading analysis being used to oppose single payer was written by an academic who has authored other single payer proposals. Fortunately, many others in the progressive community have stood up to insist that single payer be accurately portrayed.

Instead of trying to wade through the proxy arguments of these outside experts, it would be better to listen to the words of the two candidates themselves. What did they have to say in last night’s debate?

Sanders reiterated his views on a truly universal Medicare for all, whereas Clinton reiterated her views on rejecting single payer and building on the Affordable Care Act which she mentions has us at 90 percent coverage. These are policy issues.

When you look at their respective plans (links above), you can see that, from a policy perspective, Sanders’ proposal automatically covers everyone, whereas Clinton’s proposals barely nudge us in that direction but cannot come close to universal coverage. In addition, Sanders points out that the current private insurance products frequently do not meet the needs of those insured because of the exposure to high out-of-pocket costs. Again, regardless of the politics, these are fundamental policy issues that often determine whether or not people will receive the health care that they need.

We’ll continue to speak out on policy and leave it to others to get the politics right.

Physicians for a National Health Program (PNHP) is a nonpartisan educational organization. It neither supports nor opposes any candidates for public office.

Understanding What Makes Americans Dissatisfied With Their Health Care System: An International Comparison

By Joachim O. Hero, Robert J. Blendon, Alan M. Zaslavsky and Andrea L. Campbell
Health Affairs, March 2016

Abstract

For decades, public satisfaction with the health care system has been lower in the United States than in other high-income countries. To better understand the distinctive nature of US health system satisfaction, we compared the determinants of satisfaction with the health system in the United States to those in seventeen other high-income countries by applying regression decomposition methods to survey data collected in the period 2011–13. We found that concerns related to “accessing most-preferred care” (the extent to which people feel that they can access their top preferences at a time of need) were more important to satisfaction in the United States than in other high-income countries, while the reverse was true for satisfaction with recent interactions with the health system. Differences among US socioeconomic groups in survey responses regarding access to most-preferred care suggest that wide variation in insurance coverage and generosity may play a role in these differences. While reductions in the uninsured population and the movement toward minimum health plan standards could help address some concerns about access to preferred care, our results raise the possibility of public backlash as market forces push plans toward more restricted access and higher cost sharing.

From the Introduction

For at least the past twenty-five years, Americans have been consistently less satisfied than residents of other high-income countries with their own nation’s health system.

In some ways, Americans’ low levels of satisfaction with their health system seem to defy expectations. For example, system satisfaction in European countries has been found to be strongly correlated with per capita expenditures.4 However, this is not the case in the United States, where per capita expenditures are high compared to those in Europe.

In our study we applied, across countries, a measure of relative importance that combined the strength of the relationship between each factor and system satisfaction with the amount that the factor varied. We focused on domains of opinion in which we most expected the United States to differ from other countries, given its unique culture and health care system. These include access barriers, satisfaction with the last health care experience, and the newly defined construct of access to most-preferred care.

From the Study Results

We found that security in accessing most-preferred care was more important in explaining overall satisfaction in the United States than in other countries, whereas satisfaction with recent health care experiences was less important. In particular, confidence in accessing the best care available explained more variance in ratings of system satisfaction in the United States than did satisfaction with a recent hospital or doctor visit — which in most countries was the most important predictor of overall satisfaction.

From the Discussion

For years the Commonwealth Fund has fielded international surveys that use mostly objective measures of patient experience. The surveys have found that the United States underperforms its peers along many dimensions of cost, access, and quality and that Americans are more in favor of major system reform than are people in other countries. In spite of these findings, researchers using the Commonwealth Fund data did not find the desire for system change in the United States to be very sensitive to performance on these measures, even measures of affordability — which leaves the determinants of desire for system change within the United States mostly unexplained. Using a different data source and more subjective measures of personal care and satisfaction, we have taken a new look at potential drivers of satisfaction in the United States and have offered evidence on the ways in which that country differs from its peers.

Comparing results for the United States and international averages, we found that access-related concerns played an outsize role in determining system satisfaction in the United States and that confidence in accessing one’s most-preferred care mattered in particular to Americans. Conversely, satisfaction with recent health care experiences, which tended to be the most consequential to system satisfaction abroad, mattered less in the United States.

One possible explanation for the dominance of access-related beliefs over experiences with care in the United States is the structure of the health insurance system. In other high-income countries, where access to health care is more uniform and minimum standards guarantee that most people receive health care of a certain quality, access to one’s top choices may be perceived as less pressing, and recent individual experiences in the health system become more salient. The wide range of insurance coverage in the United States creates more significant gaps in the kinds of care that individuals can obtain, compared to those in other high-income countries.

This explanation is consistent with research that shows deep concerns in the United States over insurance-related economic security. Wider variation in and less certainty about coverage in the United States compared to other countries may therefore explain the greater importance of access to most-preferred care and the diminished importance of recent health care experiences.

These expectations are not a matter of simply having insurance; they are also related to the type of insurance held. The patchwork of public and private sources of insurance and the wide variation in insurance generosity in the private market create large differences in the comprehensiveness of coverage among the insured. It is perhaps because of this that access to most-preferred care remained the top predictor of system satisfaction, even among Americans with insurance.

From the Policy Implications

Our research found that the concept of access to most-preferred care is particularly salient to Americans’ satisfaction with the US health care system. This research also underscores the important role that variation in insurance coverage and type in the United States may play in system satisfaction, in part through that variation’s role in giving people security about being able to exercise health care preferences when needed. Therefore, reductions in the uninsured population resulting from the ACA may marginally improve system satisfaction.

Overall gains could be limited, however, since the reductions affect only a small segment of the population, and the types of insurance that people are acquiring tend to be less generous and more restrictive than what has been available through employers. Broader improvements in satisfaction will likely require addressing the concerns of the insured as well as those of the uninsured, and the importance of Americans’ access to their top preferences indicates that this may involve issues of network adequacy and treatment availability.

From the Conclusion

Our findings raise particularly troubling questions about the implications of health care equity as it relates to variation in the types of health insurance that Americans can obtain. Changes in insurance that threaten to widen the gaps in access to and perceived quality of care between more and less privileged Americans may serve to increase the number of people who feel that their health care preferences are out of reach.

http://content.healthaffairs.org/content/35/3/502.abstract

***

Comment:

By Don McCanne, M.D.

Even though we spend more on health care than any other high-income nation, we are less satisfied with our health care system. This study indicates that the leading reason (that happens to be unique to the United States) is the concern we have about uncertainties in being able to access our most preferred care, that is, the extent to which people feel that they can access their top health care preferences at a time of need.

Wide gaps in insurance coverage, high out-of-pocket expenses, and fragmentation in insurance and delivery systems seem to be the major factors contributing to this uncertainty.

Current trends are to further restrict access through narrower networks, and to impose ever higher cost sharing, especially through higher deductibles, while perpetuating the fragmentation of our financing system. That can only increase uncertainties about our ability to access our preferred care.

Let’s hope that the inevitable backlash will send the message that we are ready for a more equitable and effective system – an improved Medicare for all with free choice of care for everyone. Americans need to be assured that the financing system does not create barriers that impair access to their top health care preferences at a time of need.

Understanding What Makes Americans Dissatisfied With Their Health Care System: An International Comparison

By Joachim O. Hero, Robert J. Blendon, Alan M. Zaslavsky and Andrea L. Campbell
Health Affairs, March 2016

Abstract

For decades, public satisfaction with the health care system has been lower in the United States than in other high-income countries. To better understand the distinctive nature of US health system satisfaction, we compared the determinants of satisfaction with the health system in the United States to those in seventeen other high-income countries by applying regression decomposition methods to survey data collected in the period 2011–13. We found that concerns related to “accessing most-preferred care” (the extent to which people feel that they can access their top preferences at a time of need) were more important to satisfaction in the United States than in other high-income countries, while the reverse was true for satisfaction with recent interactions with the health system. Differences among US socioeconomic groups in survey responses regarding access to most-preferred care suggest that wide variation in insurance coverage and generosity may play a role in these differences. While reductions in the uninsured population and the movement toward minimum health plan standards could help address some concerns about access to preferred care, our results raise the possibility of public backlash as market forces push plans toward more restricted access and higher cost sharing.

From the Introduction

For at least the past twenty-five years, Americans have been consistently less satisfied than residents of other high-income countries with their own nation’s health system.

In some ways, Americans’ low levels of satisfaction with their health system seem to defy expectations. For example, system satisfaction in European countries has been found to be strongly correlated with per capita expenditures.4 However, this is not the case in the United States, where per capita expenditures are high compared to those in Europe.

In our study we applied, across countries, a measure of relative importance that combined the strength of the relationship between each factor and system satisfaction with the amount that the factor varied. We focused on domains of opinion in which we most expected the United States to differ from other countries, given its unique culture and health care system. These include access barriers, satisfaction with the last health care experience, and the newly defined construct of access to most-preferred care.

From the Study Results

We found that security in accessing most-preferred care was more important in explaining overall satisfaction in the United States than in other countries, whereas satisfaction with recent health care experiences was less important. In particular, confidence in accessing the best care available explained more variance in ratings of system satisfaction in the United States than did satisfaction with a recent hospital or doctor visit — which in most countries was the most important predictor of overall satisfaction.

From the Discussion

For years the Commonwealth Fund has fielded international surveys that use mostly objective measures of patient experience. The surveys have found that the United States underperforms its peers along many dimensions of cost, access, and quality and that Americans are more in favor of major system reform than are people in other countries. In spite of these findings, researchers using the Commonwealth Fund data did not find the desire for system change in the United States to be very sensitive to performance on these measures, even measures of affordability — which leaves the determinants of desire for system change within the United States mostly unexplained. Using a different data source and more subjective measures of personal care and satisfaction, we have taken a new look at potential drivers of satisfaction in the United States and have offered evidence on the ways in which that country differs from its peers.

Comparing results for the United States and international averages, we found that access-related concerns played an outsize role in determining system satisfaction in the United States and that confidence in accessing one’s most-preferred care mattered in particular to Americans. Conversely, satisfaction with recent health care experiences, which tended to be the most consequential to system satisfaction abroad, mattered less in the United States.

One possible explanation for the dominance of access-related beliefs over experiences with care in the United States is the structure of the health insurance system. In other high-income countries, where access to health care is more uniform and minimum standards guarantee that most people receive health care of a certain quality, access to one’s top choices may be perceived as less pressing, and recent individual experiences in the health system become more salient. The wide range of insurance coverage in the United States creates more significant gaps in the kinds of care that individuals can obtain, compared to those in other high-income countries.

This explanation is consistent with research that shows deep concerns in the United States over insurance-related economic security. Wider variation in and less certainty about coverage in the United States compared to other countries may therefore explain the greater importance of access to most-preferred care and the diminished importance of recent health care experiences.

These expectations are not a matter of simply having insurance; they are also related to the type of insurance held. The patchwork of public and private sources of insurance and the wide variation in insurance generosity in the private market create large differences in the comprehensiveness of coverage among the insured. It is perhaps because of this that access to most-preferred care remained the top predictor of system satisfaction, even among Americans with insurance.

From the Policy Implications

Our research found that the concept of access to most-preferred care is particularly salient to Americans’ satisfaction with the US health care system. This research also underscores the important role that variation in insurance coverage and type in the United States may play in system satisfaction, in part through that variation’s role in giving people security about being able to exercise health care preferences when needed. Therefore, reductions in the uninsured population resulting from the ACA may marginally improve system satisfaction.

Overall gains could be limited, however, since the reductions affect only a small segment of the population, and the types of insurance that people are acquiring tend to be less generous and more restrictive than what has been available through employers. Broader improvements in satisfaction will likely require addressing the concerns of the insured as well as those of the uninsured, and the importance of Americans’ access to their top preferences indicates that this may involve issues of network adequacy and treatment availability.

From the Conclusion

Our findings raise particularly troubling questions about the implications of health care equity as it relates to variation in the types of health insurance that Americans can obtain. Changes in insurance that threaten to widen the gaps in access to and perceived quality of care between more and less privileged Americans may serve to increase the number of people who feel that their health care preferences are out of reach.

http://content.healthaffairs.org/content/35/3/502.abstract

Even though we spend more on health care than any other high-income nation, we are less satisfied with our health care system. This study indicates that the leading reason (that happens to be unique to the United States) is the concern we have about uncertainties in being able to access our most preferred care, that is, the extent to which people feel that they can access their top health care preferences at a time of need.Wide gaps in insurance coverage, high out-of-pocket expenses, and fragmentation in insurance and delivery systems seem to be the major factors contributing to this uncertainty.

Current trends are to further restrict access through narrower networks, and to impose ever higher cost sharing, especially through higher deductibles, while perpetuating the fragmentation of our financing system. That can only increase uncertainties about our ability to access our preferred care.

Let’s hope that the inevitable backlash will send the message that we are ready for a more equitable and effective system – an improved Medicare for all with free choice of care for everyone. Americans need to be assured that the financing system does not create barriers that impair access to their top health care preferences at a time of need.