Figure 1. Percent of Patients Seen by 10 or More
Physicians Varies Across Academic Medical Centers
Average percentage of patients seeing 10+ different physicians
in first year of care within AMC hospitals
Lowest quintile
40
Middle quintiles
35
32
30
20
Highest quintile
25
16
20
15
17
25
18
10
0
Hip Fracture
Colorectal Cancer
Acute Myocardial
Infarction
Note: Quintiles of practice intensity (“treatment groups”) corresponded closely
to regional differences in price and to illness-adjusted Medicare spending.
Source: E.S. Fisher et al., “Variations in the Longitudinal Efficiency of Academic
Medical Centers,” Health Affairs Web Exclusive, October 7, 2004.
THE
COMMONWEALTH
FUND
Figure 2. Private-Public Collaboration Needed to
Improve Availability of Quality and Cost Information
Comprehensive
HDHP/CDHP
14%
16%
14
15
Doctors
16
12
Hospitals
15
12
Doctors
42
54
Hospitals
25
45
Doctors
15
36 (n = 76)
Hospitals
14
32 (n = 76)
Health plan provides information on
quality of care provided by:
Doctors
Hospitals
Health plan provides information on
cost of care provided by:
Of those whose plans provide info on
quality, how many tried to use it for:
Of those whose plans provide info on
cost, how many tried to use it for:
Source: P. Fronstin, S.R. Collins, Early Experience with High-Deductible and
Consumer-Driven Health Plans: Findings From the EBRI/Commonwealth Fund
Consumerism in Health Care Survey, EBRI Issue Brief, December 2005.
THE
COMMONWEALTH
FUND
Figure 3. Physicians’ Access to Quality-of-Care
or Performance Data on Their Own Care
Percent receiving data on the following aspects of patient care
100
50
25
20
18
Process of Care
Clinical
Patient Survey
Data
Outcomes Data
Data
33
0
Any Data
THE
COMMONWEALTH
FUND
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
Figure 4. Availability of Quality-of-Care Data
When Making Referrals
Percent indicating how often they have any data about a
physician’s quality of care when making referrals
Sometimes
16%
Rarely
32%
64%
Often
14%
Always
5%
Never
32%
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
THE
COMMONWEALTH
FUND
Figure 5. Hospital Charges for AMI–Medical
Management Vary Eight-Fold Across Large
Pennsylvania Hospitals
Dollars
$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.
THE
COMMONWEALTH
FUND
Figure 6. Top-Ranked and Bottom-Ranked Performances in Measures of
Quality of Care for AMI, CHF, and Pneumonia Among the 40 Largest
Hospital-Referral Regions*
Hospital-Referral
Region
AMI
Score
(%)
Top-ranked
Hospital-Referral
Region
CHF
Score Hospital-Referral
(%) Region
Top-ranked
Pneumonia
Score (%)
Top-ranked
Boston, MA
95
Boston, MA
89
Oklahoma City, OK
82
Minneapolis, MN
94
Detroit, MI
88
Indianapolis, IN
79
Kansas City, MO
94
Baltimore, MD
87
Kansas City, MO
78
Albany, NY
93
Camden, NJ
87
Camden, NJ
78
Indianapolis, IN
92
Cleveland, OH
86
Knoxville, TN
77
Bottom-ranked
Bottom-ranked
Bottom-ranked
Little Rock, AK
86
San Diego, CA
77
Miami, FL
63
Orlando, FL
86
Nashville, TN
76
Chicago, IL
61
Miami, FL
85
Orlando, FL
74
San Diego, CA
60
Memphis, TN
84
Little Rock, AK
69
Los Angeles, CA
60
San Bernardino, CA
83
Lexington, KY
68
San Bernardino, CA
59
*AMI denotes acute myocardial infarction, and CHF congestive heart failure.
Source: A K. Jha, Z. Li, E. J. Orav, and A. M. Epstein, “Care in U.S. Hospitals—The Hospital Quality
Alliance Program,” New England Journal of Medicine 353 (July 21, 2005): 265–74.
THE
COMMONWEALTH
FUND
Figure 7. Physicians’ Willingness
to Share Quality-of-Care Data
Willingness to share data with:*
Yes,
Definitely/
Probably
No,
Definitely/
Probably Not
Medical leadership
71%
27%
Physicians’ own patients
55%
44%
General public
29%
69%
Other physicians
72%
26%
*Answers to survey question: “To improve high quality of care in the U.S., which of the following
do you think should have access to ‘Quality of Care’ data about individual physicians?”
Source: The Commonwealth Fund National Survey of Physicians and Quality of Care.
THE
COMMONWEALTH
FUND
Figure 8. Hospital CEO Opposition to Disclosure of
Quality Information to the Public
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: The Commonwealth Fund 2003 International Health Policy Survey of Hospital Executives.
Figure 9. Most Costs Are Concentrated
in the Very Sick
Distribution of Health Expenditures for the U.S. Population,
By Magnitude of Expenditure, 1997
Expenditure
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
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
Figure 10. Most Trusted Sources for Information on
Health Care Providers, by Insurance Source
Percent of adults 21-64
43
42
Your doctor
20
Consumer group
25
15
16
Family member or friend
Medical association
8
Comprehensive
10
HDHP/CDHP
6
Own health plan
4
2
2
Government or other
agency
0
20
40
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
60
THE
COMMONWEALTH
FUND
Figure 11. “Perception that Health Care Is
Free”*Is Not the Problem
National Health Expenditures per Capita, US$
6000
United States
5000
4000
3000
Netherlands
2000
1000
Germany Canada
Australia
France
OECD Median
Japana
New
Zealand
0
a
0
a 2002
100
200
300
400
500
600
700
800
900
Out-of-Pocket Health Care Spending per Capita, US$
*Allan Hubbard, Director of the National Economic Council, February 14, 2006.
Note: Adjusted for Differences in the Cost of Living, 2003.
Source: Bianca K. Frogner and Gerard F. Anderson, “Multinational Comparisons of Health Systems
Data, 2005,” The Commonwealth Fund, Forthcoming.
THE
COMMONWEALTH
FUND
Figure 12. Consumers Spending More
Out-of-Pocket for Health Care
Dollars spent per capita (in 2004 dollars)
900
$788
$774
800
700
600
500
400
$667
$577
$583
300
200
100
19
7
19 0
7
19 1
7
19 2
7
19 3
7
19 4
7
19 5
7
19 6
7
19 7
7
19 8
7
19 9
8
19 0
8
19 1
8
19 2
8
19 3
8
19 4
8
19 5
8
19 6
8
19 7
8
19 8
8
19 9
9
19 0
9
19 1
9
19 2
9
19 3
9
19 4
9
19 5
9
19 6
9
19 7
9
19 8
9
20 9
0
20 0
0
20 1
0
20 2
0
20 3
04
0
Source: C. Smith et al., “National Health Spending in 2004: Recent Slowdown Led by Prescription
Drug Spending,” Health Affairs 25, no. 1 (January/February 2006); Centers for Medicare and
Medicaid Services, National Health Expenditures Data;
http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf
THE
COMMONWEALTH
FUND
Figure 13. Nearly One of Six Families
Spent 10% or More of Income (or 5% or More if LowIncome) on Out-of-Pocket Medical Costs, 2001–02
Percent of families with high out-of-pocket medical costs
relative to income, not including premiums
Spent >10% of income
20
Spent >10% of income,
or >5% of income if low-income*
15
12
10
11
8
0
1996–97
2001–02
*Low-income includes families with incomes <200% of the federal poverty level.
Source: M. Merlis, D. Gould and B. Mahato, Rising Out-of-Pocket Spending for Medical Care: A
Growing Strain on Family Budgets (New York: The Commonwealth Fund) February 2006.
THE
COMMONWEALTH
FUND
Figure 14. Cost-Sharing Reduces Use of Both
Essential and Less Essential Drugs and
Increases Risk of Adverse Events
Percent reduction in drugs per day
Elderly
Low Income
22
25
10
Elderly
140
120
20
15
Percent increase in incidence per 10,000
14
15
100
Low Income
117
97
78
80
9
43
60
40
5
20
0
0
Essential
Less Essential
Adverse Events
ED Visits
Source: R. Tamblyn et al., “Adverse Events Associated With Prescription Drug Cost-Sharing Among
Poor and Elderly Person,” JAMA 285, no. 4 (2001): 421–429.
THE
COMMONWEALTH
FUND
Figure 15. Distribution of Individuals Covered by
Private Health Insurance, by Type of Health
Plan
CDHP
1%
HDHP
9%
Comprehensive
89%
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan
w/ deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+
(ind), $2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 16. FEHBP HDHP/HSAs Plans Enroll 7,500
out of 9 Million Covered Lives
Percent
25
20
15
10
6.4
5
0.1
0
Percent of FEHBP plans that
are HDHP/HSAs
Percent of FEHBP enrollees
that are in HDHP/HSAs
Note: As of March 2005.
Source: Government Accountability Office, Federal Employees Health Benefits Program First-Year
Experience with High-Deductible Health Plans and Health Savings Accounts, Washington, DC:
GAO, January 2006; OPM, http://www.opm.gov/insure/handbook/FEHBhandbook.pdf
THE
COMMONWEALTH
FUND
Figure 17. Enrollees Who Chose HDHPs from the
Federal Employees Health Benefits Program Are
More Likely to Earn Higher Incomes
Percent of FEHBP enrollees with incomes ≥ $75,000
75
50
43
23
25
0
HDHP
All FEHBP plans
Source: Government Accountability Office, Federal Employees Health Benefits Program First-Year
Experience with High-Deductible Health Plans and Health Savings Accounts, Washington, DC:
GAO, January 2006.
THE
COMMONWEALTH
FUND
Figure 18. Age Distribution of HDHP and Other
FEHBP Enrollees
Percent FEHBP enrollees
HDHP enrollees
35
All FEHBP enrollees
30
25
20
15
10
5
0
<23
23-34
35-44
45-54
55-64
65-74
75-99
Source: Government Accountability Office, Federal Employees Health Benefits Program First-Year
Experience with High-Deductible Health Plans and Health Savings Accounts, Washington, DC:
GAO, January 2006.
>99
THE
COMMONWEALTH
FUND
Figure 19. Percentage of Individuals Covered by
Employment-Based Health Benefits With No
Choice of Health Plan, by Type of Health Plan
80
60
40
51
52
HDHP
CDHP
34
20
0
Comprehensive
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 20. Satisfaction with Quality of Health
Care Received, by Type of Health Plan
Comprehensive
80
60
72
52
HDHP
CDHP
63
40
23
20
34
28
4
0
Extremely or very
satisfied
Somewhat
satisfied
14
9
Not satisfied
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 21. Satisfaction with Out-of-Pocket Costs
for Health Care, by Type of Health Plan
Comprehensive
HDHP
CDHP
80
60
40
20
57
42
36
12
18
31
28
54
21
0
Extremely or very
Somewhat
satisfied
satisfied
Not satisfied
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 22. Satisfaction with Choice of Doctors,
by Type of Health Plan
Comprehensive
80
60
73
60
HDHP
CDHP
69
40
21
20
29
21
6
11
10
0
Extremely or very
satisfied
Somewhat
satisfied
Not satisfied
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 23. Overall Satisfaction with Health Plan,
by Type of Health Plan
80
60
40
Comprehensive
HDHP
CDHP
63
33
42
28
39
32
20
29
26
8
0
Extremely or very
satisfied
Somewhat
satisfied
Not satisfied
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 24. Likelihood of Staying With Current
Health Plan If Had the Opportunity to Change,
by Type of Health Plan
80
60
40
Comprehensive
HDHP
CDHP
61
46
30
20
28
37
21
33
33
11
0
Extremely or very
likely to stay
Somewhat likely
to stay
Not likely to stay
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 25. Likelihood of Recommending Health
Plan to Friend or Co-Worker, by Type of Health
Plan
80
60
40
20
Comprehensive
HDHP
CDHP
51
34
22
26
34
43
31
35
24
0
Extremely or very
likely
Somewhat likely
Not likely
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 26. Percent of Income Spent Annually on Outof-Pocket Medical Expenses, Including Premiums
Percent of adults 21-64 spending ≥ 5% of income
100
10%+ of income
92
5-9% of income
80
66
53
60
42
40
12
20
3
0
mp
Co
re
9
ve
nsi
e
h
HP
HD
17
23
13
4
9
HP
D
C
Total
38
34
(n = 90)
31
29
58
13
e
mp
Co
re
v
nsi
he
35
26
18
HP
HD
25
12
HP
D
C
44
33
10
mp
Co
Health Problem**
re
v
nsi
he
e
(n = 61)
HP
HD
21
HP
D
C
<$50,000
Annual Income
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
**Health problem defined as fair or poor health or one of eight chronic health conditions.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 27. Percent of Adults Who Have Delayed
or Avoided Getting Health Care Due to Cost
Percent of adults 21–64
Comprehensive
60
40
20
31
HDHP
40
35
31
48
42
(n = 61)
(n = 90)
21
17
CDHP
26
0
Total
Health Problem**
<$50,000 Annual
Income
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
** Health problem defined as fair or poor health or one of eight chronic health conditions.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 28. Percent of Adults Who Have
Skipped Doses to Make a Medication Last Longer
Percent of adults 21-64 with prescriptions in last 12 months
Comprehensive
60
35
40
20
HDHP
26
15
20
CDHP
32
29
(n = 85)
20
21
28
(n = 50)
0
Total
Health Problem**
<$50,000 Annual
Income
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
** Health problem defined as fair or poor health or one of eight chronic health conditions.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 29. Percent of Adults Who Have Not Filled
a Prescription Due to Cost
Percent of adults 21–64
Comprehensive
60
40
26
20
16
HDHP
33
20
21
26
(n = 90)
CDHP
27
32
25
(n = 61)
0
Total
Health Problem**
<$50,000 Annual
Income
Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam); HDHP = plan w/
deductible $1000+ (ind), $2000+ (fam), no account; CDHP = plan w/ deductible $1000+ (ind),
$2000+ (fam), w/ account.
**Health problem defined as fair or poor health or one of eight chronic health conditions.
Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2005.
THE
COMMONWEALTH
FUND
Figure 30. Medical Bill or Debt Problems
in Past Year, by Size of Deductible
Percent of adults ages 19–64 with any
medical bill problem or outstanding debt*
54 ^
60
46 ^
40
39^
24
20
0
$1,000 or more
$500–$999
$1–$499
None
Size of deductible
Note: Adjusted percentages based on logistic regression models; controlling for health status and income.
*Problems paying/not able to pay medical bills, contacted by a collection agency for medical bills,
had to change way of life to pay bills, or has medical debt being paid off over time.
THE
COMMONWEALTH
FUND
^Significant difference at p < .05 or better; referent category = no deductible.
Source: The Commonwealth Fund Biennial Health Insurance Survey (2003).
Figure 31. HSAs Won’t Solve the Uninsured
Problem: Income Tax Distribution of Uninsured
5%
(27% tax
bracket)
1%
(30%-39%
tax bracket)
23%
(15% tax
bracket)
16%
(10% tax
bracket)
55%
(0% tax
bracket)
Source: S.A. Glied, The Effect of Health Savings Accounts on Health Insurance Coverage, The
Commonwealth Fund, April 2005.
THE
COMMONWEALTH
FUND
Figure 32. Medicare Physician Group Practice
Demonstration
• The Everett Clinic (WA)
• Deaconess Billings
Clinic
• Park Nicollet Health
Services (MN)
• Marshfield Clinic (WI)
• St. John’s Health
System (MO)
• Univ. of Michigan
Faculty Group Practice
• Geisinger Health System
(PA)
• Forsyth Medical (NC)
• Middlesex Health (CN)
• Dartmouth-Hitchcock
Clinic
•
10 physician group
practices
•
3-year project,
began April 2005
•
Bonus pool based
on savings relative
to local area
•
Practices expected
to save 2%, keep
up to 80% of
additional savings
•
Actual bonuses
depend on savings
and quality targets
Source: “Medicare Physician Group Practice Demonstration,” www.cms.gov, January 31, 2005.
THE
COMMONWEALTH
FUND
Figure 33. Building Quality Into RIte Care
Higher Quality and Improved Cost Trends
Percent
• Quality targets and
$ incentives
Cumulative Health
Insurance Rate
Trend Comparison
160
• Improved access,
medical home
140
– One third reduction
in hospital and ER
120
100
– Tripled primary
care doctors
RI Commercial Trend
80
60
– Doubled clinic visits
40
RIte Care Trend
20
20
03
20
01
19
99
19
97
19
95
0
• Significant improvements
in prenatal care, birth
spacing, lead paint,
infant mortality,
preventive care
Source: Silow-Carroll, Building Quality into RIte Care, Commonwealth Fund, 2003.
Tricia Leddy, Outcome Update, Presentation at Princeton Conference, May 20, 2005.
THE
COMMONWEALTH
FUND