COMMISSION ON A HIGH PERFORMANCE HEALTH SYSTEM Public Views on Shaping the Future of the U.S. Health System Cathy Schoen, Sabrina K. H. How, Ilana Weinbaum, John E. Craig, Jr., and Karen Davis ONE EAST 75TH STREET AUGUST 2006 NEW YORK, NY 10021-2692 TEL 212.606.3800 FAX 212.606.3500 www.cmwf.org The Commonwealth Fund Commission on a High Performance Health System Membership James J. Mongan, M.D. Robert M. Hayes, J.D. Mary K. Wakefield, Ph.D., R.N. Chair of the Commission President Associate Dean President and CEO Medicare Rights Center School of Medicine Partners HealthCare System, Inc. Health Sciences Director and Professor Cleve L. Killingsworth Center for Rural Health Maureen Bisognano President and CEO University of North Dakota Executive Vice President & COO Blue Cross Blue Shield of Institute for Healthcare Improvement Massachusetts Alan R. Weil, J.D. Executive Director Christine K. Cassel, M.D. Sheila T. Leatherman National Academy for State Health Policy President and CEO Research Professor President American Board of Internal Medicine School of Public Health Center for Health Policy Development and ABIM Foundation University of North Carolina Judge Institute Steve Wetzell Michael Chernew, Ph.D. University of Cambridge Vice President Professor HR Policy Association Department of Health Policy Gregory P. Poulsen Harvard Medical School Senior Vice President Intermountain Health Care Patricia Gabow, M.D. Stephen C. Schoenbaum, M.D. CEO and Medical Director Dallas L. Salisbury Executive Director Denver Health President & CEO Executive Vice President for Programs Employee Benefit Research The Commonwealth Fund Fernando A. Guerra, M.D. Institute Director of Health Anne K. Gauthier San Antonio Metropolitan Health Sandra Shewry Senior Policy Director District Director The Commonwealth Fund California Department of Health Glenn M. Hackbarth, J.D. Services Cathy Schoen Chairman Research Director MedPAC Glenn D. Steele, Jr., M.D., Ph.D. Senior Vice President for Research President and CEO and Evaluation George C. Halvorson Geisinger Health System The Commonwealth Fund Chairman and CEO Kaiser Foundation Health Plan, Inc. Ilana Weinbaum Associate The Commonwealth Fund The Commonwealth Fund The Commonwealth Fund, among the first private foundations started by a woman philanthropist— Anna M. Harkness—was established in 1918 with the broad charge to enhance the common good. The mission of The Commonwealth Fund is to promote a high performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. The Fund carries out this mandate by supporting independent research on health care issues and making grants to improve health care practice and policy. An international program in health policy is designed to stimulate innovative policies and practices in the United States and other industrialized countries. PUBLIC VIEWS ON SHAPING THE FUTURE OF THE U.S. HEALTH SYSTEM Cathy Schoen, Sabrina K. H. How, Ilana Weinbaum, John E. Craig, Jr., and Karen Davis August 2006 ABSTRACT: On behalf of The Commonwealth Fund Commission on a High Performance Health System, Harris Interactive surveyed U.S. adults to determine the public’s perspectives on ways to improve patient care and on health policy priorities facing the President and Congress. Overall, the representative sample of 1,023 adults ages 18 and older revealed strong public support for efforts to improve care coordination and access to information. There is a shared belief that expanded use of information technology, care teams, and improved delivery of preventive services could improve the quality of care. Patients reported recent experiences of wasteful, inefficient, or unsafe care. In addition, half of middle-income and lower-income families reported serious problems paying for care and insurance coverage. Three-quarters of all adults said the U.S. health care system needs either fundamental change or complete rebuilding. Expanding insurance and controlling costs, they said, should be top priorities for federal action. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff, or of The Commonwealth Fund Commission on a High Performance Health System or its members. This report and other Fund publications are available online at www.cmwf.org. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 948. CONTENTS List of Figures ................................................................................................................. iv About the Authors........................................................................................................... v Introduction .................................................................................................................... 1 Care Coordination and Information on Quality and Costs ............................................... 1 Public Views of Effective Actions for Improving Care ..................................................... 4 Experiences and Concerns About Access, Costs, and Quality ........................................... 5 Overall System Views and Priorities for Federal Action.................................................. 10 Shared Views, Values, and Concerns.............................................................................. 13 Toward a High Performance Health System .................................................................. 13 Methodology................................................................................................................. 15 Notes............................................................................................................................. 16 Appendix. Demographic Characteristics of Survey Respondents .................................... 17 iii LIST OF FIGURES Figure 1 Strong Public Support for Well-Coordinated Care ......................................... 1 Figure 2 Positive Public Views on the Need for Quality and Cost Information and Payments that Reward Performance ............................. 2 Figure 3 Majority of the Public Views Information Technology, Practitioner Teams, and Group Practices as Effective Actions to Improve Care Quality ................................................................................ 4 Figure 4 Two of Five Adults Had Serious Problems with Access, Cost, or Administrative Aspects of Care.......................................................... 5 Figure 5 Insurance Complexity: Two of Five Adults Report Having to Spend Time on Paperwork or Disputes Related to Medical Bills and Health Insurance in the Past Two Years .............................. 6 Figure 6 Half of Middle- and Lower-Income Adults Experienced Serious Problems Paying for Medical Bills or Insurance in Past Two Years.................. 7 Figure 7 Inefficient, Poorly Coordinated, Unsafe Care ................................................. 8 Figure 8 Worries About Affordability and Access to High-Quality Care Spreading to Middle-Income Families ............................................................ 9 Figure 9 Americans’ Overall Views of the U.S. Health Care System, by Income, Insurance, Region, and Political Affiliation ................................ 10 Figure 10 Adults with Negative Care Experiences Are More Likely to Call for a Complete Rebuild of System .................................................... 11 Figure 11 Rating of Importance of Issues for Presidential or Congressional Action, by Political Affiliation............................................ 11 Figure 12 What Are the Most Important Health Care Issues for Presidential and Congressional Action? (by income level) ............................. 12 Figure 13 What Are the Most Important Health Care Issues for Presidential and Congressional Action? (by political affiliation)...................... 12 iv ABOUT THE AUTHORS Cathy Schoen, M.S., is senior vice president for research and evaluation at The Commonwealth Fund and research director for the Commission on a High Performance Health System, overseeing the Commission’s Scorecard project and surveys. Previously, Ms. Schoen was director of special projects at the University of Massachusetts Labor Relations and Research Center and on the research faculty of the UMass School of Public Health. During the 1980s, she directed the Service Employees International Union’s Research and Policy Department in Washington, D.C. Earlier, she served as a member of the staff of President Carter’s national health insurance task force and as a senior health advisor during the 1988 presidential campaign. Prior to federal service, she was a research fellow at the Brookings Institution. She holds an undergraduate degree in economics from Smith College and a graduate degree in economics from Boston College. She is the author and coauthor of many publications on health care coverage and quality issues. Sabrina K. H. How, M.P.A., is research associate for the Commission on a High Performance Health System. Ms. How also served as program associate for two programs, Health Care in New York City and Medicare’s Future. Prior to joining the Fund, she was a research associate for a management consulting firm focused on the healthcare industry. Ms. How holds a B.S. in biology from Cornell University and an M.P.A. in health policy and management from New York University. Ilana Weinbaum, M.Sc., joined the Fund in July 2005 as commission associate for the Commission on a High Performance Health System. Ms. Weinbaum completed her M.Sc. in Health Policy, Planning and Finance through a joint program between the London School of Economics and the London School of Hygiene and Tropical Medicine. After graduating from the University of Pennsylvania with a B.A. in Health and Societies, she worked for a small nonprofit public health agency in Philadelphia. John E. Craig, Jr., executive vice president and chief operating officer, is responsible for the management of The Commonwealth Fund’s endowment and administration, and serves also as the Fund’s treasurer and corporate secretary. He chairs staff program plan and board proposal review meetings and oversees assessments of the performance of programs and completed grants. Mr. Craig is chairman of the Nonprofit Coordinating Committee of New York City and also serves on the boards of the Greenwall Foundation, the Women’s Prison Association, the National Center on Philanthropy and the Law, and MEM Associates, as well as on the investment committee of the Social Sciences Research Council. Earlier he was chairman of the board of The Investment Fund for Foundations v and a member of the board of The Picker Institute. Prior to joining the Fund in 1981, he directed the John A. Hartford Foundation’s health care reform program, and earlier was a Foreign Service reserve officer of the U.S. Agency for International Development. Mr. Craig writes regularly on foundation endowment investment and management issues; his most recent publication is Foundation Performance Measurement: A Tool for Institutional Learning and Improvement (published in the 2005 Annual Report). A graduate of Davidson College, he received his M.P.A. from Princeton University’s Woodrow Wilson School of Public and International Affairs. Karen Davis, Ph.D., president of The Commonwealth Fund, is a nationally recognized economist with a distinguished career in public policy and research. Before joining the Fund, she served as chairman of the Department of Health Policy and Management at The Johns Hopkins Bloomberg School of Public Health, where she also held an appointment as professor of economics. She served as deputy assistant secretary for health policy in the Department of Health and Human Services from 1977 to 1980, and was the first woman to head a U.S. Public Health Service agency. A native of Oklahoma, she received her doctoral degree in economics from Rice University, which recognized her achievements with a Distinguished Alumna Award in 1991. Ms. Davis has published a number of significant books, monographs, and articles on health and social policy issues, including the landmark books Health Care Cost Containment; Medicare Policy; National Health Insurance: Benefits, Costs, and Consequences; and Health and the War on Poverty. vi PUBLIC VIEWS ON SHAPING THE FUTURE OF THE U.S. HEALTH SYSTEM INTRODUCTION Understanding how the public views and experiences the U.S. health care system provides valuable insights for policy actions that are grounded in the daily realities faced by patients and their families. On behalf of The Commonwealth Fund Commission on a High Performance Health System, Harris Interactive surveyed U.S. adults to determine the public’s perspectives on ways to improve patient care and on health policy priorities facing the President and Congress. The survey findings serve as a litmus test of public perceptions as the Commission explores concrete steps for increasing value received from the high proportion of resources the United States devotes to health care. Overall, the telephone survey of a representative sample of 1,023 adults ages 18 and older revealed strong public support for efforts to improve care coordination and access to information. There is a shared belief that expanded use of information technology, practitioner teams, and improved delivery of preventive care could improve the quality of care. Patients reported recent experiences of wasteful, inefficient, or unsafe care, and ever- wider concerns about the affordability of care. As of 2006, half of middle- and lower-income families reported serious problems paying for care and insurance coverage. Three-quarters of all adults said the U.S. health care system needs either fundamental change or complete rebuilding, reflecting shared negative experiences and concerns about the future. Expanding insurance and controlling costs, they reported, should be top priorities for federal action. CARE COORDINATION AND INFORMATION ON QUALITY AND COSTS Across the board, adults endorse the importance of well-coordinated care. Substantial majorities believe it is important to have one place or doctor responsible for care and care coordination and to have medical records easily accessible by patients and all their physicians (Figure 1). Figure 1. Strong Public Support for Well-Coordinated Care Total How important is it very or somewhat Very Somewhat to you that: (percent) important important important You have one place/doctor responsible 92 75 17 for primary care and coordinating care You have easy access to medical records 94 79 15 All your doctors have easy access to your 93 77 16 medical records Care from different doctors is 96 79 17 well coordinated Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. 1 • More than nine of 10 adults (92%) believe it is either very or somewhat important to have one place or doctor responsible for providing routine and acute medical care and coordinating all their needed care. Three-quarters view having this type of patient-centered medical home as very important. • A similarly large number of adults (94%) consider it important to have easy access to their own medical records. • More than nine of 10 adults (93%) endorse giving their doctors access to medical records across sites of care. • There is broad support for having a regular source of care and access to medical across geographic regions, income, and education groups. More generally, nearly all respondents (96%) said it is important for care from different doctors to be well coordinated. Adults quite typically face a different reality. Recent studies find that adults in the United States generally have short-term relationships with their physicians, often lack a regular source of ongoing care, and rarely have easy access to their own medical records.1 Only 37 percent have had the same physician for the past five years or more, and only 51 percent reported having access to their own records.2 The majority of adults think it is important to have access to information about the quality and cost of care. In addition, most believe that quality and efficiency should influence the amount of payments made to physicians and hospitals (Figure 2). Figure 2. Positive Public Views on the Need for Quality and Cost Information and Payments that Reward Performance Total How important is it very or somewhat Very Somewhat to you that: (percent) important important important You have information about the quality of care provided by different 95 77 18 doctors or hospitals You have information about the costs of care to you BEFORE you 91 69 22 actually get the care Insurance companies identify and reward doctors and hospitals who 87 62 25 achieve excellence in the quality and efficiency of care Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. 2 • Nearly all adults (95%) feel it is important to have information about the quality of care provided by different doctors or hospitals, with three-quarters (77%) saying this is very important. • A strong majority (91%) also thinks it is very or somewhat important to have information about the costs of care before getting care. • Most adults endorse the use of cost and quality information to determine physician payments. More than four of five Americans (87%) think it is important for insurance companies to identify and reward doctors and hospitals for excellence in quality and efficiency of care. Again, the reality patients typically encounter is quite different from their beliefs about the value of quality and cost information. Although changes in insurance benefit designs that create more cost-sharing—like high-deductible plans—require consumers to make potentially risky decisions about care, reliable information on quality and costs of care is rarely available.3 In a survey of individuals with health insurance, only 15 percent reported they had access to such information.4 Moreover, health insurance plans themselves often lack information on quality or outcomes of care over time, and are therefore unable to develop networks or incentives to reward and support clinicians who provide higher quality, more efficient care.5 3 PUBLIC VIEWS OF EFFECTIVE ACTIONS FOR IMPROVING CARE Mirroring the wide public support for well-coordinated care and easy access to medical records and provider information, most adults view efforts to facilitate information exchange and practitioner teams as effective strategies to improve quality of care (Figure 3). Figure 3. Majority of the Public Views Information Technology, Practitioner Teams, and Group Practices as Effective Actions to Improve Care Quality Somewhat effective Percent Very effective 100 92 90 88 81 22 75 27 26 34 50 71 63 63 25 47 0 Computerized Doctors and nurses Receiving Doctors practicing medical records working as a team, reminders for in groups rather expanded role for preventive care than on their own nurses Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. • More than nine of 10 Americans (92%) believe computerized medical records would be an effective strategy to improve care quality, with a substantial majority seeing electronic medical records as being very effective. • Adults also support efforts to make care more coordinated by expanding the role for nurses and having doctors and nurses work as a team. Nine of 10 respondents think this change would be effective in improving quality of care. • A similar proportion of Americans (88%) believes wider use of reminders for preventive care would improve care quality. • There is strikingly strong support for physicians practicing in group practices. Four of five adults (81%) believe that quality of care would be improved if physicians practiced in groups rather than on their own. Again, the current environment is quite different. A 2003 survey of physicians found that only one of four (27%) used electronic medical records routinely or 4 occasionally, and only half (54%) sent patients reminders about preventive care.6 One of three physicians practice in solo offices and about one-quarter are in groups of two to four physicians.7 EXPERIENCES AND CONCERNS ABOUT ACCESS, COSTS, AND QUALITY Affordability of care and insurance is of growing concern. In addition to concerns about costs, a high proportion of adults has serious problems getting timely care and reported spending time on paperwork and having disputes related to medical bills and insurance (Figure 4). Figure 4. Two of Five Adults Had Serious Problems with Access, Cost, or Administrative Aspects of Care Very serious Somewhat serious Paying for your or your family’s medical bills 19 19 38 Paying for your or your family’s health insurance 21 17 38 Getting an appointment with a doctor quickly without going to 21 19 39 the emergency room Getting information on caring for an aging parent or seriously ill 20 16 36 family member Having to spend time on paperwork or disputes related to 16 23 39 medical bills and insurance 0 25 50 Percent with problem in past two years Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. • Nearly two of five adults (38%) reported serious problems paying for their own or their family’s medical care. A similarly high proportion said it has had difficulty paying for health insurance. • Timely access is a broad concern. In the past two years, two of five adults (39%) reported serious problems getting prompt appointments to see a doctor when sick or in need of medical attention without going to the emergency room. • One-third of Americans (36%) have trouble finding information on care for a very ill or aging family member. • In addition to waiting times to see doctors, administrative aspects of health care consume patients’ time and effort. Two of five adults (39%) reported spending 5 time handling paperwork or on disputes related to medical bills and health insurance as a serious problem. o Administrative complexity appears of particular concern to low-income adults. Nearly half (46%) of Americans with incomes less than $35,000 said they had serious problems with paperwork and disputes related to bills and insurance (Figure 5). Figure 5. Insurance Complexity: Two of Five Adults Report Having to Spend Time on Paperwork or Disputes Related to Medical Bills and Health Insurance in the Past Two Years Percent 75 Somewhat serious Very serious 50 46 39 39 38 33 23 23 21 25 22 26 23 18 16 15 7 0 Total Less than $35,000– $50,000– $75,000 or $35,000 $49,999 $74,999 more Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. • Overall, more than two-thirds of respondents (69%) noted that at least one of the aforementioned issues was a serious problem in the previous two years. 6 Affordability concerns are moving up the income ladder (Figure 6). Figure 6. Half of Middle- and Lower-Income Adults Experienced Serious Problems Paying for Medical Bills or Insurance in Past Two Years Percent Percent 75 Somewhat serious 75 Somewhat serious Very serious Very serious 50 48 50 50 50 48 38 38 22 18 33 19 35 20 19 17 23 25 21 25 15 23 30 31 13 28 16 27 19 21 19 11 10 6 0 0 Total Less than $35,000– $50,000– $75,000 Total Less than $35,000– $50,000– $75,000 $35,000 $49,999 $74,999 or more $35,000 $49,999 $74,999 or more Medical bills Health insurance Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. • Half of middle-income ($35,000–$49,999 annually) and lower-income (less than $35,000 annually) families said they have had serious problems paying for care in the past two years. o With the median U.S. household income at $44,000, the findings indicate that more than half of all households are experiencing stress when paying for medical care. • A similarly high proportion of middle- and lower-income adults reported difficulties paying for health insurance. • Among these middle- and lower-income groups, more than one of four described cost concerns are “very serious.” • Affordability is a now a concern at even higher-income levels. One-third of adults with annual incomes between $50,000 and $74,999 reported serious problems in paying for care. 7 Even when care is accessible, adults reported concerns with its efficiency and safety (Figure 7). Figure 7. Inefficient, Poorly Coordinated, Unsafe Care High rates of duplicate tests, medical errors, failures to share information, or times doctors recommended unnecessary care Percent of adults reporting a time they experienced each event in the past two years Ordered a test that had already been done 17 Medical, surgical, medication, or lab test error 17 Failed to provide important medical history or test results 19 to other doctors or nurses Recommended unnecessary care or treatment 25 Any of the above 42 0 25 50 Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. • One-quarter of all adults (25%) believe their physicians recommended unnecessary care or care of little value in the past two years. • One of six (17%) said their physicians or providers repeated medical tests that had already been done. o Taken together, nearly one of three adults (30%) experienced either duplicate tests or care they believed was of little or no value. o Rather than believing more care is always better, the findings indicate patients are quite discerning when subjected to wasteful or unnecessary care. • The survey reveals disturbingly frequent breakdowns in care coordination, as well as medical errors that put patients at risk. o About one of five adults (19%) reported a time when their doctors or other medical care providers failed to provide important medical history or test results to other health care professionals who should have had them. o One of six (17%) reported a medical, medication, or lab test error in the past two years. • Altogether, 42 percent of all adults reported experiencing either inefficient care, poorly coordinated care, or unsafe care in the past two years. 8 Patients’ perceptions echo those reported by physicians. In a survey of physicians in 2003,8 72 percent reported medical records, test results, or other relevant clinical information often or sometimes were not available in the past 12 months. One-third (34%) said patients often or sometimes had tests or procedures done that had to be repeated because findings were unavailable or inadequate for interpretation. One-fourth of physicians (26%) said patients experience a problem following discharge because the physician did not receive needed information in a timely manner. Physicians also reported observing medical errors often or sometimes in the past 12 months: 15 percent said an abnormal test result was not promptly followed up and 11 percent said patients received a wrong drug, wrong dose, or preventable drug–drug interaction. Health insecurity is moving up the income ladder. A high proportion of adults is worried about the cost and quality of health care in the future (Figure 8). Figure 8. Worries About Affordability and Access to High-Quality Care Spreading to Middle-Income Families Percent worried they will not be able to Percent worried they will not get pay medical bills in event of serious illness high-quality care when needed 75 Somewhat worried 75 Somewhat worried 66 Very worried Very worried 52 53 50 50 48 47 47 50 32 50 20 26 38 34 27 25 38 31 28 25 25 23 28 34 30 27 23 19 23 16 16 11 9 0 0 Total Less than $35,000– $50,000– $75,000 Total Less than $35,000– $50,000– $75,000 $35,000 $49,999 $74,999 or more $35,000 $49,999 $74,999 or more Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. • Overall, about half of all respondents (48%) are very or somewhat worried about the affordability of care they or their families may need in the future. o Worries are acute among middle- as well as low-income families • Notably, half or more of adults with incomes up to $74,999 a year worry they will not get high-quality care when needed. 9 OVERALL SYSTEM VIEWS AND PRIORITIES FOR FEDERAL ACTION Reflecting negative experiences as well as worries about the future, three- quarters of adults believe the U.S. health care system needs to be fundamentally changed or rebuilt completely. The negative view prevails across groups by income, insurance, and political affiliation (Figure 9). Figure 9. Americans’ Overall Views of the U.S. Health Care System, by Income, Insurance, Region, and Political Affiliation Only minor Fundamental Rebuild Percent saying: changes needed changes needed completely Total 20 46 30 Annual income <$35,000 17 43 36 $35,000–$49,999 21 44 31 $50,000–$74,999 17 47 35 $75,000 or more 22 52 25 Insurance status Total insured 21 48 28 Uninsured during year 12 35 48 U.S. region Northeast 20 48 28 North Central 19 48 30 South 21 45 30 West 17 45 30 Political affiliation Republican 35 43 19 Democrat 11 44 41 Independent 16 53 27 Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. • Only 20 percent of adults think the health care system works relatively well, with only minor changes needed. • Nearly one-third (30%) believe the system needs to be completely rebuilt and another 46 percent think the system requires fundamental changes. System views are remarkably similar across income groups and regions of the country. • More Republicans (35%) than Democrats (11%) see a need for only minor changes, but very large majorities of both parties call for fundamental changes or complete rebuilding. • Strong negative views of the system were higher among those who reported having negative quality and care experiences (Figure 10). 10 Figure 10. Adults with Negative Care Experiences Are More Likely to Call for a Complete Rebuild of System Only minor Fundamental Rebuild Percent saying: changes needed changes needed completely Efficiency of care experiences Duplicate tests or 15 40 41 unnecessary treatment No duplicate tests or 22 50 25 unnecessary treatment Quality of care experiences Any medical errors 14 39 43 No medical errors 21 48 27 Access to care and cost problems* Any serious problems 16 46 33 No serious problems 28 46 22 * Problems include getting an appointment quickly, spending time on paperwork and disputes related to medical bills and insurance, paying health insurance, paying for medical bills, or finding care for aging or sick family member. Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. o Forty-three percent of those who had experienced a medical error in the past two years said the system needs to be rebuilt, compared with 27 percent of those who did not report medical errors. o Similarly, adults reporting poorly coordinated or inefficient care or access concerns are more likely to believe the system needs rebuilding. Top Priorities for Federal Action: Coverage and Costs The survey asked adults to rate the importance of seven possible policy actions for the President and Congress (Figure 11). Figure 11. Rating of Importance of Issues for Presidential or Congressional Action, by Political Affiliation Percent saying very important: Total Republican Democrat Independent Ensure that Medicare remains 84 77 91 83 financially sound in the long term Control the rising cost of medical care 84 78 89 82 Ensure that all Americans have 80 64 92 79 adequate, reliable health insurance Lower the cost of prescription drugs 78 67 87 77 Improve the quality of nursing homes 75 70 80 73 and long-term care Reduce the complexity of insurance 71 65 79 69 Reform the medical malpractice system 65 69 65 64 Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. 11 The interviewers then asked each person to select his or her top two priorities for action. • The top four priorities were: ensuring that all Americans have adequate and reliable health insurance; controlling the rising costs of medical care; lowering the cost of prescription drugs; and ensuring that Medicare remains financially sound in the long term. • The rank order was remarkably similar across income groups and regions of the country (Figure 12). Figure 12. What Are the Most Important Health Care Issues for Presidential and Congressional Action? (by income level) Percent listing issue as Less than $50,000– $75,000 first or second priority: Total $50,000 $74,999 or more Ensure that all Americans have 52 56 52 50 adequate, reliable health insurance Control the rising cost of medical care 37 35 42 39 Lower the cost of prescription drugs 31 31 27 33 Ensure that Medicare remains 29 29 32 30 financially sound in the longterm Improve the quality of nursing homes 14 16 15 13 and long-term care Reform the medical malpractice system 14 10 12 18 Reduce the complexity of insurance 12 12 10 10 Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. • However, priorities varied notably by political affiliation (Figure 13). Figure 13. What Are the Most Important Health Care Issues for Presidential and Congressional Action? (by political affiliation) Percent listing issue as first or second priority: Total Republican Democrat Independent Ensure that all Americans have 52 38 64 51 adequate, reliable health insurance Control the rising cost of medical care 37 36 36 38 Lower the cost of prescription drugs 31 29 31 31 Ensure that Medicare remains 29 28 30 30 financially sound in the long term Improve the quality of nursing homes 14 17 14 11 and long-term care Reform the medical malpractice system 14 24 6 16 Reduce the complexity of insurance 12 13 10 13 Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. 12 o Republicans were the most divided about priorities for federal action. o Those identifying themselves as Democrats or Independents ranked policies similarly, with coverage and cost leading the list. SHARED VIEWS, VALUES, AND CONCERNS Overall, the survey reveals a high level of shared public values, experiences, and concerns regarding the current U.S. health care system. Worries about the future combined with experience-based concerns about quality, access, and costs are fueling negative overall views of the current system and stimulating calls for fundamental change. Priorities, views, and experiences are often shared across income groups and geographic regions of the country. The strong positive views of the importance of care coordination and a team approach to care, combined with support for better information systems and group practice of medicine, indicate public support of more integrated approaches for delivering patient care. Negative access and care experiences are also becoming increasingly shared concerns. Disturbingly large numbers of survey respondents reported duplicative or unnecessary care. Rather than perceiving that more care is always better, patients are quite discerning of waste—of their time and of health care resources. Those who have experienced care that is inefficient, unsafe, or costly are the most critical of the current system of care. But regardless of their individual care experiences, people in all income brackets, and those with and without insurance, did not vary in their thoughts about the importance of key values of a high performance health system. Nor did they vary in their opinions of major actions to achieve better coordinated, higher quality, more efficient care. Across income groups and regions of the country, there was resounding agreement that ensuring reliable health insurance and controlling rising costs are the most pressing health policy issues for the President and Congress to tackle. The majority consistently ranked coverage and costs as their top two priorities (Figure 12). TOWARD A HIGH PERFORMANCE HEALTH SYSTEM These public views underscore the values and call for change underpinning the recent framework statement issued by The Commonwealth Fund Commission on a High Performance Health System.9 The Commission concluded that while the United States delivers some of the best medical care in the world, it falls far short of providing high- quality, safe, well-coordinated, and efficient care accessible to all Americans. The 13 Commission’s report, which proposes a framework for dramatically improving the health care in the U.S., emphasizes how the current system fails to deliver adequate value for the very high proportion of resources the nation devotes to health care. Emerging from an exhaustive review of evidence on health system performance, the Commission report pointed to concrete steps for improving value. These include implementing approaches for improving quality and safety, expanding the use of information technology, rewarding performance for quality and efficiency through payment system reforms, increasing public reporting on quality and costs, and ensuring affordable insurance coverage for all. Central to implementing these changes is the need to establish more organized systems of care that provide consumers a patient-centered medical home that is accountable for ensuring value for money. The United States is on the wrong track. Health care costs are escalating and the numbers who are uninsured or underinsured are growing ever greater. Patients and families want transformative change. Listening to the voices of patients about their care experiences provides a prescription for what is most ailing in our current system. Patients want a genuine system of health care—one where care is coordinated, no one falls through the cracks, and every one is secure in the knowledge that the best of American medicine will be there for them. It is a clarion call that should not go unheard. 14 METHODOLOGY The survey was conducted by Harris Interactive, Inc., by telephone with a representative sample of 1,023 adults ages 18 and older, living in households with telephones in the continental United States (see Appendix for demographic characteristics of survey respondents). Interviews took place between June 1 and June 5, 2006. Harris Interactive selected the sample using random-digit dialing—a technique to ensure geographic representation of households with listed and unlisted telephone numbers. Survey questions focused on: public health system values and views of effective mechanisms to improve quality of care; recent access, quality, efficiency, and affordability experiences; and concerns and priorities for federal action. Samples of this size have an overall margin of sampling error of +/– 3 percent. The survey questions were included as part of ongoing surveys of the public conducted by Harris Interactive. 15 NOTES 1 C. Schoen, R. Osborn, P. T. Huynh et al., “Primary Care and Health System Performance: Adults’ Experiences in Five Countries,” Health Affairs Web Exclusive (Oct. 28, 2004):W4-487– W4-503; T. Bodenheimer, E. Wagner, and K. Grumbach, “Improving Primary Care for Patients with Chronic Illness: The Chronic Care Model, Part 2,” Journal of the American Medical Association, Oct. 16, 2002 288(15):1909–14. 2 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care. 3 P. Fronstin and S. R. Collins, Early Experience with High-Deductible and Consumer-Driven Health Plans: Findings from the EBRI/Commonwealth Fund Consumerism in Health Care Survey (New York: The Commonwealth Fund, Dec. 2005). 4 Ibid. 5 Medicare Payment Advisory Commission, Report to the Congress: Increasing the Value of Medicare (Washington, D.C.: MedPAC, June 2006). 6 A.-M. J. Audet, K. Davis, and S. C. Schoenbaum, “Adoption of Patient-Centered Care Practices by Physicians: Results from a National Survey,” Archives of Internal Medicine, Apr. 10, 2006 166(7):754–59. 7 The Commonwealth Fund Commission on a High Performance Health System, Framework for a High Performance Health System for the United States (New York: The Commonwealth Fund, Aug. 2006). 8 2003 Commonwealth Fund National Survey of Physicians and Quality of Care. 9 Commission High Performance, Framework, Aug. 2006. 16 Appendix. Demographic Characteristics of Survey Respondents Weighted distribution (%) Age 18–34 31 35–54 39 55–64 14 65 and older 16 Household income Less than $35,000 26 $35,000–$49,999 15 $50,000–$74,999 17 $75,000 or more 21 Insurance status Insured all year 76 Private only 60 Public/other 40 Uninsured during year 22 Race/ethnicity White, non-Hispanic 69 Black, non-Hispanic 11 Hispanic 13 Other 5 Education level Less than high school 7 High school graduate 29 Associate’s degree or some college 27 College graduate or higher 35 Region of the United States Northeast 19 Northcentral 23 South 36 West 22 Political affiliation Democrat 36 Republican 24 Independent/other 35 Note: Totals may not add up to 100%. “Don’t know/refused to answer” not shown. Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006. 17 RELATED PUBLICATIONS Publications listed below can be found on The Commonwealth Fund’s Web site at www.cmwf.org. Framework for a High Performance Health System for the United States (Aug. 2006). The Commonwealth Fund Commission on a High Performance Health System. Gaps in Health Insurance: An All-American Problem—Findings from the Commonwealth Fund Biennial Health Insurance Survey (Apr. 2006). Sara R. Collins, Karen Davis, Michelle M. Doty, Jennifer L. Kriss, and Alyssa L. Holmgren, The Commonwealth Fund. Health Information Technology: What Is the Federal Government’s Role? (Mar. 2006). David Blumenthal, Institute for Health Policy, Massachusetts General Hospital. Prepared for the Commonwealth Fund/Alliance for Health Reform 2006 Bipartisan Congressional Health Policy Conference. Workers’ Health Insurance: Trends, Issues, and Options to Expand Coverage (Mar. 2006). Paul Fronstin, Employee Benefit Research Institute. Prepared for the Commonwealth Fund/Alliance for Health Reform 2006 Bipartisan Congressional Health Policy Conference. Toward a High Performance Health System for the United States (Mar. 2006). Anne Gauthier, Stephen C. Schoenbaum, and Ilana Weinbaum, The Commonwealth Fund. Prepared for the Commonwealth Fund/Alliance for Health Reform 2006 Bipartisan Congressional Health Policy Conference. Quality Development in Health Care in The Netherlands (Mar. 2006). Richard Grol, Centre for Quality of Care Research, Radboud University Nijmegen Medical Centre. Prepared for the Commonwealth Fund/Alliance for Health Reform 2006 Bipartisan Congressional Health Policy Conference. Medicare’s New Adventure: The Part D Drug Benefit (Mar. 2006). Jack Hoadley, Health Policy Institute, Georgetown University. Prepared for the Commonwealth Fund/Alliance for Health Reform 2006 Bipartisan Congressional Health Policy Conference. Measuring, Reporting, and Rewarding Performance in Health Care (Mar. 2006). Richard Sorian, National Committee for Quality Assurance. Prepared for the Commonwealth Fund/Alliance for Health Reform 2006 Bipartisan Congressional Health Policy Conference. Can Medicaid Do More with Less? (Mar. 2006). Alan Weil, National Academy for State Health Policy. Prepared for the Commonwealth Fund/Alliance for Health Reform 2006 Bipartisan Congressional Health Policy Conference. Recent Growth in Health Expenditures (Mar. 2006). Stephen Zuckerman and Joshua McFeeters, The Urban Institute. Prepared for the Commonwealth Fund/Alliance for Health Reform 2006 Bipartisan Congressional Health Policy Conference. A Need to Transform the U.S. Health Care System: Improving Access, Quality, and Efficiency: A Chartbook (Oct. 2005). Anne Gauthier and Michelle Serber, The Commonwealth Fund. 18