THE COMMONWEALTH FUND Multinational Comparisons of Health Systems Data, 2005 Bianca K. Frogner and Gerard F. Anderson, Ph.D. Johns Hopkins University April 2006 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. Additional copies of this and other Commonwealth Fund publications are available online at www.cmwf.org. To learn about new Fund publications when they appear, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 825. 2 Contents I. Overview 7 II. Total Health Care Spending 18 Chart II-1 Health Care Spending per Capita in 2003 19 Chart II-2 Average Annual Growth Rate of Real Health Care Spending per Capita, 1993–2003 20 Chart II-3 Average Annual Growth Rate of Real Health Care Spending per Capita, 1983–2003, 1993–2003 21 Chart II-4 Percentage of Gross Domestic Product Spent on Health Care in 2003 22 Chart II-5 Percentage of Gross Domestic Product Spent on Health Care, 1993 and 2003 23 III. Public and Private Health Care Financing 24 Chart III-1 Percentage of Total Population with Health Insurance Coverage Through Public Programs in 2003 25 Chart III-2 Public Spending on Health Care per Capita in 2003 26 Chart III-3 Private Spending on Health care per Capita in 2003 27 Chart III-4 Out-of-Pocket Health Care Spending per Capita in 2003 28 Chart III-5 Health Care Expenditure per Capita by Source of Funding in 2003 29 THE COMMONWEALTH FUND 3 IV. Health Spending by Type of Service 30 Chart IV-1 Distribution of Health Spending by Type of Service 31 Chart IV-2 Percentage of Total Health Care Spending on Hospital Care in 2003 32 Chart IV-3 Percentage of Total Health Care Spending on Hospital Care, 1993 and 2003 33 Chart IV-4 Percentage of Total Health Care Spending on Physician Services in 2003 34 Chart IV-5 Percentage of Total Health Care Spending on Physician Care, 1993 and 2003 35 Chart IV-6 Percentage of Total Health Care Spending on Pharmaceuticals in 2003 36 Chart IV-7 Percentage of Total Health Care Spending on Pharmaceuticals, 1993 and 2003 37 Chart IV-8 Percentage of Total Health Care Spending on Long-Term Institutional Care and Home Health Care in 2003 38 V. Hospitals 39 Chart V-1 Hospital Spending per Capita in 2003 40 Chart V-2 Average Annual Growth Rate of Real Spending per Capita on Hospital Services, 1993–2003 41 Chart V-3 Hospital Spending per Inpatient Acute Care Day in 2003 42 Chart V-4 Hospital Spending per Discharge in 2003 43 Chart V-5 Hospital Discharges per 1,000 Population in 2003 44 Chart V-6 Average Length of Stay for Acute Care in 2003 45 Chart V-7 Average Length of Hospital Stay for Acute Myocardial Infarction in 2003 46 Chart V-8 Average Length of Stay for Normal Delivery in 2003 47 Chart V-9 Average Annual Hospital Inpatient Acute Care Days per Capita in 2003 48 Chart V-10 Number of Acute Care Hospital Beds per 1,000 Population in 2003 49 Chart V-11 Hospital Employment per 1,000 Inpatient Acute Care Days in 2003 50 THE COMMONWEALTH FUND 4 VI. Long-Term Care 51 Chart VI-1 Long-Term Institutional Care Spending per Capita in 2003 52 Chart VI-2 Average Annual Growth Rate of Real Spending per Capita on Long-Term Institutional Care, 1993–2003 53 Chart VI-3 Home Health Care Spending per Capita in 2003 54 Chart VI-4 Average Annual Growth Rate of Real Spending per Capita on Home Health Care, 1993–2003 55 Chart VI-5 Number of Long-Term Care Beds per 1,000 Population over Age 65 in 2003 56 VII. Physicians 57 Chart VII-1 Spending on Physician Services per Capita in 2003 58 Chart VII-2 Average Annual Growth Rate if Real Spending per Capita on Physician Services, 1993–2003 59 Chart VII-3 Number of Practicing Physicians per 1,000 Population in 2003 60 Chart VII-4 Average Annual Growth Rate of Practicing Physicians per 1,000 Population, 1993–2003 61 Chart VII-5 Average Annual Number of Physician Visits per Capita in 2003 62 VIII. Nursing 63 Chart VIII-1 Number of Practicing Nurses per 1,000 Population in 2003 64 Chart VIII-2 Number of Practicing Nurses per Acute Care Bed in 2003 65 THE COMMONWEALTH FUND 5 IX. Pharmaceuticals 66 Chart XI-1 Pharmaceutical Spending per Capita in 2003 67 Chart XI-2 Average Annual Growth Rate of Real Spending per Capita on Pharmaceuticals, 1993–2003 68 Chart XI-3 Relative Prices of Thirty Pharmaceuticals in Four Countries in 2003 69 Chart XI-4 Percentage of Total Population with Pharmaceutical Goods Coverage Through Public Programs in 2003 70 Chart XI-5 Percentage of Population over Age 65 with Influenza Immunization in 2003 71 X. Medical Procedures Involving Sophisticated Technology 72 Chart X-1 Magnetic Resonance Imaging (MRI) Units per Million Population in 2003 73 Chart X-2 Computer Tomography (CT) Scanners per Million Population in 2003 74 Chart X-3 Cardiac Catheterization Procedures per 1,000 Population in 2003 75 Chart X-4 Percutaneous Transluminal Coronary Angioplasty (PTCA) Interventions per 100,000 Populations in 2003 76 Chart X-5 Coronary Bypass Procedures per 100,000 Population in 2003 77 Chart X-6 Number of Knee Replacements per 100,000 Population in 2003 78 Chart X-7 Number of Patients Undergoing Dialysis Treatment per 100,000 Population in 2003 79 THE COMMONWEALTH FUND 6 XI. Non-Medical Determinants of Health 80 Chart XI-1 Percentage of Adults Who Reported Being Daily Smokers in 2003 81 Chart XI-2 Decreases in Smoking Rates Between 1983–2003 82 Chart XI-3 Annual Alcohol Consumption in Liters per Capita for People Age 15 and Older in 2003 83 Chart XI-4 Obesity (BMI >30) Prevalence in 2003 84 Chart XI-5 Changes in Obesity Rates, 1993–2003 85 XII. Mortality 86 Chart XII-1 Life Expectancy at Birth in 2003 87 Chart XII-2 Life Expectancy at Age 65 in 2003 88 Chart XII-3 Increases in Life Expectancy at Birth, 1983–2003 89 Chart XII-4 Increases in Life Expectancy at Age 65, 1983–2003 90 Chart XII-5 Breast Cancer Five-Year Relative Survival in 1997 91 Chart XII-6 Breast Cancer Screening in 2001 92 Chart XII-7 Kidney Transplant Five-Year Survival in 2001 93 XIII. Country Summaries 94 XIV. Appendix: Notes and Definitions 103 THE COMMONWEALTH FUND 7 I. Overview THE COMMONWEALTH FUND 8 International data allow policymakers to compare the performance of their own health care system with those of other countries. In this chartbook, we use data collected by the Organization for Economic Cooperation and Development (OECD) to compare health care systems and performance in nine industrialized countries: Australia, Canada, France, Germany, Japan, the Netherlands, New Zealand, the United Kingdom, and the United States. Whenever possible, we also present the median value of all 30 members of the OECD. The chart book is organized into eleven sections: • Total Spending • Public and Private Health Care Financing • Health Spending by Type of Service • Hospitals • Long-Term Care • Physicians • Nursing • Pharmaceuticals • Medical Procedures Involving Sophisticated Technology • Non-Medical Determinants of Health • Mortality THE COMMONWEALTH FUND 9 Methods The source for most of the data is the OECD. Data were sent to each country for review, and any additional sources are noted on individual charts. Every effort is made to standardize the comparisons, but countries inevitably differ in their definitions of terms and how they collect data. The most recent year is used whenever possible, but when it is not available for a specific country, data from earlier years are substituted, with the substitution noted on the chart. All health spending was adjusted to U.S. dollars using purchasing power parities, a common method of adjusting for cost-of-living differences. Because of definitional and data concerns, the comparisons should be seen as guides to relative orders of magnitude rather than as indicators of precise differences. Detailed methodological notes and definitions are provided in the appendix. THE COMMONWEALTH FUND 10 Total Spending In 2003, per capita spending for all health care services ranged from a high of $5,635 in the United States to a low of $1,886 in New Zealand. The median for all 30 OECD countries was $2,280. The United States spent 15 percent of GDP on health care services, compared with 8.4 percent in the median OECD country. Most of the countries had an increase in health spending as a percentage of GDP between 1993 and 2003. Over the last 20 years, the United States had the fastest average annual growth rate of real health spending per capita and Germany had the slowest rate. Public and Private Health Care Financing Universal publicly financed health insurance coverage exists in Australia, Canada, France, Japan, New Zealand, and the United Kingdom. In Germany and the Netherlands, every citizen has access to public coverage, but individuals with higher incomes may opt for private coverage instead. Among all OECD countries, the United States had the highest level of health financing from public sources in 2003. This is surprising because only one-quarter of all Americans have publicly financed health insurance. The United States spent nearly 25 times more than the median OECD country on private health care spending (excluding out-of-pocket spending). In the United States, private health insurance coverage is the most common source of health insurance, but other countries primarily use private insurance as a supplement to public insurance coverage. Out-of-pocket spending per capita in the United States was almost twice as high as in the median OECD country. THE COMMONWEALTH FUND 11 Health Spending by Type of Service In 2003, the median OECD country spent 40 percent on hospitals, 15 percent on physicians, 16 percent on pharmaceuticals, and 10 percent on long-term institutional health care and home health care. The remainder was spent on multiple health care services, including dentists and durable medical equipment, as well as biomedical research and development. Hospitals In 2003, the United States spent the most per capita on hospital services. Canada and Japan spent the least per capita on hospital services. An alternative measure is inpatient acute care spending per day; the United States spent two times the median OECD country and five times more than Japan. The United States falls below the median OECD country, and often at the bottom of the nine countries, in certain service utilization measures: hospital discharges, average length of stay for acute care, average length of stay for acute myocardial infarction, average length of stay for normal delivery, and average annual number of acute care days, and the number of acute care beds. Germany and Japan were consistently above the median OECD country on these utilization measures. The United States had the highest number of health employees per 1,000 acute care days, and more than twice that of Germany, the country with the least number of health employees per acute care day. THE COMMONWEALTH FUND 12 Long-Term Care Canada had the most long-term care beds per 1,000 people over the age of 65 in 2003, while the United Kingdom had the fewest. Canada and the United States spent the most on long-term institutional care per capita, and the United States spent the most on home health care per capita in 2003. France spent the least on long-term institutional care per capita, and France and Japan spent the least on home health care per capita. Germany experienced fastest growth rate in long-term institutional health care spending per capita, and had the fastest growth rate in home health care spending per capita. Physicians The United States spent almost three times the median OECD country on physician services per capita in 2003. In the last decade, the United States and Australia experienced the most rapid increase in average annual growth rate in real spending on physician services, while Japan had a decrease in the spending growth rate. The number of physician visits per capita is relatively similar in all nine of the countries except for Japan, which had many more physician visits. The nine countries also had similar numbers of physicians. The United Kingdom and the United States experienced the fastest increase in practicing physicians per 1,000 people between 1993 and 2003 while Canada saw a decrease. THE COMMONWEALTH FUND 13 Nursing In 2003, the Netherlands had the most nurses per 1,000 people, while France had the least. The United States had below the OECD median number of nurses per 1,000 people. The United Kingdom had almost four times the number of nurses per acute care bed as France. Pharmaceuticals The United States spent more than two times the OECD median per capita on pharmaceuticals in 2003. The Netherlands spent the least on pharmaceuticals per capita among the nine countries. Spending for pharmaceuticals increased the fastest between 1993 and 2003, at a rate of approximately 9 percent in both Australia and the United States. Japan only had a 1.1 percent average annual growth rate in real pharmaceutical spending. THE COMMONWEALTH FUND 14 Medical Procedures Involving Sophisticated Technology The diffusion of medical technology occurs at different rates across the nine countries. For example, the number of magnetic resonance imagers (MRIs) and computer tomography (CT) units per capita varied considerably. Japan had the most MRIs and CTs, with almost 13 times the number of MRIs per capita as France and nearly 16 times the number of CT units per capita as the United Kingdom in 2003. Japan, Germany, and the United States consistently have the most technology available, while France, New Zealand, and the United Kingdom tend to have the least. A comparison of utilization rates for specific procedures is confounded by differences in the incidence of disease and disease classification, among other factors. However, there are striking differences in utilization rates for certain procedures. For example, Germany had 794 cardiac catheterizations procedures per 100,000 people while the United Kingdom had only 14. The United States performed the most percutaneous transluminal coronary angioplasty procedures, coronary bypass procedures, and knee replacement procedures per 100,000 people in 2003. Japan and the United States had the highest number of patients undergoing dialysis. France, New Zealand, the Netherlands, and the United Kingdom had consistently lower rates of these procedures. THE COMMONWEALTH FUND 15 Non-Medical Determinants of Health About one-third of the population in the Netherlands and Japan were daily tobacco smokers in 2003. Canada and the United States had the lowest rates of daily tobacco smoking. Australia, Canada, and the United States have experienced the largest drop in smoking rates over the last 20 years. Alcohol consumption is highest in France and lowest in Canada. A large proportion of the United States population is obese. Japan had the lowest obesity prevalence. Japan also had the smallest change in obesity rates between 1993 and 2003, while the United Kingdom had experienced the largest increase in obesity rates. THE COMMONWEALTH FUND 16 Mortality Measuring health outcomes is extremely difficult as all the widely available indicators are crude proxies and not very sensitive to changes in health care financing and delivery. In 2003, men lived an average of 5.6 fewer years than women. Japan maintained the longest life expectancy at birth for men and women. The United States had the shortest life expectancy at birth for men and women. Over the last twenty years, Japanese women and Australian men had the largest gain in life expectancy among the nine OECD countries. The Netherlands had the smallest increase in life expectancy for both men and women. At the age of 65, Japanese men and women had the longest life expectancy. Japanese women had the largest increase in life expectancy at the age of 65 over the past 20 years, and the United States had the smallest increase. Australian men had the largest increase in life expectancy at age of 65 while men in the Netherlands had the smallest increase. Mortality rates are influenced by many factors in addition to health care. One indicator that is potentially sensitive to health care intervention is the five-year survival rate for certain diseases. Breast cancer survival rates in the United States are slightly higher than those in Australia, France, and England (United Kingdom data not available). Breast cancer screening rates are similar in Canada, Australia, the United States, and England, but lower in New Zealand. Kidney transplant five-year survival rate was highest in Canada, and lowest in the United States. THE COMMONWEALTH FUND 17 Summary In 2003, the United States continued the trend of spending the most per capita on health care services among the 30 OECD countries. The United States also spent the greatest proportion of total spending on health care services. International comparisons reveal three areas that are partially responsible for the higher spending in the United States: hospital spending per acute care day, spending on physician services, and prices of pharmaceuticals. In each of these three categories, the United States spent double the amount of the next highest country. Resources and utilization rates in the United States are low especially for acute care days and other utilization measures. The United States is also a clear outlier in insurance coverage. While the other eight countries have achieved nearly universal health insurance coverage, approximately 40 million people in the United States are estimated to be uninsured in 2005. The United States spent the most on publicly financed and privately financed health insurance and also paid the most out- of-pocket. On one important outcome measure, longevity, the United States was consistently at or near the bottom among the nine countries. THE COMMONWEALTH FUND 18 II. Total Health Care Spending THE COMMONWEALTH FUND 19 Chart II-1 Health Care Spending per Capita in 2003 Adjusted for Differences in Cost of Living $6,000 $5,635 $5,000 $4,000 $3,003 $2,996 $2,976 $2,903 $2,903 $3,000 $2,280 $2,231 $2,139 $1,886 $2,000 $1,000 $0 a United Canada Germany Netherlands Australia France OECD United Japan New a States Median Kingdom Zealand THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 20 Chart II-2 Average Annual Growth Rate of Real Health Care Spending per Capita, 1993–2003 5% 4.0% 4% 3.4% 3.4% 3.4% 3.4% 3.4% 3.1% 3% 2.5% 2.4% 2.3% 2% 1% 0% a United United OECD Australia Netherlands New Japan Canada France Germany a THE Kingdom States Median Zealand COMMONWEALTH FUND a 1993–2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 21 Chart II-3 Average Annual Growth Rate of Real Health Care Spending per Capita, 1983–2003, 1993–2003 5% 4.3% 1983–2003 1993–2003 4.0% 4% 3.8% 3.4% 3.4% 3.4% 3.4% 3.4% 3.4% 3.2% 3.1% 2.9% 2.9% 2.9% 3% 2.9% 2.8% 2.5% 2.4% 2.3% 2.2% 2% 1% 0% b United United Australia Netherlands OECD New Japan Canada France Germany a Kingdom States Median Zealand THE COMMONWEALTH a FUND 1993–2002 b1985–2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 22 Chart II-4 Percentage of Gross Domestic Product Spent on Health Care in 2003 16% 15.0% 14% 12% 11.1% 10.1% 9.9% 9.8% 9.7% 10% 8.4% 8.1% 7.9% 7.7% 8% 6% 4% 2% 0% a United Germany France Canada Netherlands Australia OECD New Japan United a States Median Zealand Kingdom THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 23 Chart II-5 Percentage of Gross Domestic Product Spent on Health Care, 1993 and 2003 16% 15.0% 14% 13.2% 1993 2003 12% 11.1% 9.9% 10.1% 9.9% 9.9% 9.8% 9.7% 10% 9.4% 8.6% 8.4% 8.2% 8.1% 8.0% 7.9% 7.7% 8% 7.2% 6.9% 6.5% 6% 4% 2% 0% a United Germany France Canada Netherlands Australia OECD New Japan United a States Median Zealand Kingdom THE COMMONWEALTH FUND a 1993–2002 Source: OECD Health Data 2005. 24 III. Public and Private Health Care Financing THE COMMONWEALTH FUND 25 Chart III-1 Percentage of Total Population with Health Insurance Coverage Through Public Programs in 2003 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.9% 100% 90.1% 76.4% 75% 50% 26.6% 25% 0% a Australia Canada Japan New OECD United France GermanyNetherlands United THE COMMONWEALTH Zealand Median Kingdom States FUND a Source: OECD Health Data 2005. 2002 26 Chart III-2 Public Spending on Health Care per Capita in 2003 Adjusted for Differences in Cost of Living $3,000 $2,503 $2,500 $2,343 $2,214 $2,100 $1,973 $2,000 $1,860 $1,856 $1,768 $1,743 $1,484 $1,500 $1,000 $500 $0 a United Germany France Canada Australia United Netherlands OECD Japan New a States Kingdom Median Zealand THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 27 Chart III-3 Private Spending on Health Care per Capita in 2003 Excluding Out-of-Pocket Spending, Adjusted for Differences in the Cost of Living $2,500 $2,339 $2,000 $1,500 $1,000 $887 $455 $398 $500 $341 $341 $106 $94 $26 $0 a United NetherlandsCanada France Australia Germany New OECD Japan States Zealand Median THE COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 28 Chart III-4 Out-of-Pocket Health Care Spending per Capita in 2003 Adjusted for Differences in the Cost of Living $1,000 $793 $750 $590 $500 $448 $399 $370 $312 $296 $291 $233 $250 $0 a United Australia Canada OECD Japan Germany New FranceNetherlands States Median Zealand THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 29 Chart III-5 Health Care Expenditure per Capita by Source of Funding in 2003 Adjusted for Differences in Cost of Living $6,000 793 Out-of-Pocket Spending $5,000 Private Spending Public Spending $4,000 2339 $3,000 448 312 233 291 341 590 455 398 887 793 341 371 $2,000 370 94 26 296 106 2503 2343 $1,000 2100 1973 2214 1856 1768 1860 1743 1484 $0 a United Canada Germany Netherlands Australia France OECD United Japan New a States Median Kingdom Zealand THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 30 IV. Health Spending by Type of Service THE COMMONWEALTH FUND 31 Chart IV-1 Distribution of Health Spending by Type of Service Australia Canada France Germany Japan a United States Pharmaceuticals 14.0% 16.9% 20.9% 14.6% 18.4% 12.9% Physician 16.5% 9.6% 12.5% 10.1% 25.9% 22.6% Services Hospitals1 33.4% 28.1% 41.2% 35.8% 40.0% 27.1% Home Health 0.1% 1.8% 0.4% 4.3% 0.5% 2.4% Care Other2 36.0% 43.6% 25.0% 35.2% 15.2% 35.0% 1. Hospital spending includes some long-term institutional care and cannot be separated. 2. Other includes some long-term institutional care, dental, clinical laboratory, diagnostic imaging, patient transport and emergency rescue, administration, and R&D. THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 32 Chart IV-2 Percentage of Total Health Care Spending on Hospital Care in 2003 50% 41.2% 40.0% 39.6% 38.9% 40% 35.8% 33.4% 30% 28.1% 27.1% 20% 10% 0% a France Japan Netherlands OECD Germany Australia Canada United Median States THE COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 33 Chart IV-3 Percentage of Total Health Care Spending on Hospital Care, 1993 and 2003 60% 1993 2003 49.8% 50% 47.4% 44.6% 44.6% 42.9% 41.2% 40.0% 39.6% 38.9% 40% 37.4% 35.8% 33.4% 34.1% 32.2% 30% 28.1% 27.1% 20% 10% 0% a France Japan Netherlands OECD Germany Australia Canada United THE Median States COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 34 Chart IV-4 Percentage of Total Health Care Spending on Physician Services in 2003 30% 25.9% 25% 22.6% 20% 16.5% 14.8% 15% 12.9% 12.5% 10.1% 10% 5% 0% a Japan United Australia OECD Canada France Germany States Median THE COMMONWEALTH FUND Source: OECD Health Data 2004; Canadian Institute for Health a 2002 Information (Canada); AIHW Health Expenditure Australia 2003–04. 35 Chart IV-5 Percentage of Total Health Care Spending on Physician Care, 1993 and 2003 40% 35.3% 35% 1993 2003 30% 25.9% 25% 23.1% 22.6% 20% 16.5% 14.4% 15.0%14.8% 14.9% 15% 12.9% 12.5% 11.5% 10.1% 9.6% 10% 5% 0% a Japan United Australia OECD France Germany Canada States Median THE COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 36 Chart IV-6 Percentage of Total Health Care Spending on Pharmaceuticals in 2003 25% 20.9% 20% 18.4% 16.9% 16.0% 14.6% 15% 14.0% 12.9% 11.4% 10% 5% 0% a France Japan Canada OECD Germany Australia United Netherlands Median States THE COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005. 37 Chart IV-7 Percentage of Total Health Care Spending on Pharmaceuticals, 1993 and 2003 25% 22.3% 1993 2003 20.9% 20% 18.4% 17.5% 16.9% 16.0% 14.6% 15% 14.0% 13.0% 13.2% 13.2% 12.9% 11.4% 11.0% 10.4% 10% 8.6% 5% 0% a b France Japan Canada OECD Germany Australia United Netherlands THE Median States COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005. 38 Chart IV-8 Percentage of Total Health Care Spending on Long-Term Institutional Care and Home Health Care in 2003 Home Health Care 15% Long-Term Inpatient Care 13.1% 12.8% 12.2% 0.5% 1.8% 10.7% 3.8% 9.6% 10% 9.2% 4.3% 1.8% 2.4% 6.5% 12.3% 0.1% 11.3% 5% 4.2% 8.4% 7.8% 0.4% 6.4% 6.8% 6.4% 3.8% 0% a Canada Japan Netherlands Germany OECD United Australia France Median States THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 39 V. Hospitals THE COMMONWEALTH FUND 40 Chart V-1 Hospital Spending per Capita in 2003 Adjusted for Differences in Cost of Living $2,000 $1,526 $1,500 $1,196 $1,178 $1,073 $1,024 $1,000 $904 $855 $842 $500 $0 b a United France Netherlands Germany Australia OECD Japan Canada States Median THE COMMONWEALTH a FUND 2002 b 2001 Source: OECD Health Data 2005. 41 Chart V-2 Average Annual Growth Rate of Real Spending per Capita on Hospital Services, 1993-2003 6% 5.8% 5% 4.7% 4% 3% 2.2% 2.0% 2.0% 2.0% 2% 1.8% 1.6% 1% 0% a b Japan Australia United France OECD Germany Canada Netherlands States Median THE COMMONWEALTH a FUND 1993–2002 b 1993–2001 Source: OECD Health Data 2005. 42 Chart V-3 Hospital Spending per Inpatient Acute Care Day in 2003 Adjusted for Differences in Cost of Living $2,500 $2,180 $2,000 $1,500 $1,251 $1,196 $1,024 $924 $1,000 $804 $554 $500 $389 $0 b b a a a United Netherlands France Australia OECD Canada Germany Japan States Median THE COMMONWEALTH a FUND 2002 b 2001 Source: OECD Health Data 2005. 43 Chart V-4 Hospital Spending per Discharge in 2003 Adjusted for Differences in Cost of Living $15,000 $12,466 $12,137 $10,000 $9,107 $8,383 $6,196 $5,893 $5,222 $4,560 $5,000 $0 a a a a United Netherlands Canada Japan Australia OECD Germany France a States Median THE COMMONWEALTH FUND Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04 a 2002 and AIHW Australian Hospital Statistics 2003–04. 44 Chart V-5 Hospital Discharges per 1,000 Population in 2003 300 251 247 250 204 202 200 160 157 150 117 102 97 100 88 50 0 a a a France United New Germany OECD Australia United Japan Netherlands Canada a Kingdom Zealand Median States THE COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005. 45 Chart V-6 Average Length of Stay for Acute Care in 2003 25 20.7 20 15 9.2 10 8.6 7.4 6.8 6.7 6.2 5.7 5.6 5 0 a b a b Japan GermanyNetherlands Canada OECD United Australia United France Median Kingdom States THE COMMONWEALTH a FUND 2002 b 2001 Source: OECD Health Data 2005. 46 Chart V-7 Average Length of Hospital Stay for Acute Myocardial Infarction in 2003 12 10.3 10 9.2 9.2 8.4 8.1 8 7.5 7.2 6.4 5.6 6 4 2 0 a a a GermanyNetherlands United OECD Canada New France Australia United a a Kingdom Median Zealand States THE COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 47 Chart V-8 Average Length of Stay for Normal Delivery in 2003 5 4.8 4.4 4 3.0 3 2.8 2.3 2.0 2.0 1.9 1.9 2 1 0 a a a France Germany OECD AustraliaNetherlands New Canada United United a a Median Zealand Kingdom States THE COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 48 Chart V-9 Average Annual Hospital Inpatient Acute Care Days per Capita in 2003 2.5 2.1 2.0 1.9 1.5 1.1 1.0 1.0 1.0 1.0 1.0 0.8 0.7 0.5 0.0 a a a b Japan Germany United France Australia OECD Canada Netherlands United THE Kingdom Median States COMMONWEALTH a2002 FUND b2001 Source: OECD Health Data 2005. 49 Chart V-10 Number of Acute Care Hospital Beds per 1,000 Population in 2003 10 8.5 8 6.6 6 3.8 3.8 3.7 4 3.6 3.2 3.2 2.8 2 0 a a a a Japan Germany France OECD United Australia CanadaNetherlands United THE Median Kingdom States COMMONWEALTH FUND a2002 Source: OECD Health Data 2005. 50 Chart V-11 Hospital Employment per 1,000 Inpatient Acute Care Days in 2003 6 5.4 5 3.9 4 3.7 3.5 3.4 3.3 3.0 3 2.4 2 1 0 a b a a United Canada Netherlands Australia OECD France United Germany States Median Kingdom THE COMMONWEALTH a FUND 2002 b 2001 Source: OECD Health Data 2005. 51 VI. Long-Term Care THE COMMONWEALTH FUND 52 Chart VI-1 Long-Term Institutional Care Spending per Capita in 2003 Adjusted for Differences in Cost of Living $387 $381 $400 $340 $319 $319 $300 $271 $190 $200 $122 $100 $0 a b Canada United Netherlands Germany OECD Japan Australia France States Median THE COMMONWEALTH a2002 FUND b2001 Source: OECD Health Data 2005. 53 Chart VI-2 Average Annual Growth Rate of Real Spending per Capita on Long-Term Institutional Care, 1993–2003 7% 6.4% 6.4% 5.8% 6% 5.0% 5% 4% 3.5% 3% 2% 1% 0% -0.1% -1% a Germany France Australia Canada United States Netherlands THE COMMONWEALTH FUND a1993–2001 Source: OECD Health Data 2005. 54 Chart VI-3 Home Health Care Spending per Capita in 2003 Adjusted for Differences in Cost of Living $150 $138 $128 $113 $100 $53 $53 $50 $12 $10 $0 a United Germany Netherlands Canada OECD France Japan States Median THE COMMONWEALTH FUND a Source: OECD Health Data 2005. 2002 55 Chart VI-4 Average Annual Growth Rate of Real Spending per Capita on Home Health Care, 1993–2003 20% 15.6% 15% 10% 5.5% 4.8% 4.3% 5% 0% -2.2% -5% Germany France Canada United States Netherlands THE COMMONWEALTH FUND Source: OECD Health Data 2005. 56 Chart VI-5 Number of Long-Term Care Beds per 1,000 Population over Age 65 in 2003 120 103 100 80 60 50 40 29 28 27 26 22 20 8 0 b a b Canada United Australia OECD Netherlands Japan United France a States Median Kingdom THE COMMONWEALTH a FUND 2002 b2001 Source: OECD Health Data 2005. 57 VII. Physicians THE COMMONWEALTH FUND 58 Chart VII-1 Spending on Physician Services per Capita in 2003 Adjusted for Differences in Cost of Living $1,500 $1,271 $1,000 $553 $480 $500 $428 $363 $304 $287 $0 a United Japan Australia OECD France Germany Canada States Median THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005; AIHW Health Expenditure Australia 2003–04. 59 Chart VII-2 Average Annual Growth Rate of Real Spending per Capita on Physician Services, 1993–2003 2.9% 3% 2.8% 1.9% 2% 1.8% 1.1% 1.0% 1% 0% -0.2% -1% b a Australia United France OECD Canada Germany Japan States Median THE COMMONWEALTH a1993–2002 FUND b1993–2001 Source: OECD Health Data 2005. 60 Chart VII-3 Number of Practicing Physicians per 1,000 Population in 2003 4 3.4 3.4 3.1 3.1 3 2.5 2.3 2.2 2.2 2.1 2.0 2 1 0 a a France Germany Netherlands OECD Australia United New United Canada Japan a Median States Zealand Kingdom THE COMMONWEALTH FUND a Source: OECD Health Data 2005. 2002 61 Chart VII-4 Average Annual Growth Rate of Practicing Physicians per 1,000 Population, 1993–2003 3% 2.6% 2.2% 2% 1.7% 1.6% 1.6% 1.5% 1.5% 1% 0.6% 0.5% 0% -0.5% -1% b c a United United OECD Germany Japan Netherlands New France Australia Canada a Kingdom States Median Zealand a THE 1993–2002 COMMONWEALTH b1992–2002 FUND c1991–2003 Source: OECD Health Data 2005. 62 Chart VII-5 Average Annual Number of Physician Visits per Capita in 2003 15 14.1 10 6.9 6.2 6.2 6.0 5.6 5.2 5 4.0 3.6 0 a a b a Japan France Canada OECD Australia Netherlands United New United a Median Kingdom Zealand States THE COMMONWEALTH a FUND 2002 b2001 Source: OECD Health Data 2005, New Zealand Health Survey 2002–2003. 63 VIII. Nursing THE COMMONWEALTH FUND 64 Chart VIII-1 Number of Practicing Nurses per 1,000 Population in 2003 15 12.8 10.2 9.8 9.7 9.7 10 9.2 9.1 7.9 7.8 7.3 5 0 b NetherlandsAustralia Canada Germany United OECD New United Japan France a Kingdom Median Zealand States THE COMMONWEALTH a FUND 2002 b2001 Source: OECD Health Data 2005. 65 Chart VIII-2 Number of Practicing Nurses per Acute Care Bed in 2003 2.0 1.8 1.5 1.5 1.4 1.0 0.9 0.8 0.5 0.5 0.0 a a United Australia United States OECD Median Germany France Kingdom THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005. 66 IX. Pharmaceuticals THE COMMONWEALTH FUND 67 Chart IX-1 Pharmaceutical Spending per Capita in 2003 Adjusted for Differences in Cost of Living $800 $728 $606 $600 $507 $436 $393 $400 $353 $347 $340 $200 $0 a a United France Canada Germany Japan Australia OECD Netherlands States Median THE COMMONWEALTH FUND a 2002 Source: OECD Health Data 2005. 68 Chart IX-2 Average Annual Growth Rate of Real Spending per Capita on Pharmaceuticals, 1993–2003 10% 9.4% 9.0% 8% 6.3% 6% 4.7% 4.6% 4.4% 4% 3.5% 2% 1.1% 0% b a Australia United Canada OECD France Netherlands Germany Japan States Median THE COMMONWEALTH FUND a1993–2002 b Source: OECD Health Data 2005. 1993–2001 69 Chart IX-3 Relative Prices of Thirty Pharmaceuticals in Four Countries in 2003 Assuming No Discount for U.S. Purchasers $100 $100 $75 $53 $48 $50 $41 $25 $0 United States United Kingdom Canada France THE COMMONWEALTH FUND Source: G. F. Anderson et al., “Doughnut Holes and Price Controls,” Health Affairs Web Exclusive (July 21, 2004): W4-396–W4-404. 70 Chart IX-4 Percentage of Total Population with Pharmaceutical Goods Coverage Through Public Programs in 2003 100.0% 100.0% 100.0% 100.0% 100.0% 99.9% 100% 90.1% 80% 62.6% 60% 50.0% 40% 20% 0% a Australia Japan New OECD United France Germany Netherlands Canada Zealand Median Kingdom THE COMMONWEALTH FUND a Source: OECD Health Data 2005. 2002 71 Chart IX-5 Percentage of Population over Age 65 with Influenza Immunization in 2003 80% 77.0% 76.9% 71.0% 67.0% 65.5% 62.4% 62.0% 60% 56.1% 48.0% 43.0% 40% 20% 0% b a Netherlands Australia United France United Canada New OECD Germany Japan a Kingdom States Zealand Median THE COMMONWEALTH FUND a2002 b2001 Source: OECD Health Data 2005. 72 X. Medical Procedures Involving Sophisticated Technology THE COMMONWEALTH FUND 73 Chart X-1 Magnetic Resonance Imaging (MRI) Units per Million Population in 2003 40 35.3 30 20 10 8.6 6.0 5.6 5.2 4.5 3.7 3.7 2.8 0 a a Japan United Germany OECD United Canada Australia New France a b States Median Kingdom Zealand THE COMMONWEALTH FUND a2002 b2001 Source: OECD Health Data 2005. 74 Chart X-2 Computer Tomography (CT) Scanners per Million Population in 2003 100 92.6 80 60 40 20 14.2 13.1 13.1 11.5 10.3 8.4 5.8 0 a a Japan Germany OECD United New Canada France United a b Median States Zealand Kingdom THE COMMONWEALTH a FUND 2002 b Source: OECD Health Data 2005. 2001 75 Chart X-3 Cardiac Catheterization Procedures per 100,000 Population in 2003 794 800 600 425 386 400 303 302 231 189 200 14 0 b a a Germany United France Australia OECD Canada Netherlands United States Median Kingdom THE COMMONWEALTH a FUND 2002 b Source: OECD Health Data 2005. 2001 76 Chart X-4 Percutaneous Transluminal Coronary Angioplasty (PTCA) Interventions per 100,000 Population in 2003 450 426 400 350 300 270 250 200 156 140 130 150 130 99 93 92 100 50 0 b a a United Germany France Canada Australia OECD United Netherlands New States Median Kingdom Zealand THE COMMONWEALTH a FUND 2002 b Source: OECD Health Data 2005. 2001 77 Chart X-5 Coronary Bypass Procedures per 100,000 Population in 2003 200 181 175 150 125 98 97 100 87 82 75 65 56 53 50 41 25 0 a a b United Canada New Germany Australia OECD United Netherlands France b States Zealand Median Kingdom THE COMMONWEALTH FUND a2002 b Source: OECD Health Data 2005. 2001 78 Chart X-6 Number of Knee Replacements per 100,000 Population in 2003 175 155 144 150 125 111 107 100 92 92 85 75 54 50 25 0 a b United Australia United Netherlands Canada OECD France New States Kingdom Median Zealand THE COMMONWEALTH a FUND 2002 b Source: OECD Health Data 2005; AIHW Australian Hospital Statistics 2003–04. 2001 79 Chart X-7 Number of Patients Undergoing Dialysis Treatment per 100,000 Population in 2003 200 184 175 149 150 125 100 71 75 54 45 42 50 39 33 25 0 a Japan United Germany Canada OECD New Australia United a a States Median Zealand Kingdom THE COMMONWEALTH FUND a Source: OECD Health Data 2005. 2002 80 XI. Non-Medical Determinants of Health THE COMMONWEALTH FUND 81 Chart XI-1 Percentage of Adults Who Reported Being Daily Smokers in 2003 34.0% 35% 30.3% 30% 28.6% 26.4% 26.0% 25.0% 24.3% 25% 20% 17.5% 17.4% 17.0% 15% 10% 5% 0% c b a Netherlands Japan France OECD United New Germany United Australia Canada Median Kingdom Zealand States THE a2004 COMMONWEALTH FUND b2002 Source: OECD Health Data 2005; AIHW 2004 National c2001 Drug Strategy Household Survey: First Results, 2005. 82 Chart XI-2 Decreases in Smoking Rates Between 1983–2003 United OECD New United a b Australia States Canada Median Japan Netherlands Zealand Kingdom 0% -5% -8.0% -8.0% -8.0% -10% -9.5% -10.3% -15% -14.2% -14.6% -18.0% -20% THE COMMONWEALTH FUND a1983–2004 b Source: OECD Health Data 2005. 1983–2001 83 Chart XI-3 Annual Alcohol Consumption in Liters per Capita for People Age 15 and Older in 2003 14.8 15 11.2 10.2 9.8 9.8 9.6 10 8.9 8.3 7.8 5 0 a a a a France United Germany Australia Netherlands OECD New United Canada a Kingdom Median Zealand States THE COMMONWEALTH FUND a Source: OECD Health Data 2005. 2002 84 Chart XI-4 Obesity (BMI>30) Prevalence in 2003 35% 30.6% 30% 25% 23.0% 20.9% 20.8% 20% 14.3% 15% 12.9% 12.9% 10.0% 9.4% 10% 5% 3.2% 0% b a a United United New Australia Canada OECD Germany Netherlands France Japan a States Kingdom Zealand Median THE COMMONWEALTH a Source: OECD Health Data 2005; AIHW Australian FUND 2002 b Diabetes, Obesity and Lifestyle Study 1999–2000. 1999/2000 85 Chart XI-5 Changes in Obesity Rates, 1993–2003 10% 8.0% 8% 7.3% 6% 3.9% 4% 2.8% 2% 1.6% 0.8% 0% a a United United Netherlands France Canada Japan b Kingdom States THE COMMONWEALTH a FUND 1993–2002 b Source: OECD Health Data 2005. 1991–2002 86 XII. Mortality THE COMMONWEALTH FUND 87 Chart XII-1 Life Expectancy at Birth in 2003 Female Male 90 85.3 82.9 82.8 82.1 81.3 81.1 81.1 80.9 80.7 79.9 78.4 77.8 77.2 80 75.8 75.5 76.3 75.5 76.2 76.2 74.5 70 60 50 40 30 20 10 0 a Japan France Australia Canada Germany New OECD Netherlands United United a a Zealand Median Kingdom States THE COMMONWEALTH FUND a2002 Source: OECD Health Data 2005. 88 Chart XII-2 Life Expectancy at Age 65 in 2003 25 Female Male 23.0 21.3 21.0 20.6 20.0 19.6 19.6 19.5 19.5 19.1 20 18.0 17.6 16.9 17.2 16.7 16.6 16.0 16.1 15.8 16.1 15 10 5 0 b a b Japan France Australia Canada New Germany OECD Netherlands United United a a a Zealand Median States Kingdom THE COMMONWEALTH FUND a2002 b2001 Source: OECD Health Data 2005. 89 Chart XII-3 Increases in Life Expectancy at Birth, 1983–2003 6 5.7 Female Male 5.5 5.4 5.1 4.8 4.8 4.9 5 4.5 4.2 4.1 4.0 4.0 3.9 4 3.8 3.5 3.4 3.3 3 2.4 2 1.8 1.3 1 0 a Japan France Australia Germany New OECD United Canada United Netherlands a a Zealand Median Kingdom States THE COMMONWEALTH FUND a Source: OECD Health Data 2005. 1993–2002 90 Chart XII-4 Increases in Life Expectancy at Age 65, 1983–2003 5 4.6 Female Male 4 3.4 3.1 2.9 2.9 3 2.8 2.7 2.7 2.7 2.7 2.6 2.4 2.4 2.2 2.1 2.1 2.0 2 1.4 1.2 0.9 1 0 b b a Japan France Australia Germany New OECD United Canada Netherlands United a a b Zealand Median Kingdom States THE COMMONWEALTH FUND a1993–2002 b1993–2001 Source: OECD Health Data 2005. 91 Chart XII-5 Breast Cancer Five-Year Relative Survival in 1997 100% 85.5% 79.8% 79.4% 78.0% 80% 74.7% 60% 40% 20% 0% a United States Australia New Zealand Canada England THE COMMONWEALTH FUND a2000 Source: Commonwealth Fund International Working Group on Quality Indicators. 92 Chart XII-6 Breast Cancer Screening in 2001 Percentage of Women Receiving a Mammogram 100% Survey Organized Program 80% 73.0% 72.0% 70.0% 70.0% 63.0% 60% 40% 20% 0% a Canada Australia United States England New Zealand THE COMMONWEALTH FUND a1999 Source: Commonwealth Fund International Working Group on Quality Indicators. 93 Chart XII-7 Kidney Transplant Five-Year Survival in 2001 100% 93.7% 88.0% 86.0% 86.0% 83.0% 80% 60% 40% 20% 0% a a Canada Australia England New Zealand United States THE COMMONWEALTH FUND a2000 Source: Commonwealth Fund International Working Group on Quality Indicators. 94 XIII. Country Summaries THE COMMONWEALTH FUND 95 The Australian Health Care System Who is covered? • Private Insurance: Mainly not-for-profit mutual insurers cover the gap between Medicare benefits and schedule fees for inpatient services. • Australia’s public health insurance scheme, Medicare, provides Doctors may bill above the scheduled fee. Private insurers also cover universal coverage for citizens, permanent residents, and visitors from private hospital accommodations, choice of specialists, and avoidance countries that have reciprocal arrangements with Australia. of queues for elective surgery. What is covered? • Private insurance covers 49 percent of the population (43 percent have • Services: Free or subsidised access to most medical services; inpatient hospital cover with nearly all of these also having ancillary cover, whilst and outpatient hospital care; physician services; some allied health 6 percent of the population are covered for ancillary services only). services for the chronically ill; inpatient and outpatient drugs; specified Expenditure by private health insurance funds accounts for 7.1 percent optometric and dental surgery services; mental health care; and of total health expenditure. Through a rebate, 30 percent of private rehabilitation. Free choice of general practitioner. health insurance premiums are paid by the Australian government. The rebate increases to 35 percent for people aged 65 to 69 years, and to 40 • Cost-sharing: Medicare reimburses 75 percent of the scheduled fee for percent for those aged 70 years and over. private inpatient services and 85 percent to 100 percent of ambulatory services. Doctors are free to charge above the scheduled fee, or they How is the delivery system organized? can treat patients for the cost of the subsidy and bill the government • Physicians: Primary care physicians act as gatekeepers. Physicians are directly, with no patient charge (referred to as bulk billing). There is a generally reimbursed by a fee-for-service system. The government sets bulk-billing incentive scheme and almost 75 percent of medical services the fee schedules, but these are not maximum prices. are bulk billed. Prescription pharmaceuticals have a patient copayment. Out-of-pocket payments account for 19.7 percent of total health • Hospitals: Mostly public, run by the states. The states pay for public expenditures. hospitals with Australian government assistance negotiated via five yearly agreements. Physicians in public hospitals are either salaried • Safety nets: A Medicare safety net for non-inpatient services, and a (but may have private practices and fee-for-service income) or paid on a separate pharmaceutical safety net, protect against high out-of-pocket per-session basis. costs. • Government: The Australian government has control over hospital How are revenues generated? benefits, pharmaceuticals, and medical services. States are charged • National Health Insurance (Medicare): Compulsory national health with operating public hospitals and regulating all hospitals, nursing insurance administered by the Australian (federal) government. National homes, and community-based general services. health insurance is funded by a mixture of general tax revenue, a 1.5 How are costs controlled? percent levy on taxable income (accounting for 17.3 percent of federal outlays on health) and fees paid by patients. Additionally, a Medicare • Australia controls its health care costs through a combination of global Levy Surcharge applies to high-income individuals without private health hospital budgets, fee schedules, limited diffusion of technology, insurance for hospital coverage. Government funds almost 70 percent of copayments for pharmaceuticals, and waiting lists. The government also total health expenditures (46 percent federal and 22 percent state/local). restricts the number of medical students and Medicare-licensed providers. THE COMMONWEALTH FUND 96 The Canadian Health Care System Who is covered? drugs, rehabilitation services, private care nursing, and private rooms in hospitals. Private health expenditures represent approximately 30 • Coverage is universal for eligible residents of Canada. percent of total health expenditures. What is covered? How is the delivery system organized? • Services: Through the Canada Health Act, the federal government • Physicians: Most physicians are in group or private practices and requires that provincial and territorial health insurance plans cover all remunerated on a fee-for-service basis. However, many Canadian medically necessary physician and hospital services to qualify for full physicians receive some payment for clinical care through alternative federal transfers. The federal government is also directly responsible for public payment plans. In 2002–03, about 17.5 percent of total clinical health care services for specific groups, including the Royal Canadian payments to physicians were made through these types of Mounted Police, serving members of the armed forces, eligible arrangements. Provincial/territorial medical associations generally veterans, First Nations individuals living on reserves, the Inuit, and negotiate the fee schedule for insured services with provincial/territorial inmates in federal penitentiaries. health ministries. Physicians must opt out of the public system of • Supplementary benefits: Provincial and territorial governments also payment to have the right to charge their own rates for medically provide supplementary benefits for certain groups such as senior necessary services. citizens and social assistance recipients. Benefits include services such • Nurses: Most nurses are primarily employed either in hospitals or by as prescription drugs, dental care, home care, aids to independent community health care organizations, including home care and public living, and ambulance services. health services. Nurses are generally paid salaries negotiated between • Cost-sharing: No cost-sharing for insured physician and hospital their unions and their employers. services. However, there may be charges for other, non-insured • Other health professionals: Dentists, optometrists, therapists, services. psychologists, pharmacists, and public health inspectors may be How are revenues generated? employed or self-employed, and are generally paid salaries negotiated between their unions and their employers. • Publicly funded health care: Public health insurance plans are administered by the provinces/territories and generally funded by • Hospitals: Mainly public and private non-profit hospitals that operate general taxation. Three provinces charge additional health care under annual, global budgets. Budgets are negotiated with the premiums. Federal transfers to provinces/territories are tied to provincial/territorial ministries of health or regional health authority, with population and other factors and are conditional on meeting the some fee-for-service payment. principles of the Canada Health Act. Public funding accounts for • Government: Provincial/territorial governments have the authority to approximately 70 percent of total health expenditures. regulate health providers. However, they typically delegate control over • Privately funded health care: Many Canadians have supplemental physicians and other providers to professional “colleges,” which license private insurance coverage through group plans, which extend the providers and set standards for practice. range of insured services to include vision and dental care, prescription How are costs controlled? • Cost-control measures include mandatory annual global budgets for hospitals/health regions, negotiated fee schedules for health care THE providers, formularies for public drug plans and limits on the diffusion of COMMONWEALTH FUND technology. 97 The German Health Care System Who is covered? How is the delivery system organized? • Up to the determined income level, every employee must enroll with • Physicians: General practitioners (GPs) have no formal gatekeeping any of the Sickness Insurance Funds (SIFs) offering the same function. However, in 1994, special GP contracts required all SIFs to comprehensive health care coverage. Individuals above that income offer at least one model of GP gatekeeping to their enrollees. All level have the right to opt out and obtain private coverage instead. physicians in the outpatient sector are paid on a fee-for-service basis. Representatives of the SIFs negotiate with the regional associations of What is covered? physicians to determine aggregate payments. • Services: Statutory benefit package includes preventive services; • Hospitals: Hospitals are mainly non-profit, both private and public. They inpatient and outpatient hospital care; physician services; mental health are staffed with salaried doctors. Senior doctors may also treat privately care; dental care; prescription drugs; rehabilitation; and sick leave insured patients on a fee-for-service basis. Representatives of the SIFs compensation. Long-term care is covered by a separate insurance negotiate payment rates with hospitals at the regional level. A new scheme. Free choice of ambulatory care physicians. payment system based on diagnosis-related group per-admission • Cost-sharing: Traditionally few cost-sharing provisions confined to payments was introduced in 2004. copayments for all services and products. Out-of-pocket payments • Government: The German government delegates regulation to the self- (glasses, OTC drugs, others) accounted for 11 percent of health governing corporatist bodies of both the SIFs and the medical providers’ care expenditures. associations. However, given lack of efficacy and compliance, the How are revenues generated? government is increasingly willing to replace the self-regulating system and delegate more purchasing powers to the SIFs. • Sickness Insurance Funds: There are approximately 249 SIFs— autonomous, not-for-profit, nongovernmental, although regulated by How are costs controlled? the government, bodies. They are funded by compulsory payroll • The government imposes sector-wide budgets for physician and contributions averaging 14.2 percent of wages, equally shared by hospital services. Budget ceilings for prescription drugs were abolished employers and employees. SIFs cover approximately 88 percent of the in early 2001, leading to an unprecedented increase of expenditures for population. Dependents are covered through the primary SIF enrollee. pharmaceuticals and increasing financial strain on the SIFs. Health care While the unemployed continue to contribute to the SIF proportionate reforms in the 90s included increased competition among sickness to their unemployment entitlements, health care costs incurred by funds; the introduction of a per-admission hospital payment system; the welfare recipients, asylum seekers, and the homeless, are financed control of physician supply; and moderate cost-sharing provisions. through general revenues. In 1998, SIFs accounted for 81 percent of health care expenditures. • Private insurance: Private insurance, which provides health insurance based on voluntary, individual premiums, covers 8.1 percent of the population, including the affluent, the self-employed, and civil servants. Private insurance accounts for 8 percent of health care expenditures. THE COMMONWEALTH FUND 98 The Dutch Health Care System Who is covered? • Cost-sharing: Each insurance arrangement, including public sickness funds and private plans, require some form of cost-sharing, including • Public and private coverage is nearly universal. copayments and deductibles. All those insured by the ZFW incur a What is covered? 20 percent co-insurance rate. • Normal, necessary medical care. How are revenues generated? – The Sickness Funds Act (ZFW) compulsorily insures people • The AWBZ is funded by premiums paid by people covered under the whose annual salary falls below a statutory ceiling and all scheme, local taxes, and government subsidies. recipients of social security benefits, up to age 65. This covers • Contributions through the tax system to the national government provide about 65 percent of the population. funding for all national health insurance schemes. A portion of employed – Other health insurance schemes cover various categories of civil individuals’ income is deducted by employers and paid to the national servants, accounting for around 5 percent of the population. health insurance funds. The percentage withheld corresponds to level of income. Those insured by the ZWF pay an additional non-income- – Those not covered by the ZFW or schemes for civil servants can related premium. obtain private health insurance coverage on a voluntary basis. Approximately 30 percent of the population is privately insured. • Local taxation: Local taxes are a supplementary source of funding for most health insurance arrangements. – Beginning January 1, 2006, all citizens will have compulsory basic insurance, the distinction between private and public • Central government grants and payments: A series of grants are insurance will no longer apply. Insurers will be obliged to accept available for the purchase of services not covered by entitlement patients for this basic insurance, and will need to compete on programs. These include services earmarked for future inclusion in the price and quality. entitlement package, as well as innovative forms of care. The central government also uses a portion of general revenues to supplement • Long-term care and high-cost treatments are covered for all by the funding of entitlement programs. Exceptional Medical Expenses Act (AWBZ). • Out-of-pocket expenditures account for approximately 9 percent of total • Public universal insurance for “exceptional medical expenses,” including health care costs. Four percent is covered by copayments under the long-term care, mental health, etc. Compulsory social health insurance AWBZ, 2 percent by copayments and deductibles under the ZFW, and 3 for the low income, voluntary private health insurance for the high percent by direct payments for private complementary or supplementary income, and voluntary supplemental insurance for all. Ambulatory care insurance plans. Those covered by private insurance pay a nominal is provided by independent GPs, who mostly work in private practices. premium, averaging $1,277 (USD) in 2003. Beginning in 200, all Almost all Dutch citizens have regular GPs, who handle 95 percent of patients will have compulsory basic insurance with a nominal premium health problems within primary care practices. Patients with more of about $1,300–$1,400 (USD) and an income-related premium add-on. complex problems are referred to other care providers. • Private insurance: Private insurance coverage is funded out of premiums and cost sharing. Those who opt for private coverage are required to pay “solidarity” contributions to the national health insurance scheme. A portion of each individual’s premium accounts for this THE contribution. Private insurance packages are available as stand-alone COMMONWEALTH and supplementary coverage. FUND 99 The Dutch Health Care System (continued) How is the delivery system organized? • Government: Much of the responsibility for managing the health insurance schemes is handled at the regional level. Thirty-one regional • Physicians: Physicians practice under national contracts negotiated by health care offices carry out duties such as contracting with providers, health insurers and providers’ representative organizations. GPs are collecting patient contributions, and organizing regional alliances. The paid on a capitation basis for patients insured under the ZFW and on a national government approves all contracts negotiated between regional fee-for-service basis for privately insured patients. Beginning in 2006, councils, insurers, and providers. GPs will receive a capitation payment for each patient on the practice list and a fee per consultation. Additional budgets can be negotiated for How are costs controlled? extra services, practice nurses, complex locations, etc. Experiments • Providers negotiate contracts that dictate the volume of services to with pay-for-performance quality are underway. Specialists working in be delivered, as well as charges to be assessed to users. These hospitals are self-employed, and are paid a capitated amount based on contracts are subject to the approval of the national government, which negotiations between insurers and specialists’ organizations. Some sets limits on the amounts that doctors, hospitals, and nursing homes specialists are paid on a fixed income/salaried basis and have contracts can charge. Costs are expected to be increasingly controlled by the with the hospitals. Future payment will be related to a new payment new DBC system in which hospitals have to compete on price for system, Diagnose Treatment Combination (DBC). specific medical interventions. • Hospitals: The majority of hospitals are private and non-profit. Hospital budgets are based on a formula that pays a fixed amount per bed, patient volume, and number of licensed specialists, in addition to other considerations. Additional funds are provided for capital purchases. As of 2000, payments to hospitals are rated according to performance on a number of accessibility indicators. Hospitals that produce fewer inpatient days than agreed with health insurers are paid less, a measure designed to reduce waiting lists. A new payment system, DBC, is currently being introduced, and 10 percent of all medical interventions are now reimbursed on the basis of these DBCs. In some experimental hospitals, 100 percent of all interventions are based on DBCs. It is expected that most future care will be defined under this new system, although there is debate regarding its feasibility. THE COMMONWEALTH FUND 100 The New Zealand Health Care System Who is covered? How is the delivery system organized? • All New Zealand residents have access to a broad range of health services • Physicians: GPs act as gatekeepers and are independent, self-employed with substantive government funding. providers paid through a combination of payment methods: fee-for-service with partial government subsidy, mostly capitation funded through PHOs. What is covered? Consultants (specialists) working for DHBs are salaried but may supplement • Services: Public health preventive and promotional services; inpatient their salaries through treatment of private patients in private (noncrown) and outpatient hospital care; primary health care services; inpatient and hospitals. outpatient prescription drugs; mental health care; dental care for school • Primary Health Organisation: The government has injected substantial children; and disability support services. Free choice of general practitioner. additional funding into subsidising primary health care to improve access to • Cost-sharing: Copayments are required for general practitioner (GP) and services. From July 2002 to date, 79 PHOs have been formed under general practice nurse primary health care services, and non-hospital government policy to reduce health disparities and take a population prescription drugs. Health care is substantially free for children under approach to primary health care. Ninety-two percent of the New Zealand age 6 and is partially subsidized for most other people depending on age population is now enrolled with and receiving care from PHOs. PHOs will and income. Patient copayments account for 16 percent of health care have a range of different clinical and non-clinical health practitioners on staff expenditures (2002–03). and be funded partly by capitation and partly by fee-for-service. By July 2007, all New Zealanders will be able to receive low cost access to primary How are revenues generated? health services provided by PHOs. • General taxation: Public funding is derived from taxation. It accounts for • District Health Boards: The DHBs (21 in the country) are partly elected by about 78.3 percent of health care expenditures (2003–04). the people of a geographic area and partly appointed by the Minister of • The government sets a global budget annually for publicly funded health Health. They are responsible for determining the health and disability services. This is distributed to District Health Boards (DHBs). DHBs support service needs of the population living in their districts, and planning, provide services at government-owned facilities (about one-half, by value, providing, and purchasing those services. A board’s organization has a of all health services) and purchase other services from privately owned funding arm and a service provision arm, operating government-owned providers, such as GPs, most of whom are grouped as Primary Health hospitals, health centers, and community services. Organizations (PHOs), disability support services, and community care. • Government: New Zealand’s government has responsibility for legislation, • Patient copayments: People pay fee-for-service co-payments to GPs and regulation, and general policy matters. It funds 78.3 percent of health care for pharmaceuticals, and for some private hospital or specialist care and expenditures and owns DHB assets. adult dental care. In addition, complementary and alternative medicines How are costs controlled? and therapies are paid for out-of-pocket. • The government sets an annual publicly funded health budget. In addition, • Private insurance: Not-for-profit insurers generally cover private medical care. New Zealand is shifting from open-ended, fee-for-service arrangements to Private insurance is most commonly used to cover cost-sharing requirements, contracting and funding mechanisms such as capitation. Booking systems elective surgery in private hospitals, and specialist outpatient consultations. are being introduced to replace waiting lists to ensure that elective surgery About one-third of New Zealanders have private health services are targeted to those people best able to benefit. Early intervention, insurance, accounting for approximately 6 percent of total health promotion, and disease prevention are being emphasized in primary health care expenditures. THE care and by DHBs. COMMONWEALTH FUND 101 The British Health Care System Who is covered? How is the delivery system organized? • Coverage is universal. • Physicians: General practitioners (GPs) act as gatekeepers and are brought together in Primary Care Trusts (PCTs), with budgets for most of What is covered? the care of their enrolled population and responsibility for the provision of • Services: Publicly funded coverage (the National Health Service) primary and community services. Most GPs are paid directly by the includes preventive services; inpatient and outpatient hospital care; government through a combination of methods: salary, capitation, and physician services; inpatient and outpatient drugs; dental care; mental fee-for-service. Some, however, are employed locally and a new GP health care; and rehabilitation. Free choice of general practitioner. contract will introduce greater use of local contracting and introduce quality incentives. Private providers set their own fee-for-service rates • Cost-sharing: There are relatively few cost-sharing arrangements for but are not generally reimbursed by the public system. covered services. For example, drugs prescribed by family doctors are subject to a prescription charge, but many patients are exempt. • Hospitals: Mainly semi-autonomous, self-governing public trusts that Dentistry services are subject to copayments. Out-of-pocket payments contract with PCTs. Recently, some routine elective surgery has been account for 8 percent of health expenditures. procured for NHS patients from purpose-built Treatment Centers, which may be owned and staffed by private sector health care providers. How are revenues generated? Consultants (i.e., specialist physicians) work mainly in NHS Trust • National Health Service (NHS): The NHS is administered by the NHS hospitals but may supplement their salary by treating private patients. Executive, Department of Health, and by the Health Authorities. In 1997, • Government: Responsibility for health legislation and general policy the new government shifted from the internal market to integrated care, matters rests with Parliament at Westminster and in Scotland and with partnership, and long-term service agreements between providers and the Assemblies in Wales and Northern Ireland. commissioners. More recent policy developments include an expansion of patient choice and a move to case-mix reimbursement of hospitals. How are costs controlled? The NHS, which is funded by a mixture of general taxation and national • The government sets the budget for the NHS on a three-year cycle. To insurance contributions, accounts for 88 percent of health expenditures. control utilization and costs, the United Kingdom has controlled physician • Private insurance: Mix of for-profit and not-for-profit insurers covers training, capital expenditure, pay, and PCT revenue budgets. There are private medical care, which plays a complementary role to the NHS. also waiting lists. In addition, a centralized administrative system results Private insurance offers choice of specialists, avoidance of queues for in lower overhead costs. Other mechanisms contributing to improved elective surgery, and higher standards of comfort and privacy than the value include arrangements for the systematic appraisal of new NHS. Private insurance covers 12 percent of the population and technologies (i.e., the National Institute for Clinical Excellence) and for accounts for 4 percent of health expenditures. monitoring the quality of care delivered (i.e, the Healthcare Commission). THE COMMONWEALTH FUND 102 The United States Health Care System Who is covered? individuals, or it can be funded by voluntary premium contributions shared by employers and employees on a negotiable basis. Private • Public and private health insurance covers 84 percent of the population. insurance covers 68 percent of the population, including individuals In 2004, 45.8 million were uninsured. covered by both public and private insurance. It accounts for 36 percent What is covered? of total health expenditures. • Services: Benefit packages vary according to type of insurance, but • Others: Private and public funds account for 18 percent of expenditures. often include inpatient and outpatient hospital care and physician How is the delivery system organized? services. Many also include preventive services, dental care, and prescription drug coverage. • Physicians: General practitioners have no formal gatekeeper function, except within some managed care plans. The majority of physicians are • Cost-sharing: Cost-sharing provisions vary by type of insurance. Out-of- in private practice. They are paid through a combination of methods: pocket payments account for 14 percent of health expenditures. charges, discounted fees paid by private health plans, capitation rate How are revenues generated? contracts with private plans, public programs, and direct patient fees. • Medicare: Social insurance program for the elderly, some of the • Hospitals: For-profit, non-profit, and public hospitals are paid through a disabled under age 65, and those with end-stage renal disease. combination of methods: charges, per admission, and capitation. Administered by the federal government, Medicare covers 14 percent of • Government: The federal government is the single largest health care the population. The program is financed through a combination of insurer and purchaser. payroll taxes, general federal revenues, and premiums. It accounts for 17 percent of total health expenditures. Beginning January 2006, How are costs controlled? Medicare will be expanded to cover outpatient prescription drugs. • Payers have attempted to control cost growth through a combination of • Medicaid: Joint federal-state health insurance program covering certain selective provider contracting, discount price negotiations, utilization groups of the poor. Medicaid also covers nursing home and home control practices, risk-sharing payment methods, and managed care. health care and is a critical source of coverage for frail elderly and the • Recently, the Medicare Prescription Drug, Improvement, and disabled. Medicaid is administered by the states, which operate within Modernization Act of 2003 included new provisions for tax credits for broad federal guidelines. It covers 13 percent of the population and Health Savings Accounts (HSAs) when coupled with high deductible accounts for 16 percent of total health expenditures. (i.e., $1,000 or more) health insurance plans. HSAs allow individuals to • Private Insurance: Provided by more than 1,200 not-for-profit and for- save money tax-free to use on out-of-pocket medical expenses. Tax profit health insurance companies regulated by state insurance incentives plus double-digit increases in premiums have led to a shift in commissioners. Private health insurance can be purchased by benefit design toward higher patient payments. THE COMMONWEALTH FUND 103 XIV. Appendix: Notes and Definitions Overall • Definition: The 30 OECD countries are Australia, Austria, Belgium, Canada, the Czech Republic, Denmark, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, Mexico, the Netherlands, New Zealand, Norway, Poland, Portugal, Slovak Republic, Spain, Sweden, Switzerland, Turkey, the United Kingdom, and the United States. • Method: OECD Median: Throughout the chartbook, there must be data from at least 15 of the 30 countries to present the OECD median. Missing data are substituted with data from the closest years (±3 years) for calculation of the median. II. Total Health Care Spending II-1. Health Care Spending per Capita in 2003 • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. II-2. Average Annual Growth Rate of Real Health Care Spending per Capita, 1993–2003 • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2004. • Method: The average annual growth rates are calculated in units of each country’s national currency adjusting for general inflation using each country’s GDP price deflator. II-3. Average Annual Growth Rate of Real Health Care Spending per Capita, 1983–2003, 1993–2003 • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. • Method: The average annual growth rates are calculated in units of each country’s national currency adjusting for general inflation using each country’s GDP price deflator. THE COMMONWEALTH FUND 104 II-4. Percentage of Gross Domestic Product Spent on Health Care in 2003 • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. • Definition: Gross domestic product (GDP) is defined as total final expenditures at purchasers’ prices (including the free on board value of goods and services) less the value of imports of goods and services. II-5. Percentage of Gross Domestic Product Spent on Health Care, 1993–2003 • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. • Definition: Gross domestic product (GDP) is defined as total final expenditures at purchasers’ prices (including the free on board value of goods and services) less the value of imports of goods and services. III. Public and Private Health Care Financing III-1. Percentage of Total Population with Health Insurance Coverage through Public Programs in 2003 • Definition: The share of the population that is eligible to receive health care goods and services that are included in total public health spending. The percent covered is therefore independent of the scope of the coverage. III-2. Public Spending on Health Care per Capita in 2003 • Definition: Public spending on health includes all health expenditure incurred by state, regional and local government bodies and social security schemes. It does not reflect differences among countries in the sources of the public revenues. For example, there are differences among countries in the coverage provided by publicly financed health insurance. • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. THE COMMONWEALTH FUND 105 III-3. Private Spending on Health Care per Capita in 2003 • Definition: Private spending on health care includes private insurance programs, charities, and occupational health care. It does not reflect differences among countries in the sources of the private revenues. For example, the role of private insurance differs widely among OECD countries. • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. For Australia, figures are for “other private spending.” III-4. Out-of-Pocket Health Care Spending per Capita in 2003 • Definition: Out-of-pocket spending includes cost-sharing, self-medication, and other expenditures paid directly by private households, irrespective of whether the contact with the health care system is established on referral or on the patient’s own initiative. • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. III-5. Health Care Expenditure per Capita by Source of Funding in 2003 • Definition: Public spending on health includes all health expenditure incurred by state, regional and local government bodies and social security schemes. It does not reflect differences among countries in the sources of the public revenues. For example, there are differences among countries in the coverage provided by publicly financed health insurance. • Definition: Private spending on health care includes private insurance programs, charities, and occupational health care. It does not reflect differences among countries in the sources of the private revenues. For example, the role of private insurance differs widely among OECD countries. • Definition: Out-of-pocket spending includes cost-sharing, self-medication, and other expenditures paid directly by private households, irrespective of whether the contact with the health care system is established on referral or on the patient’s own initiative. IV. Health Spending by Type of Service IV-1. Distribution of Health Spending by Type of Service • Definition: Hospital spending refers to expenditures on inpatient care. Inpatient expenditures include curative, rehabilitative, and long-term nursing care for inpatients. Inpatient is a patient who is formally admitted (or “hospitalized”) to an institution for treatment and/or care and stays for a minimum of one night in the hospital or other institution providing inpatient care. Inpatient care is mainly delivered in hospitals, but partially also in nursing and residential care facilities or in establishments that are classified according to their focus of care under the ambulatory-care industry, but perform inpatient care as a secondary activity. Inpatient care includes accommodation provided in combination with medical treatment when the latter is the predominant activity provided during the stay as an inpatient. Although spending for hospital outpatient services is not included in this definition, there are differences in definitions between countries. THE COMMONWEALTH FUND 106 • Definition: Pharmaceutical spending includes all spending on pharmaceuticals and other medical non-durables including medicinal preparations, branded and generic medicines, drugs, patent medicines, serums and vaccines, vitamins and minerals, and oral contraceptives. • Definition: Spending on physician services includes expenditures on professional health services provided by general practitioners and specialists. The data also includes expenditures on services of osteopaths. • Definition: Spending for home health care includes all medical and paramedical services delivered to patients at home. IV-2. Percentage of Total Health Care Spending on Hospital Care in 2003 • Definition: Hospital spending refers to expenditures on inpatient care. Inpatient expenditures include curative, rehabilitative, and long-term nursing care for inpatients. Inpatient is a patient who is formally admitted (or “hospitalized”) to an institution for treatment and/or care and stays for a minimum of one night in the hospital or other institution providing inpatient care. Inpatient care is mainly delivered in hospitals, but partially also in nursing and residential care facilities or in establishments that are classified according to their focus of care under the ambulatory-care industry, but perform inpatient care as a secondary activity. Inpatient care includes accommodation provided in combination with medical treatment when the latter is the predominant activity provided during the stay as an inpatient. Although spending for hospital outpatient services is not included in this definition, there are differences in definitions between countries. • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. IV-3. Percentage of Total Health Care Spending on Hospital Care, 1993 and 2003 • Definition: Hospital spending refers to expenditures on inpatient care. Inpatient expenditures include curative, rehabilitative, and long-term nursing care for inpatients. Inpatient is a patient who is formally admitted (or “hospitalized”) to an institution for treatment and/or care and stays for a minimum of one night in the hospital or other institution providing inpatient care. Inpatient care is mainly delivered in hospitals, but partially also in nursing and residential care facilities or in establishments that are classified according to their focus of care under the ambulatory-care industry, but perform inpatient care as a secondary activity. Inpatient care includes accommodation provided in combination with medical treatment when the latter is the predominant activity provided during the stay as an inpatient. Although spending for hospital outpatient services is not included in this definition, there are differences in definitions between countries. • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. THE COMMONWEALTH FUND 107 IV-4. Percentage of Total Health Care Spending on Physician Services in 2003 • Definition: Spending on physician services includes expenditures on professional health services provided by general practitioners and specialists. The data also includes expenditures on services of osteopaths. • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. IV-5. Percentage of Total Health Care Spending on Physician Services, 1993 and 2003 • Definition: Spending on physician services includes expenditures on professional health services provided by general practitioners and specialists. The data also includes expenditures on services of osteopaths. • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. IV-6. Percentage of Total Health Care Spending on Pharmaceuticals in 2003 • Definition: Pharmaceutical spending includes all spending on pharmaceuticals and other medical non-durables including medicinal preparations, branded and generic medicines, drugs, patent medicines, serums and vaccines, vitamins and minerals, and oral contraceptives. • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. IV-7. Percentage of Total Health Care Spending on Pharmaceuticals, 1993 and 2003 • Definition: Pharmaceutical spending includes all spending on pharmaceuticals and other medical non-durables including medicinal preparations, branded and generic medicines, drugs, patent medicines, serums and vaccines, vitamins and minerals, and oral contraceptives. • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. THE COMMONWEALTH FUND 108 IV-8. Percentage of Total Health Care Spending on Long-Term Institutional Care and Home Health Care in 2003 • Definition: Spending for long-term institutional care includes all nursing care delivered to inpatients that need assistance on a continuing basis due to chronic impairments and a reduced degree of independence and activities of daily living. Inpatient long-term nursing care is provided in institutions or community facilities. Only health services are included, not social services. Spending for home care includes all medical and paramedical services delivered to patients at home. • Definition: Total health care spending includes personal health care (inpatient, ambulatory, medical goods), collective programs (promotion and prevention, maternal and child health, administration, etc.), and investment (physical assets as well as new knowledge). There are some differences in the specific definitions used in each country. For example, some private spending is not included in total health care spending for the United Kingdom and Japan. For complete definitions, please refer to OECD Health Data 2005. V. Hospitals V-1. Hospital Spending per Capita in 2003 • Definition: Hospital spending refers to expenditures on inpatient care. Inpatient expenditures include curative, rehabilitative, and long-term nursing care for inpatients. Inpatient is a patient who is formally admitted (or “hospitalized”) to an institution for treatment and/or care and stays for a minimum of one night in the hospital or other institution providing inpatient care. Inpatient care is mainly delivered in hospitals, but partially also in nursing and residential care facilities or in establishments that are classified according to their focus of care under the ambulatory-care industry, but perform inpatient care as a secondary activity. Inpatient care includes accommodation provided in combination with medical treatment when the latter is the predominant activity provided during the stay as an inpatient. Although spending for hospital outpatient services is not included in this definition, there are differences in definitions between countries. • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. V-2. Average Annual Growth Rate of Real Spending per Capita on Hospital Services, 1993–2003 • Definition: Hospital spending refers to expenditures on inpatient care. Inpatient expenditures include curative, rehabilitative, and long-term nursing care for inpatients. Inpatient is a patient who is formally admitted (or “hospitalized”) to an institution for treatment and/or care and stays for a minimum of one night in the hospital or other institution providing inpatient care. Inpatient care is mainly delivered in hospitals, but partially also in nursing and residential care facilities or in establishments that are classified according to their focus of care under the ambulatory-care industry, but perform inpatient care as a secondary activity. Inpatient care includes accommodation provided in combination with medical treatment when the latter is the predominant activity provided during the stay as an inpatient. Although spending for hospital outpatient services is not included in this definition, there are differences in definitions between countries. • Method: The average annual growth rates are calculated in units of each country’s national currency adjusting for general inflation using each country’s GDP price deflator. THE COMMONWEALTH FUND 109 V-3. Hospital Spending per Inpatient Acute Care Day in 2003 • Definition: Hospital spending refers to expenditures on inpatient care. Inpatient expenditures include curative, rehabilitative, and long-term nursing care for inpatients. Inpatient is a patient who is formally admitted (or “hospitalized”) to an institution for treatment and/or care and stays for a minimum of one night in the hospital or other institution providing inpatient care. Inpatient care is mainly delivered in hospitals, but partially also in nursing and residential care facilities or in establishments that are classified according to their focus of care under the ambulatory-care industry, but perform inpatient care as a secondary activity. Inpatient care includes accommodation provided in combination with medical treatment when the latter is the predominant activity provided during the stay as an inpatient. Although spending for hospital outpatient services is not included in this definition, there are differences in definitions between countries. • Definition: An inpatient acute care day is one during which a person is confined to a bed and in which the patient stays overnight in a hospital. Day cases (patients admitted for a medical procedure or surgery in the morning and released before the evening) are excluded. • Method: Hospital spending per day is calculated by the authors by dividing total hospital spending by the total number of acute care hospital days in each country. Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. V-4. Hospital Spending per Discharge in 2003 • Definition: Hospital spending refers to expenditures on inpatient care. Inpatient expenditures include curative, rehabilitative, and long-term nursing care for inpatients. Inpatient is a patient who is formally admitted (or “hospitalized”) to an institution for treatment and/or care and stays for a minimum of one night in the hospital or other institution providing inpatient care. Inpatient care is mainly delivered in hospitals, but partially also in nursing and residential care facilities or in establishments that are classified according to their focus of care under the ambulatory-care industry, but perform inpatient care as a secondary activity. Inpatient care includes accommodation provided in combination with medical treatment when the latter is the predominant activity provided during the stay as an inpatient. Although spending for hospital outpatient services is not included in this definition, there are differences in definitions between countries. • Definition: Discharge is the formal release of an inpatient from an acute care institution after a period of "hospitalization". It includes deaths in hospitals, but excludes same-day separations and transfers to other care units within the same institution. • Method: Hospital spending per discharge is calculated by dividing total hospital spending by the total number of discharges in each country. V-5. Hospital Discharges per 1,000 Population in 2003 • Definition: Discharge is the formal release of an inpatient from an acute care institution after a period of "hospitalization". It includes deaths in hospitals, but excludes same-day separations and transfers to other care units within the same institution. • Method: For Canada, data is for acute care hospitals only. For France, data includes same-day separations. For the United Kingdom, data include NHS admissions only (the private sector is excluded). Discharge rates are calculated by the OECD Secretariat. The number is expressed as discharges per 100,000 population in the OECD Health Data 2005. The authors re-calculated this ratio to express the number per 1,000 population. THE COMMONWEALTH FUND 110 V-6. Average Length of Stay for Acute Care in 2003 • Definition: Average length of stay (ALOS) is computed by dividing the number of days stayed (from the date of admission in an inpatient institution) by the number of separations (discharges plus deaths) during the year. • Definition: Acute care includes all types of medical care, excluding long-term care. It includes rehabilitative care, palliative care and acute psychiatric care. • Method: For the United Kingdom, data include NHS admissions only (the private sector is excluded). V-7. Average Length of Hospital Stay for Acute Myocardial Infarction in 2003 • Definition: Average length of stay (ALOS) is computed by dividing the number of days stayed (from the date of admission in an inpatient institution) by the number of separations (discharges plus deaths) during the year. • Definition: Acute myocardial infarction is defined as ICD-10 I21-I22 or ICD-9 410. • Method: Data on ALOS for New Zealand is based on public hospitals only. For the United Kingdom, data include NHS admissions only (the private sector is excluded). V-8. Average Length of Stay for Normal Delivery in 2003 • Definition: Average length of stay (ALOS) is computed by dividing the number of days stayed (from the date of admission in an inpatient institution) by the number of separations (discharges plus deaths) during the year. • Definition: Normal delivery is defined as ICD-10 O80 or ICD-9 650. • Method: Data on ALOS for New Zealand is based on public hospitals only. For the United Kingdom, data include NHS admissions only (the private sector is excluded). V-9. Average Annual Hospital Inpatient Acute Care Days per Capita in 2003 • Definition: An inpatient acute care day is one during which a person is confined to a bed and in which the patient stays overnight in a hospital. Day cases (patients admitted for a medical procedure or surgery in the morning and released before the evening) are excluded. V-10. Number of Acute Care Hospital Beds per 1,000 Population in 2003 • Definition: Acute care includes all types of medical care, excluding long-term care. It includes rehabilitative care, palliative care and acute psychiatric care. V-11. Hospital Employment per 1,000 Inpatient Acute Care Days in 2003 • Definition: Hospital employment includes the number of persons employed (head counts) and the number of full-time equivalent (FTE) persons employed in general and specialty hospitals. Self-employed are included. • Definition: An inpatient acute care day is one during which a person is confined to a bed and in which the patient stays overnight in a hospital. Day cases (patients admitted for a medical procedure or surgery in the morning and released before the evening) are excluded. THE • Method: Hospital employment per inpatient acute care days is calculated by the authors as the number of hospital employees divided by COMMONWEALTH inpatient acute care days. The ratio is multiplied by 1,000 to achieve the number of hospital employees per 1,000 inpatient acute care day. FUND 111 VI. Long-Term Care VI-1. Long-Term Institutional Care Spending per Capita in 2003 • Definition: Spending for long-term institutional care includes all nursing care delivered to inpatients that need assistance on a continuing basis due to chronic impairments and a reduced degree of independence and activities of daily living. Inpatient long-term nursing care is provided in institutions or community facilities. Only health services are included, not social services. • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. VI-2. Average Annual Growth Rate of Real Spending per Capita on Long-Term Institutional Care, 1993–2003 • Definition: Spending for long-term institutional care includes all nursing care delivered to inpatients that need assistance on a continuing basis due to chronic impairments and a reduced degree of independence and activities of daily living. Inpatient long-term nursing care is provided in institutions or community facilities. Only health services are included, not social services. • Method: The average annual growth rates are calculated in units of each country’s national currency adjusting for general inflation using each country’s GDP price deflator. VI-3. Home Health Care Spending per Capita in 2003 • Definition: Spending for home care includes all medical and paramedical services delivered to patients at home. • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. VI-4. Average Annual Growth Rate of Real Spending per Capita on Home Health Care, 1993–2003 • Definition: Spending for home care includes all medical and paramedical services delivered to patients at home. • Method: The average annual growth rates are calculated in units of each country’s national currency adjusting for general inflation using each country’s GDP price deflator. VI-5. Number of Long-Term Care Beds per 1,000 Population over Age 65 in 2003 • Definition: Long-term care beds include those for inpatients who need assistance on a continuing basis due to chronic impairments and a reduced degree of independence in activities of daily living. These beds can be provided in different institutional settings, including hospitals, nursing homes and the like. • Method: Some countries report only beds in nursing homes while others include beds in non-acute care hospitals (or hospital wards). The U.S. figures do not include day care beds. The figures refer to beds maintained (i.e., open and ready to receive patients). THE COMMONWEALTH FUND 112 VII. Physicians VII-1. Spending on Physician Services per Capita in 2003 • Definition: Spending on physician services includes expenditures on professional health services provided by general practitioners and specialists. The data also includes expenditures on services of osteopaths. • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed market basket of goods. The basket of goods used here is broad-based, not health-based. VII-2. Average Annual Growth Rate of Real Spending per Capita on Physician Services, 1993–2003 • Definition: Spending on physician services includes expenditures on professional health services provided by general practitioners and specialists. The data also includes expenditures on services of osteopaths. • Method: The average annual growth rates are calculated in units of each country’s national currency adjusting for general inflation using each country’s GDP price deflator. VII-3. Number of Practicing Physicians per 1,000 Population in 2003 • Definition: “Practicing physicians” is defined as the number of physicians, general practitioners, and specialists (including the self-employed) who are actively practicing medicine in public and private institutions. • Method: The number of practicing physicians includes foreign physicians licensed to practice and actively practicing medicine in the country. The data excludes dentists, stomatologists, qualified physicians who are working abroad, working in administration, research and industry positions. Differences exist across the countries in the types of services provided by physicians and in which practitioners are counted as physicians. The U.K. figures do not include the private sector or non-practicing physicians. VII-4. Average Annual Growth Rate of Practicing Physicians per 1,000 Population, 1993–2003 • Definition: “Practicing physicians” is defined as the number of physicians, general practitioners, and specialists (including the self-employed) who are actively practicing medicine in public and private institutions. • Method: The number of practicing physicians includes foreign physicians licensed to practice and actively practicing medicine in the country. The data excludes dentists, stomatologists, qualified physicians who are working abroad, working in administration, research and industry positions. Differences exist across the countries in the types of services provided by physicians and in which practitioners are counted as physicians. The U.K. figures do not include the private sector or non-practicing physicians. THE COMMONWEALTH FUND 113 VII-5. Average Annual Number of Physician Visits per Capita in 2003 • Definition: The annual number of physician visits per capita is defined as the number of contacts with an ambulatory care physician divided by the population. • Method: The number of contacts includes: visits/consultations of patients at the physician’s office; physician’s visits made to a person in institutional settings such as liaison visits or discharge planning visits, made in a hospital or nursing home with the intent of planning for the future delivery of service at home; telephone contacts when these are in lieu of a first home or hospital visit for the purpose of preliminary assessment at home; and visits made to the patient’s home. The number of physician contacts according to the above definition is only a crude measure of the volume of services provided. A simple comparison of physician visits per capita ignores differences in the duration of the visit, scope of services offered, quality of care provided, level of skill/training of the physician, and provision of outpatient surgery in physician offices. VIII. Nursing VIII-1. Number of Practicing Nurses per 1,000 Population in 2003 • Definition: “Practicing nurses” is defined as the total number of nurses certified/registered and actively practicing in public and private hospitals, clinics and other health care facilities, including the self-employed. This definition differs slightly in each country. • Method: Fully-qualified nurse (with post-secondary education in nursing) and associate/practical/vocational nurses (with a lower level of nursing skills but also usually registered) are included. The following are excluded: nursing aid/assistants and care workers who do not have any recognized qualification/certification in nursing; midwives (however registered nurses working part-time as midwives should be included), nurses working abroad, working in administrative, research and industry positions. France includes midwives. In France, the FTE method is used for nurses in public and private hospitals. The U.S. data includes nurse educators and nurses in hospitals, and nurse midwives. VIII-2. Number of Practicing Nurses per Acute Care Bed in 2003 • Definition: The number of nurses per acute care bed is defined as the number of full-time equivalent first- and second-level nurses employed in hospitals and other institutions, where the primary focus of activity is on acute care delivered to inpatients, divided by the number of available beds. The definition does not account for differences between countries in the severity of illness of hospitalized individuals. IX. Pharmaceuticals XI-1. Pharmaceutical Spending per Capita in 2003 • Definition: Pharmaceutical spending includes all spending on pharmaceuticals and other medical non-durables including medicinal preparations, branded and generic medicines, drugs, patent medicines, serums and vaccines, vitamins and minerals, and oral contraceptives. THE COMMONWEALTH • Method: Purchasing power parities are used to adjust for differences in cost of living across countries by comparing prices for a fixed FUND market basket of goods. The basket of goods used here is broad-based, not health-based. 114 IX-2. Average Annual Growth Rate of Real Spending per Capita on Pharmaceuticals, 1993–2003 • Definition: Pharmaceutical spending includes all spending on pharmaceuticals and other medical non-durables including medicinal preparations, branded and generic medicines, drugs, patent medicines, serums and vaccines, vitamins and minerals, and oral contraceptives. • Method: The average annual growth rates are calculated in units of each country’s national currency adjusting for general inflation using each country’s GDP price deflator. IX-3. Relative Prices of Thirty Pharmaceuticals in Four Countries in 2003 • Method: The price index is constructed by comparing the prices of the basket of 30 drugs (including generics) with highest sales in the United States. The price data are purchased from IMS Health, a private consulting firm. IX-4. Percentage of Total Population with Pharmaceutical Goods Coverage through Public Programs in 2003 • Definition: The share of the population that is eligible to receive a defined set of health care goods and services that are included in total public health spending. The percent covered is therefore independent of the scope of the coverage. IX-5. Percentage of Population over Age 65 with Influenza Immunization in 2003 • Definition: The proportion of people aged 65 and older who have been immunized against influenza during the last 12 months. • Method: Influenza vaccination rates are based on national surveys. Survey design and responses may differ across countries. For Germany, the age is 60 and older. X. Medical Procedures Involving Sophisticated Technology X-1. Magnetic Resonance Imaging (MRI) Units per Million Population in 2003 • Definition: Magnetic Resonance Imaging (MRI) refers to a diagnostic modality in which the magnetic nuclei (especially protons) of a patient are aligned in a strong, uniform magnetic field, absorb energy from tuned radio frequency pulses, and emit radio frequency signals as their excitation decays. These signals, which vary in intensity according to nuclear abundance and molecular chemical environment, are converted into sets of tomographic images by using field gradients in the magnetic field, which permit 3-D localization of the point sources of the signals. • Method: Australia data represents the number of units approved for billing to Medicare only. The U.S. data on MRIs show the number of hospitals with this equipment, not the actual number of MRIs. Some hospitals may have more than one unit, and some units may not be located in hospitals. For the U.K., the raw numbers of CT scanners for England and Wales have been increased pro-rata by the OECD Secretariat to provide appropriate numbers for the U.K., enabling the correct computation of rates using the U.K. population data stored within the database. THE COMMONWEALTH FUND 115 X-2. Computer Tomography (CT) Scanners per Million Population in 2003 • Definition: Computer Tomography (CT) scanners image anatomical information from a cross sectional plane of the body. Each image is generated by a computer synthesis of x-ray transmission data obtained in many different directions in a given plane. • Method: Australia data represents the number of units approved for billing to Medicare only. Germany data includes the number of positron emission tomography units. The U.S. data on CT scanners show the number of hospitals with this equipment, not the actual number of CT scanners. Some hospitals may have more than one unit, and some units may not be located in hospitals. For the U.K., the raw numbers of CT scanners for England and Wales have been increased pro-rata by the OECD Secretariat to provide appropriate numbers for the U.K., enabling the correct computation of rates using the U.K. population data stored within the database. X-3. Cardiac Catheterization Procedures per 100,000 Population in 2003 • Definition: Cardiac catheterization is defined as ICD-9-CM 37.21-23 or equivalent. • Method: The utilization rate is not risk-adjusted and so does not reflect differences in the patient populations between countries. The rates also do not control for differences in the incidence of underlying disease. X-4. Percutaneous Transluminal Coronary Angioplasty (PTCA) Interventions per 100,000 Population in 2003 • Definition: PTCA is defined as ICD-9-CM 36.0 or equivalent. • Method: The utilization rate is not risk-adjusted and so does not reflect differences in the patient populations between countries. The rates also do not control for differences in the incidence of underlying disease. X-5. Coronary Bypass Procedures per 100,000 Population in 2003 • Definition: Coronary bypass is defined as ICD-9-CM 36.1 or equivalent. • Method: The utilization rate is not risk-adjusted and so does not reflect differences in the patient populations between countries. The rates also do not control for differences in the incidence of underlying disease. X-6. Number of Knee Replacements per 100,000 Population in 2003 • Definition: Knee replacement is defined as ICD-9-CM 81.54-55 or equivalent. • Method: The utilization rate is not risk-adjusted and so does not reflect differences in the patient populations between countries. The rates also do not control for differences in the incidence of underlying disease. For Australia, knee replacement is defined as ICD-10-AM 1518, 1519, 1523, and 49527-00. X-7. Number of Patients Undergoing Dialysis Treatment per 100,000 Population in 2003 • Definition: The number of patients undergoing dialysis treatments includes hospital/center and home haemodialysis/haemoinfiltration, intermittent peritoneal dialysis, continuous ambulatory peritoneal dialysis (CAPD), and continuous cyclical peritoneal dialysis (CCPD) on December 31 of each year. THE • Method: The utilization rate is not risk-adjusted and so does not reflect differences in the patient populations between countries. The COMMONWEALTH rates also do not control for differences in the incidence of underlying disease. FUND 116 XI. Non-Medical Determinants of Health XI-1. Percentage of Adults Who Reported Being Daily Smokers in 2003 • Definition: “Daily smokers” is defined as the percentage of the population age 15 and older who report that they are daily smokers. • Method: International comparability is limited because of the lack of standardization in the measurement of smoking habits in health interview surveys across OECD countries. There is variation in the wording of the question, the response categories, and the related administrative methods. For Australia, the age is 16 and older. Estimates of the total population of daily smokers have been calculated for the OECD Secretariat as the unweighted average of the male and female rates for all years in Japan. The Netherlands includes both regular and occasional smokers. For New Zealand, the age is 18 and older. For the United Kingdom, the age is 16 and older for Great Britain only. For the United States, the age is 18 and older. XI-2. Decreases in Smoking Rates between 1983–2003 • Definition: “Daily smokers” is defined as the percentage of the population age 15 and older who report that they are daily smokers. • Method: International comparability is limited because of the lack of standardization in the measurement of smoking habits in health interview surveys across OECD countries. There is variation in the wording of the question, the response categories, and the related administrative methods. For Australia, the age is 14 and older. Estimates of the total population of daily smokers have been calculated for the OECD Secretariat as the unweighted average of the male and female rates for all years in Japan, until 1989 in the Netherlands and Germany, and until 1988 in Canada. The Netherlands includes both regular and occasional smokers. For New Zealand, the age is 18 and older. For the United Kingdom, the age is 16 and older for Great Britain only. For the United States, the age is 18 and older. XI-3. Annual Alcohol Consumption in Liters per Capita for People Age 15 and Older in 2003 • Definition: Alcohol consumption is defined as liters of pure alcohol per person aged 15 years and over. • Method: Alcohol consumption figures are based on alcohol sales data. Methodology to convert alcoholic drinks to pure alcohol may differ across countries. Typically beer is weighted as 4%–5%, wine as 11%–16% and spirits as 40% of pure alcohol equivalent. XI-4. Obesity (BMI > 30) Prevalence in 2003 • Definition: “Obesity” is defined as a body mass index (BMI) of 30kg/m2 or more. • Method: Figures are based on national health interview survey data from populations age 15 and older. For Australia, the age is 25 to 64. For Japan, the age is 20 and older. For the Netherlands, the age is 20 and older. For the United States, the age is 20 to 74. For the United Kingdom, the age is 16 and older. The total percentage of the population (persons) is calculated by applying Health Survey for England male/female percentages to the male/female populations of England and summing both as a proportion of the total population of England. Definitions of obesity vary due to method of collection, either self-report or measured. THE COMMONWEALTH FUND 117 XI-5. Changes in Obesity Rates, 1993–2003 2 • Definition: “Obesity” is defined as a body mass index (BMI) of 30kg/m or more. • Method: Figures are based on national health interview survey data from populations age 15 and older. For Australia, the age is 25 and older. For Japan, the age is 20 and older. For the Netherlands, the age is 20 and older. For the United States, the age is 20 to 74. For the United Kingdom, the age is 16 and older. The total percentage of the population (persons) is calculated by applying Health Survey for England male/female percentages to the male/female populations of England and summing both as a proportion of the total population of England. XII. Mortality XII-1. Life Expectancy at Birth in 2003 • Definition: Life expectancy at birth is the average number of years that a person at that age can be expected to live, assuming that age-specific mortality levels remain constant. XII-2. Life Expectancy at Age 65 in 2003 • Definition: Life expectancy at age 65 is the average number of years that a person at that age can be expected to live, assuming that age-specific mortality levels remain constant. XII-3. Increases in Life Expectancy at Birth, 1983–2003 • Definition: Life expectancy at birth is the average number of years that a person at that age can be expected to live, assuming that age-specific mortality levels remain constant. XII-4. Increases in Life Expectancy at Age 65, 1983–2003 • Definition: Life expectancy at age 65 is the average number of years that a person at that age can be expected to live, assuming that age-specific mortality levels remain constant. XII-5. Breast Cancer Five-Year Relative Survival in 1997 • Definition: The breast cancer relative survival rate is the percentage of survivors among all women diagnosed with breast cancer, adjusted for expected deaths from other causes. • Method: Some differences may be due to differences in age-standardization methods. THE COMMONWEALTH FUND 118 XII-6. Breast Cancer Screening in 2001 • Definition: The breast cancer screening rate is the percentage of women reporting receiving a mammogram. • Method: England and New Zealand measure the number of women screened within the past three years. Australia, Canada, and the United States measure the number of women screened within the past two years. • Method: England and New Zealand measure women age 50–64, Australia and Canada measure women age 50–69, and the United States measures women age 40 and older. • Method: Surveys in the five countries may differ on dimensions including questions used, survey design and administration, sampling methodology, sample size, response rate, cultural orientation of respondents, etc. Data from organized programs, on the other hand, are based on administrative records. Organized programs are aimed at specific target populations which may differ between countries. XII-7. Kidney Transplant Five-Year Survival in 2001 • Definition: The kidney transplant survival rate is the percentage of survivors after five years among those receiving a kidney transplant. • Method: Rates for Australia and New Zealand do not include live donors; the other three rates do. The Australian and U.S. rates are not age- standardized. In New Zealand, relatively few transplants are performed leading to wider uncertainty around the estimate. THE COMMONWEALTH FUND