New international health survey of sicker adults: Those with a medical home fare better

Chronically and seriously ill adults who received care from a medical home—an accessible primary care practice that helps coordinate care—were less likely to report medical errors, test duplication, and other care coordination failures, according to a new Commonwealth Fund international survey of patients' experiences in the U.S. and 10 other high-income countries. Published as a Health Affairs "Web First" article, the study also found that patients connected with medical homes had better relationships with their doctors and rated their care more highly.

The 2011 survey of more than 18,000 sicker adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States included people who reported they were in fair or poor health, had surgery or had been hospitalized in the past two years, or had received care for a serious or chronic illness, injury, or disability in the past year. The study identified patients as having a medical home if they reported having a regular source of care that knows their medical history, is accessible, and helps coordinate care received from other providers.

Sicker adults in the U.K. and Switzerland were most likely to have a medical home, with nearly three-quarters connected to practices that have characteristics of a medical home, compared to about 33 percent to 65 percent in the other nine countries. U.K. and Swiss patients also reported more positive health care experiences than sicker adults in the other countries: they were more likely to be able to get a same- or next-day appointment when sick and to have easy access to after-hours care, and they were less likely to experience poorly coordinated care.

Sicker adults in the U.S. stood out for having the highest rates of problems paying medical bills and going without needed care because of the cost. Forty-two percent reported not visiting a doctor, not filling a prescription or skipping medication doses, or not getting recommended care—a significantly higher proportion than in all the other countries, and more than double the rates in Canada, France, the Netherlands, Norway, Sweden, Switzerland, and the U.K. Moreover, U.S. patients had among the highest rates of self-reported medication, lab, or medical errors, as well as gaps in coordination of care.

Medical Homes Improve Care Experiences, Care Coordination, and Care Management

Across the wide diversity of health care systems included in the study, patients who were connected to a medical home in general had more positive care experiences, including better support for managing chronic conditions, better communication, and better care coordination. Patients with medical homes were also less likely to report medical mistakes and far more likely to rate their care highly.

"We found that to varying degrees in all countries, chronically ill or sicker patients encounter failures of providers to communicate with each other or coordinate care," said Commonwealth Fund senior vice president Cathy Schoen, lead author of the study. "Yet in each country, patients with practices that help them navigate the care system and provide easy access are far less likely to encounter duplication, delays, and failures to share important information." Schoen says the study highlights the critical importance of patient-centered primary care as a foundation for a high-performing health system.

U.S. Sicker Adults: High Levels of Access Problems and Medical Bill Concerns

Sicker adults in the U.S. stood out as the most likely to have problems getting needed care because of the cost, or to have medical bill or debt problems. More than two of five (42%) sicker adults in the U.S. went without care because of costs. More than one of four (27%) said they could not pay, or had serious problems paying, medical bills, compared with between 1 percent and 14 percent of adults in the other 10 countries. And more than one-third (36%) spent more than $1,000 on medical costs, compared with fewer than 10 percent in France, Sweden, and the U.K., the countries with the lowest rates—a reflection, the authors say, of high cost-sharing and high uninsured rates in the U.S.

In the U.S., cost-related access problems and medical bill burdens reported in the survey were concentrated among adults under age 65. Compared to adults 65 or older with Medicare coverage, under-65 adults were far more likely to go without care because of the cost or to have problems paying medical bills. Half of U.S. adults under 65 (51%) went without care because of costs, compared to 19 percent of adults age 65 or older; 35 percent of those under 65 had problems with medical bills, compared with only 6 percent of adults 65 or older. Whether insured all year or uninsured, under-65 sicker adults in the U.S. were at high risk for access problems, bill concerns, or high out-of-pocket costs.

"Despite spending far more on health care than any other country, the United States practically stands alone when it comes to people with illness or chronic conditions having difficulty affording health care and paying medical bills," said Commonwealth Fund president Karen Davis. "This is a clear indication of the urgent need for Affordable Care Act reforms geared toward improving coverage and controlling health care costs. It is crucial that as reforms are implemented, we control costs in ways that ensure those facing serious and chronic illness have affordable access to the health care they need and that preserve the gains made by Medicare."

Other Findings: Access to Health Care and Care Coordination

The survey found wide variations in access, coordination, and patient-reported medical errors.

  • Despite having very different health care systems, the U.K. and Switzerland were leaders in having rapid access to primary care, easy access to after-hours care, and comparatively low rates of coordination gaps and patient-reported medical errors.
  • More than seven of 10 patients in the U.K., Switzerland, France, New Zealand, and the Netherlands were able to get same- or next-day appointments when they were sick. In contrast, only half of patients in Sweden and Canada reported such rapid access to care.
  • One-third or more of sicker adults in all 11 countries had visited an emergency department in the past two years. Emergency department use was highest in Canada, Sweden, the U.S., Australia, and New Zealand.
  • More than half of German (56%) and French (53%) patients and more than two of five Norwegian (43%) and U.S. (42%) patients reported gaps in care coordination, including duplicate tests being ordered, medical records or test results not being available during a medical appointment, or providers not sharing important information with each other. In contrast, only 20 percent of U.K. patients and 23 percent of Swiss patients reported such care gaps.
  • The proportion of patients reporting medical errors (including prescription and lab test errors) ranged from a low of 8 percent to 9 percent in the U.K. and Switzerland to 22 percent or more in New Zealand, Norway, and the U.S.
Shared Challenges

Overall, the survey found that countries are facing similar challenges in providing effective treatment to sicker adults. Evident in every country surveyed were gaps in care coordination, gaps in transitions between hospitals and other community-based care settings, lapses in communication between specialists and primary care physicians, failure to review medications, and delays in receiving test results. The authors point to opportunities for learning as each country implements reforms aimed at improving care outcomes and resource use, including reforms to payment and information systems and the redesign of health care delivery to support team-based care.

"All the other study countries already spend far less than the United States, yet provide more comprehensive, protective benefits," the study's authors note. "Comparative research finds the higher costs in the United States are largely due to paying higher prices and not related to the generosity of insurance." They conclude that as the U.S. seeks to address future cost trends, policies will need to maintain the Affordable Care Act's commitment to improving access and affordability and prevent more costs from being shifted to patients.

More information: A summary of the Health Affairs article, "New 2011 Survey of Patients with Complex Care Needs in Eleven Countries Finds That Care is Often Poorly Coordinated," by Cathy Schoen, Robin Osborn, David Squires, and Michelle Doty of The Commonwealth Fund, and Roz Pierson and Sandra Applebaum of Harris Interactive, will be available on the Commonwealth Fund's Web site on November 9th at www.commonwealthfund.org/Publi… vey-Of-Patients.aspx , with a link to the article.

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