The Reading Blog

A study “In Chronic Condition: Experiences of Patients With Complex Health Care Needs, in Eight Countries, 2008,” supported by the Commonwealth Fund and published in the November 13 issue of the journal Health Affairs, concluded  that “Chronically ill U.S. patients have the most negative access, coordination, and safety experiences” compared with similar patients in Australia, Canada, France, Germany, the Netherlands, New Zealand, and the United Kingdom. The study authors, Cathy Schoen and her colleagues, surveyed 7,500 patients who had one or more of the following chronic conditions: hypertension, heart disease, diabetes, arthritis, lung problems, cancer, or depression.

As pointed out in the November 17, 2008 The New York Times editorial, “The Wrong Place to Be Chronically Ill” this study,

[...] is the latest telling evidence that the dysfunctional American health care system badly needs reform. The results of the study [...] belie the notion held by many American politicians that health care in this country is the best in the world. That may be true at a handful of pre-eminent medical centers, but it is hardly true for the care provided to a huge portion of the population. [...]

The care they received in this country — or more often did not receive — ought to be a cause for shame. More than half of the American patients went without care because of high out-of-pocket costs. They did not visit a doctor when sick, skipped a recommended test or treatment or failed to fill a prescription. The uninsured suffered most, but even 43 percent of those who had insurance all year skipped care because of costs.

Americans also were most likely to report wasting time because their care was so poorly organized. About a third reported that medical records and test results were not available when needed or that tests were duplicated unnecessarily. A third experienced a medical error, such as being given the wrong medication or test results. Some 40 percent found it very difficult to get after-hours care without going to an emergency room. The United States did comparatively well in some areas, such as providing relatively prompt access to specialists and clear instructions to patients leaving the hospital. But the nation’s overall performance was abysmal.

By contrast, Dutch patients reported far more favorable experiences with their health care system, largely because the Netherlands provides universal coverage (through individual mandates and private health insurance), a strong primary care system and widespread use of electronic medical records. It should be possible to achieve the same level of performance here.

To pinpoint specific areas of improvement for the U.S. health care system, here are some highlights from the study discussion section:

The survey findings of significant variations in care experiences regarding access, safety, and coordination/efficiency indicate that countries’ policies and care systems make a difference for patients coping with complex, chronic conditions. U.S. patients appear at particularly high risk as a result of coverage gaps and poorly organized care. Chronically ill patients in countries with strong primary care infrastructures tend to fare better. Yet deficits in transitional care when patients leave the hospital, inadequate coordination for patients seen by multiple clinicians, and weak efforts to engage or support patients to manage their conditions exist in all countries.

Countries’ policies make a difference. Repeating patterns observed in earlier surveys, the United States continues to stand out for more negative patient experiences, ranking last or low for access, care coordination/efficiency, and patient-reported safety concerns. The percentage of chronically ill U.S. adults who reported access problems, errors, delays, duplication, and other symptoms of poorly organized care was two to three times the level reported in the lowest-rate countries in the survey (a 20-30 percentage point spread). Along with Canadians, U.S. patients were also the most likely to indicate a primary care system under stress–lack of rapid access, difficulty getting care after hours, and high ER use.

The United States did comparatively well on measures of transitional care during hospital discharge, and responses were more positive on some items related to patient-centered care (for example, setting goals and priorities). Yet U.S. patients often cannot afford to follow recommended care. Recent studies indicate that the trend toward higher cost sharing for insured patients appears to be undermining access and adherence to recommended care.¹³ In effect, insurance designs may be undermining efforts to hold physicians accountable for achieving outcome targets or evidence-based guidelines. Lack of affordable access, waits for primary care, and inadequate coordination put chronically ill U.S. patients–especially those with multiple chronic conditions–at high risk of poor health outcomes. Notably, despite spending much more, the United States has been falling behind all of the other surveyed countries in reducing premature deaths from conditions amenable to health care.¹⁴