Chronically ill U.S. patients have the least access, the worst coordination of care, and the worst medical safety experiences among patients in the developed world's eight most developed nations, a new study released last week in Health Affairs In Chronic Condition: Experiences Of Patients With Complex Health Care Needs, In Eight Countries, 2008
- shows. Regardless of the fact that we pay more, we get far less. In essence, this study also shows beyond a shadow of a doubt that the US is rationing healthcare. Healthcare that the chronically ill in most other developed nations usually receive is unaffordable to many chronically ill adults in the US.

For the chronically ill in the US, this often results in tragic outcomes that are completely preventable.

http://content.healthaffairs.org/cgi/con tent/full/hlthaff.28.1.w1/DC1

In Chronic Condition:
Experiences Of Patients With
Complex Health Care Needs,
In Eight Countries, 2008

Chronically ill U.S. patients have the most negative access,
coordination, and safety experiences.

by Cathy Schoen, Robin Osborn, Sabrina K.H. How,
Michelle M. Doty, and Jordon Peugh

ABSTRACT:

This 2008 survey of chronically ill adults in Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States finds major differences among countries in access, safety, and care efficiency. U.S. patients were at particularly high risk of forgoing care because of costs and of experiencing inefficient, poorly organized care, or errors. The Dutch, who have a strong primary care infrastructure, report notably positive access and coordination experiences. Still, deficits in care management during hospital discharge or when seeing multiple doctors occurred in all countries. Findings highlight the need for system innovations to improve outcomes for patients with complex chronic conditions. [Health Affairs 28, no. 1 (2009): w1-w16 (published online 13 November 2008; 10.1377/hlthaff.28.1.w1)]

Medical science advances and improved living standards have saved lives and contributed to longer life expectancy, yet industrialized nations now face the growing challenge of caring for patients with chronic diseases. Health systems initially designed to respond to acute, episodic illness increasingly care for patients with ongoing conditions, where the goals include preventing complications or deterioration rather than cure. Often coping with multiple conditions, chronically ill patients may see multiple clinicians at different care sites, increasing the risks of errors and poor care coordination. Across industrialized nations, chronically ill patients account for a disproportionate share of national health spending, placing them at the center of initiatives to improve health system performance.1

Experiences of chronically ill patients, especially those with recent hospitalizations or serious illnesses, offer unique perspectives. To learn from such patients, the 2008 Commonwealth Fund International Health Policy Survey interviewed adults with chronic conditions who had recent health care experiences in eight countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. Including France for the first time, the survey builds on an annual series that informs a symposium with ministers and policy experts from surveyed countries. This study focuses on access, coordination, safety, and care management experiences.

The countries participating in the survey represent a diverse mix of insurance designs and primary care systems. Among the eight countries, the United States stands out for having the most expensive system ($7,000 per capita compared to under $3,500 in the other countries as of 2006), for its gaps in coverage, and for high cost sharing even for patients with insurance.2 The other seven countries have systems with comprehensive minimum benefits and universal coverage. Canada, the Netherlands, and the United Kingdom have no cost sharing for primary care. France's insurance system protects patients with specific chronic illnesses from coinsurance. Germany limits cost sharing to 1 percent of income for the chronically ill and 2 percent for all households.3 The Netherlands, New Zealand, and the United Kingdom require patients to register with a general practitioner (GP) who acts as a gateway to more specialized care. The Netherlands and the United Kingdom are noted for their strong primary care foundations.4

" U.S. uninsured adults were significantly more likely than those insured all year to go without care because of costs and to wait when sick. Remembering that all in this study have chronic (often multiple) conditions, a disturbingly high 82 percent of the uninsured did not fill a prescription, get recommended care, or see a doctor when sick because of costs. Uninsured chronically ill adults were also more likely than those with insurance to report errors as a result of higher rates of delays in hearing about abnormal lab tests and wrong-dose/ wrong-medication errors. Not surprisingly, given these experiences, the uninsured were also more negative about the U.S. health system than insured adults were.

Still, the experience of fragmented and inefficient care in the United States cuts across insurance status. Insured and uninsured chronically ill U.S. adults reported similarly high rates of coordination concerns (duplication and records/tests not available) and perceptions of excess care or time wasted because of poorly organized care.

Although insured U.S. adults fared better than the uninsured, they were still more likely than their counterparts in other countries to forgo care because of cost and to encounter poor coordination. Their perceptions of waste, patient-reported errors, and negative system views also remained at the high end of the country range.

Discussion And Implications

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"