December 14, 2014

Compare and Contrast

I’ve long wondered how the US compares to other developed countries in providing medical care for older people. Our overall performance in the health care domain, when compared to the achievements of countries such as Australia, Canada, France, and Switzerland, has regularly demonstrated deficiencies —but many of these are related to the enormous number of uninsured individuals in the US. Seldom were people over 65, who in the US are almost all covered by Medicare, considered separately. At last, the Commonwealth Fund, which has carried out many of the previous surveys, looked into the situation for older adults. The results are illuminating.

First, the good news. The US is not at the bottom of the list on all of the indices, just some. Compared to the other 10 countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the UK), the US did quite well in a few areas. Older Americans rarely had to wait over a month for an appointment to see a specialist (only 14% reported such a long wait, compared to more than half of the respondents in Canada and in Norway). Fewer American elderly patients reported problems related to discharge planning after hospitalization—issues such as inadequate follow up or lack of information about their medications (28% did have problems, however, but this compares favorably to 70% in Norway and 67% in Sweden). And despite all the discussion in the US about the lamentable state of advance care planning, far more American older patients reported having had a discussion with someone about the care they would want if they became very ill and could not make decisions for themselves than did their counterparts in other countries (78% of Americans said they had had such a conversation, compared to 20% in Norway and 12% in France). The majority of Americans (67%) said they had designated a health care proxy, whereas the percentages were below 10% in Scandinavia and in the 25% range in New Zealand, Switzerland, and the UK. 

And then the bad news. Despite universal coverage, a sizable fraction of older Americans have substantial out of pocket expenses for health care, expenses that they often cannot meet: 19% said they had cost-related access problems in the past year, 21% said they had out of pocket expenses of $2000 or more, and 11% said they had trouble paying their medical bills. The corresponding figures in all the other countries were far lower except for Switzerland, where patients reported high out of pocket expenses but said they did not have problems paying them. In addition, nearly a quarter of American older patients reported that test results or records were not available at their appointment or that duplicate tests were ordered; this occurred far more rarely elsewhere. Getting a next day appointment when they were acutely ill was difficult for Americans, making them worse off than patients in France, Germany, the Netherlands, New Zealand, Switzerland and the UK—and leading to excess use of emergency rooms.

Finally, the surprising news: older Americans reported higher rates of chronic disease than anyone else: fully 87% said they had at least one of seven major conditions and 68% had at least two. By contrast, only one-third of older adults in the UK said they had multiple medical problems. Either Americans are more knowledgeable about their medical problems (the entire survey depended on self-report), or Americans are just sicker.

Interestingly, all the patients interviewed were pretty happy with their medical care: most everyone felt the doctor spent enough time with them and that they had a plan for self-management of their disease.

So what should we make of all this? The report is based entirely on computer-assisted telephone interviews of a random sample of people 65 and over. Relying on self-report may give a biased view of the medical care these patients actually received. But at the very least, the report offers the opportunity to look at what’s different in the health care systems in which patients are very satisfied with their care. England, for example, outperformed the US in self-management of chronic conditions and in England, the vast majority of primary care practices used nurse case managers or navigators for the patients with the most serious problems. France, which had particularly good care coordination, has a special program that incentivizes primary care physicians and specialists to develop shared care plans. In countries with better access to care, it is either free at the point of service or free for most chronic conditions, or subsidized for low-income individuals. 

If we have the humility to acknowledge that we’re not always the best, maybe we could learn something from our friends.

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