What We Have in Common(wealth)

A year ago, I reported on an interesting comparative study of older adults: the Commonwealth Fund surveyed the health care experience of adults 55 and older in eleven developed countries and found some striking differences. Now Commonwealth has drilled deeper into its data and analyzed differences among “high need” patients in the US and eight other countries (Australia, Canada, France, Germany, the Netherlands, Norway, Sweden, and Switzerland). As usual when we compare ourselves to other countries in the health arena, we don't do so well. And as usual, the differences are enlightening.

This new study looks at patients who are “high need.” I like that term: instead of talking about “high risk” patients--patients who are really at high risk of hospitalization, institutionalization, or death because they already have a lot of needs, not because we can magically determine that they might develop needs in the future--we focus on people who have problems now. The study defines people as high need if they have either three or more chronic conditions or need help in one of their basic daily activities. I might have preferred a composite measure of chronic diseases and functional difficulties, but it turns out to be useful to separate the two for purposes of international comparisons. 

Which brings me to the first interesting observation: the US has more people with at least 3 chronic diseases than anyone else, by a lot. In the US, 42 percent of people over 65 have at least 3 chronic diseases. No other country even comes close. Switzerland is the best, at 19 percent. Everyone else is in the 20-29 range. Does this reflect actual disease rates? Or is it just that we are more thorough in diagnosis—some might say by over-diagnosing disease? The flip side of this finding is that the US performed best in ADLs—only 14 percent of Americans reported they needed a moderate amount or a lot of help, compared to 50 percent of the French. Surely this is cultural—I can imagine that individualistic Americans like to be self-reliant and don’t want to accept help; perhaps the residents of other countries are far more likely to feel that as they get older, they deserve help.

If the populations are as different as the disease and ADL prevalence variability suggests, then the differences that were found in access, costs, and coordination may be meaningless. But for what it’s worth, here's what the study found: the US has a high rate of preventable emergency room visits (19 percent, compared to a low of 4 percent in Germany); and a high rate of cost-related access problems (22 percent vs a low of 5 percent in Switzerland).

Coordination of care was poor across the board—except in France. It sounds as though French people like to have things done for them, both in terms of assistance in basic activities and having someone arrange their health care for them. They report that they actually get help with coordination; I wonder if they feel they get the help they need in other domains as well.

The US came out on top in a single area: the proportion of older people who report they have a “plan of care.” Since having a plan doesn’t amount to much if you can’t access the services you need in order to implement the plan and you don’t have anyone to help you make sure you get what the plan says you need, this accomplishment isn’t terribly impressive. But I think it does tell us something—just as in the earlier Commonwealth study, which found that American patients were more likely than their European counterparts to have designated a health care proxy, what we see here is that America does well on form. We don’t do as well on substance. That’s the disconnect we need to remedy.