Health Affairs: Sick adults fare better in medical homes
Across 11 countries, adults with complex care needs who had a "medical home" reported fewer coordination failures with their care, including medical errors and test duplication, as well as better relationships with their doctors and greater satisfaction with care, according to an online first article in Health Affairs.
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.
“In high-income countries, patients with complex care needs account for a disproportionate share of national health spending,” wrote Cathy Schoen, MS, senior vice president of the Commonwealth Fund, and colleagues. “In the United States, for example, 89 percent of total national health spending is concentrated among the sickest 30 percent of the population.”
Conducted by Harris Interactive on behalf of the Commonwealth Fund by telephone between March and June, the survey collected data from 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. The survey 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. Only 1,200 respondents were from the U.S.
Sicker adults in the U.K. and Switzerland were most likely to have a medical home, with nearly 75 percent 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 healthcare experiences than sicker adults in the other countries: they were more likely to be able to get a same-day 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.
The U.S. stood out for having the highest rates of problems paying medical bills and going without needed care because of the cost, according to the report. Forty-two percent reported not visiting a doctor, not filling a prescription, 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. U.S. patients also had among the highest rates of self-reported medication, lab or medical errors, as well as gaps in coordination of care.
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 percent) sicker adults in the U.S. went without care because of costs. More than one of four (27 percent) 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 percent) 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, the report found. 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. Fifty-one percent of U.S. adults under 65 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.
The survey found wide variations in access, coordination and patient-reported medical errors:
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.
“In high-income countries, patients with complex care needs account for a disproportionate share of national health spending,” wrote Cathy Schoen, MS, senior vice president of the Commonwealth Fund, and colleagues. “In the United States, for example, 89 percent of total national health spending is concentrated among the sickest 30 percent of the population.”
Conducted by Harris Interactive on behalf of the Commonwealth Fund by telephone between March and June, the survey collected data from 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. The survey 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. Only 1,200 respondents were from the U.S.
Sicker adults in the U.K. and Switzerland were most likely to have a medical home, with nearly 75 percent 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 healthcare experiences than sicker adults in the other countries: they were more likely to be able to get a same-day 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.
The U.S. stood out for having the highest rates of problems paying medical bills and going without needed care because of the cost, according to the report. Forty-two percent reported not visiting a doctor, not filling a prescription, 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. U.S. patients also had among the highest rates of self-reported medication, lab or medical errors, as well as gaps in coordination of care.
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 percent) sicker adults in the U.S. went without care because of costs. More than one of four (27 percent) 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 percent) 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, the report found. 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. Fifty-one percent of U.S. adults under 65 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.
The survey found wide variations in access, coordination and patient-reported medical errors:
- 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.
- Fifty-six percent of German and 53 percent of French patients and more than two of five Norwegian (43 percent) and U.S. (42 percent) 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.