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At the Intersection of Health, Health Care and Policy

doi: 10.1377/hlthaff.2011.0923, , no. (2011):Health Affairs

That Care Is Often Poorly CoordinatedNew 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds

ApplebaumCathy Schoen, Robin Osborn, David Squires, Michelle Doty, Roz Pierson and Sandra

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By Cathy Schoen, Robin Osborn, David Squires, Michelle Doty, Roz Pierson, and Sandra Applebaum

New 2011 Survey Of PatientsWith Complex Care Needs

In Eleven Countries Finds ThatCare Is Often Poorly Coordinated

AB ST RA CT Around the world, adults with serious illnesses or chronic

conditions account for a disproportionate share of national health care

spending. We surveyed patients with complex care needs in eleven

countries (Australia, Canada, France, Germany, the Netherlands, New

Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the

United States) and found that in all of them, care is often poorly

coordinated. However, adults seen at primary practices with attributes of

a patient-centered medical homewhere clinicians are accessible, know

patients medical history, and help coordinate caregave higher ratings

to the care they received and were less likely to experience coordination

gaps or report medical errors. Throughout the survey, patients in

Switzerland and the United Kingdom reported significantly more positive

experiences than did patients in the other countries surveyed. Reported

improvements in the United Kingdom tracked with recent reforms there

in health care delivery. Patients in the United States reported difficulty

paying medical bills and forgoing care because of costs. Our studyindicates a need for improvement in all countries through redesigning

primary care, developing care teams accountable across sites of care, and

managing transitions and medications well. The United States in

particular has opportunities to learn from diverse payment innovations

and care redesign efforts under way in the other study countries.

In all high-income countries, patientswith serious illnesses or complexchronic conditions account for a dispro-

portionate share of national healthspending. In the United States, for ex-

ample, 89 percent of total national health spend-ing is concentrated on the sickest 30 percent ofthe population.1 Because these patients typicallyseemultiple clinicians at different locations, carecoordination is imperative. Without effectivecommunication among providers,these patientsare at risk for experiencing delays, errors, andineffective care.

In addition, the growth of ever-more-special-ized care has tended to fragment delivery sys-

tems, and community-based practices, hospi-tals, and long-term care often are not well co-ordinated.To improve care, initiativesunder way

internationally are focused on developing inte-grated care and team approaches that organizecare around patients and their families. In theUnited States, such initiatives include redesign-ing primary care into patient-centered medicalhomes that provide enhanced access and com-prehensive, coordinated care, including teamstomanage care for those with chronic conditions.2

Patient surveys offer valuable perspectives oncare gaps and targets for improvement to informthese redesign efforts. Building on past inter-national surveys, in this article we report results

doi: 10.1377/hlthaff.2011.0923

HEALTH AFFAIRS 30,

NO. 12 (2011):

2011 Project HOPEThe People-to-People HealthFoundation, Inc.

Cathy Schoen ([email protected])is the senior vice presidentfor policy, research, andevaluation at theCommonwealth Fund, in NewYork City.

Robin Osborn is the vicepresident and director of theInternational Program inHealth Policy and Innovationat the Commonwealth Fund.

David Squires is a seniorresearch associate in theCommonwealth FundsInternational Program inHealth Policy and Innovation.

Michelle Doty is vicepresident of survey researchand evaluation at theCommonwealth Fund.

Roz Pierson is vice presidentof public affairs at HarrisInteractive, in New York City.

Sandra Applebaum is a seniorresearch manager at HarrisInteractive.

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from a 2011 survey of patients with serious ill-nesses, serious injuries, or chronic diseases ineleven countries: Australia, Canada, France,Germany, the Netherlands, New Zealand,Norway, Sweden, Switzerland, the United King-dom, and the United States. The survey focusedon access, care coordination and management,patient engagement, safety, and the extent to

which having a primary care practice with attri-butes of a patient-centered medical home influ-enced the patients care experience.

The surveyed countries represent a diverse mixof care systems and provider payment systems,and they differ in the way they pay primary carepractices and specialists, use incentives to im-prove or support care teams, and encourage theuse of electronic health records (AppendixExhibit 1).36

The countries alsodiffer in insurance designs.7

Some countries, such as the United Kingdom,Sweden, Norway, and New Zealand, feature na-

tional health systems where primary care prac-tices are community based and where hospitalstypically operate within set budgets and withsalaried specialists. In the Netherlands, theUnited Kingdom, and New Zealand, patientsregister with general (primary care) practices,which serve as gateways for referrals to more-specialized care.

Universal insurance systems are present inAustralia, Canada,France, Germany, the Nether-lands, and Switzerland. In these systems, na-tional (France), provincial (Australia, Canada),or competing health insurers (Germany, the

Netherlands, Switzerland) finance care for thepopulation, supported by varying mixes of pre-miums and taxes. Hospitals in these countriesare a mix of public and private institutions.France, Germany, Norway, and Canada use fi-nancial incentives to encourage patients to useprimary care for referrals but do not require it.

The United States has a mix of publicly andprivately financed insurance, supported by vary-ing mixes of premiums and taxes.Most hospitalsare private, but many are public. The UnitedStates is unique in its high percentage of un-insured people and the absence of national stan-

dards for essential benefits or financial protec-tion. However, with full implementation of the

Affordable Care Act in 2014, the number of un-insured people will fall dramatically, and therewill be new insurance standards.

Amid these distinct systems, the countriesshare the challenge of how to meet the needsof patients with complex conditions in oftenfragmented care systems. Our study points toareas of shared concern and opportunities toimprove primary care, care coordination, andcommunication.

Study Data And MethodsThe survey screened random samples of adultsage eighteen or older to identify people withcomplex health care needs who met at leastone of four criteria: They rated their health asfair or poor; reported having received medicalcare for a serious chronic illness, serious injury,or disability in thepast year; reportedhaving had

surgery in the past two years; or reported havingbeen hospitalized in the past two years.

The survey was administered using computer-assisted telephone interviews and a commonquestionnaire that was translated and adjustedfor country-specific wording. Random samples,designed to ensure geographic representation,drew from national phone directories. Mobilephones were included in France, the Nether-lands, and Norway, where there was easy accessto mobile phone registries. Harris Interactiveand country contractors conducted the inter-

views from Marchthrough June 2011 (field times

varied by country). International partners joinedwith the Commonwealth Fund to sponsor coun-try surveys or expand samples beyond the mini-mum (750) for within-country analyses.8

After screening, the final country samples,shown in Exhibit 1, ranged from 750 to morethan 4,800.9 The analysis weighted final samplesto reflect the distribution of theadult populationin each country.10

The survey questions identified adults whohad complex chronic conditions and had re-cently made extensive use of the health system.

Across countries, 6080 percent of thefinal sam-

ples reported at least one of eight chronic con-ditions; one-fourth or more had two or moreconditions (Appendix Exhibit 2).3 More thanhalf of the respondents in all countries had re-ceived care for a serious illness, injury, or dis-ability in the past year; one-third or more hadbeen hospitalized or had had major surgery inthepasttwoyears;andthevastmajorityhadseenmultiple physicians.

We refer to the final samples as sicker adultsthroughout the analysis, given their health andrecent care experiences. Exhibits 14 show coun-try averages. These are repeated in Appendix

Exhibits 36 with statistical tests that compareeach country to the other ten (p < 0:05).3

P r im a ry C a re M e di c a l H o me To provide aworking definition of the medical home concept,we used positive responses to four domains ofpatient experiences to create a composite indi-cator.These responses were as follows: The adultreported having a regular doctoror place of care;thepracticestaffalways or often knew importantinformation about the patients medical history;the adult received an appointment the same ornext day the last time he or she was sick, or the

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practice always or often called back the same dayto answer questions; and the practice always oroften helped coordinate or arrange care fromother providers, or, if the adult reported achronic condition, there was one person respon-sible for care received for that condition.

The composite medical home variable thus in-dicates adults who have a primary care source

that knows them, is accessible, and helps coor-dinate care. In contrast, we classified adults witha negative answer to any domain as having nomedical home. In the analysis, we compared ex-periences within each country for adults with orwithout a medical home.

Limitations This was a rapid-response surveythat drew from a combination of land lines andmobile phones in France, the Netherlands, andNorway, and land lines only in the other coun-tries. The relatively low response rates or lack ofmobile phones in some countries introduces po-tential bias, although thedirection of that poten-

tial bias is unknown. To the extent that the sur-vey missed adults with more-complex conditionsor those who are more vulnerable because of lowincomes or lack of proficiency in the survey lan-guages, the results may underestimate concerns.

Study FindingsC o s ts A n d A c c es s Given their frequent careneeds, sicker adults can be particularly vulner-able to high out-of-pocket spending for services.The survey results showed wide differences

among countries regarding exposure to suchspending (Exhibit 1). Australian, US, and Swisspatients were significantly more likely to havespent more than US$1,000 out of pocket in thepast year than patients in the other countries.11

Patients in the United Kingdom were the mostprotected.

High out-of-pocket expenses, though, did not

always translate into greater difficulty payingmedical bills. Here US sicker adults stood out:27 percent encountered serious problems payingor were unable to pay medical bills in the past

year, compared with only 8 percent of Australianand Swiss patients who reported problems pay-ing bills (Exhibit 1).In those twocountries,a mixof out-of-pocket spending caps and protectionsfor lower-income patients appeared to helpshield more-vulnerable households from eco-nomic distress because of sickness- and disabil-ity-related costs.7 Patients in the United King-dom, Sweden, and France were the least likely

to report high out-of-pocket expenses or prob-lems paying for care.

In addition to financial burdens, US sickeradults were the most likely to forgo needed carebecause of cost in the past year: 42 percent re-ported not visiting a doctor, not filling a pre-scription, skipping doses of medication, or notgetting recommended care. In the United States,rates of forgone care because of cost were at leastdouble the rates in every other country but

Australia, New Zealand, and Germany.The survey found wide variations in access to

E xh i bit 1

Health Care Costs And Access Among Sicker Adults In Eleven Countries, 2011

Percent of respondents who:

Had out-of-pocket costs inpast year:

Had difficultypaying or unableto pay medicalbills inpast year

Had cost-relatedaccessproblemsin past yeara

Saw a doctor or nurse thelast time they were sick:

Said obtainingafter-hourscare was somewhator very difficultb

Used EDin past2 yearsCountry (N)

Less than$100

More than$1,000

Same ornext day

After6 daysor more

AUS (1,500) 13% 39% 8% 30% 63% 10% 56% 48%

CAN (3,958) 30 24 8 20 51 23 63 58

FRA (1,001) 47 6 5 19 75 8 55 33

GER (1,200 20 12 6 22 59 23 40 31

NETH (1,000) 30 11 14 15 70 12 34 32

NZ (750) 29 13 11 26 75 5 40 47

NOR (753) 12 16 7 14 59 14 35 40

SWE (4,804) 21 5 4 11 50 22 52 50

SWI (1,500) 14 35 8 18 79 4 26 39

UK (1,001) 58 1 1 11 79 2 21 40

US (1,200) 19 36 27 42 59 16 55 49

SOURCE 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults In Eleven Countries. NOTES Significance tests are available in online Appendix 3(Note 3 in text). ED is emergency department. aSee online Appendix 7 for details (Note 3 in text). bBase: needed care.

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care across countries. When asked how quicklythey saw a doctor or nurse when last sick, morethan seven in ten patients reported same- ornext-day appointments in the United Kingdom,Switzerland, France, New Zealand, and theNetherlands (Exhibit 1). In contrast, only halfof Swedish and Canadian patients reported suchrapidaccess,andmorethanoneinfivewaitedsix

days or more. Compared with the leading coun-tries, German, Norwegian, and US patients werealso less likely to have timely access.

Asked about gaining access to care during eve-nings and weekends without going to the emer-gency department, more than half of the sickeradults in Canada, Australia, the United States,France, and Sweden reported difficulty obtain-ing such care. Swiss and UK patients were theleast likely to report difficulty gaining accessafter hours, followed by their Dutch andNorwegian peers.

Hospital emergency departments play a cen-

tral role in providing care for sicker adults. In alleleven countries one-third or more of the sickeradults had visited the emergency department inthe past two years. Emergency department userates in Canada, Sweden, the United States,

Australia, and New Zealand were significantlyhigher than use rates in the other countries.

About half or more of patients in these five coun-tries reported such use, often multiple times.Canadian patientsreportedthe highest use rates,which probably reflects the lack of after-hoursalternatives.

Across countries, the United Kingdom stands

out for low cost burdens and, with Switzerland,for rapid access to primary care and easy accessto after-hours care.

Care Coordination And Safety Well-coordi-nated care is critical for sicker patients, many ofwhom have multiple conditions. Without com-munication and accountability when receivingcare in different settings, such patients are atrisk for complications, medical errors, andundergoing duplicate tests. Patient reports indi-cate that coordination gaps exist in all countriesto varying degrees (Exhibit 2). One-fifthto morethan half of the sicker adults identified in the

survey reported coordination gaps related tomedical records or tests, or communication fail-ures between providers. Among theeleven coun-tries, patients in the United Kingdom andSwitzerland reported the lowest rates of co-ordination gaps.

With respect to medical records or tests, one-fourth of US and Canadian patients and 22 per-cent of Norwegian patients reported that theirmedical records or test results were not availableduring a scheduled visit or that tests were dupli-catednearly double the rates reported in the

United Kingdom and Switzerland (Exhibit 2).Regarding communication between clinicians,French andGerman patients werethe mostlikelyto report that specialists and primary care physi-cians failed to share information with one an-other, and Germans were the most likely to saythat providers failed to share important infor-mation.

Comparatively high proportions of Norwegianand Swedish patients also reported communica-tion gaps. Combining the two categoriespa-tients reporting that medical records were notavailable during a scheduled visit or that theirdoctors did not share information with eachother40 percent of Canadian, Norwegian,Swedish, and US sicker adults and more thanhalf of French and German sicker adults re-ported that they had experienced these failuresto coordinate care.

When respondents were asked about experi-ences after surgery or after being discharged

from the hospital, a significant percentage inall countries reported gaps in discharge plan-ning. These included not receiving instructionsabout when to seek follow-up care, not knowingwhom to contact with questions, not having awritten discharge plan or follow-up appoint-ment, or notbeing given clear instructionsaboutwhat medications to continue taking. Dischargeplanning gaps ranged from 26 percent and29 percent of UK and US patients, respectively,to half or more patients in the other countries.The most common discharge gaps were notplanning for follow-up care and not providing

written instructions. (For details, see AppendixExhibit 8.)3

Further indicating lack of follow-up after dis-charge, one-third of Swedish patients and one-fifth of patients in Australia, Canada, NewZealand, and Norway said that their regulardoctor was not informed about the care receivedwhile they were hospitalized (Exhibit 2). In con-trast, only 10 percent or fewer Dutch, US, or UKpatients reported this concern.

A significantly lower percentage of UK andSwiss patients reported experiencing medical,medication, or laboratory test errors (Exhibit 2)

than did patients in the other countries (8 per-cent and 9 percent, respectively, compared with25 percent of Norwegianpatients and22 percentof US and New Zealand patients). In seven coun-tries, including the United States, one-fifth toone-fourth of patients reported experiencing atleast one type of error inthe past two years. In allcountries, the likelihood of an error increasedwith the number of doctors seen (datanot shown).

Failure to review medications regularly canalso put patients at risk. Yet with the exception

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of patients in the United Kingdom, between one-

quarter to more than half of the patients takingmore than one medication said that their medi-cations had not been reviewed in the past year(Exhibit 2).

E ng agi ng P ati e nt s And Car e M anag e m e nt

Communicating well with patients who haveserious illnesses or chronic conditions and help-ing patients manage their care at home can beinstrumental in avoiding complications and im-proving outcomes. Such patients often followcomplex regimens of medication, diet, exercise,and self-monitoring. Adherence depends onclear instructions, supportive teams, and shared

decisionmaking about care. The survey indicatesopportunities to improve communication andpatient engagement in all countries (Exhibit 3).

Asked about interactions with their regulardoctors or care team, one-fourth to more thanhalf of sicker adults in all eleven countries saidthat their doctordid not spend enough time withthem, encourage them to ask questions, or ex-plain things in a way that is easy to understand.Patients in Norway and Sweden were the leastlikely to report positive interactions; rates therewere particularly low on encouraging questions

and providing explanations. Swiss, UK, Austral-

ian, NewZealand,and US patients were themostpositive, with strong majorities (6573 percent)saying that their clinicians always or often spentenough time with them, encouraged questions,and provided clear explanations (Exhibit 3).

The patients surveyed gave a wide range ofresponses when asked whether specialists en-gaged them in shared decision making overtreatment options. Just half or fewer of German,French, Norwegian, and Swedish patients saidthat specialists often or always provide opportu-nities to ask questions, tell them about choices,or involve them in decisions about care. In con-

trast,eightin tenSwiss andUK patients reportedshared decision making with specialists.

Among patients reporting chronic disease, thesurvey found sizable gaps in guidance and sup-port in managing their condition. Thirty percentto more than half of chronically ill patients saidtheir care team did not discuss main goals, helpmake a plan, or give clear instructionsin thepast

year (answered no on at least one question).Swiss and UK patients were the most likely(69 percent and 67 percent, respectively) andSwedish and Norwegian patients the least likely

E xh i bit 2

Coordination Of Care, Medical Errors, And Safety Among Sicker Adults In Eleven Countries, 2011

Percent of respondents who:

Experienced coordination gaps in past 2 years

Experiencedgapsin hospital/surgerydischargeplanninga

Reportedregulardoctorseemeduninformedabouthospital/surgery careb

Experiencedmedical,medication,or lab errorc

Reportedpharmacistor doctor didnot reviewprescriptionsin past yeardCountry

Test results/recordsnot available atappointment orduplicate testsordered

Keyinformationnot sharedamongproviders

Specialistlackedmedicalhistoryor regulardoctornot informedaboutspecialistcare

Anygap

AUS 19% 12% 19% 36% 55% 18% 19% 34%

CAN 25 14 18 40 50 19 21 28

FRA 20 13 37 53 73 15 13 58

GER 16 23 35 56 61 17 16 29

NETH 18 15 17 37 66 9 20 41

NZ 15 12 12 30 51 19 22 31

NOR 22 19 25 43 71 18 25 62SWE 16 18 20 39 67 35 20 55

SWI 11 10 9 23 48 15 9 25

UK 13 7 6 20 26 11 8 16

US 27 17 18 42 29 12 22 28

SOURCE 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults In Eleven Countries. NOTE Significance tests are available in online Appendix 4(Note 3 in text). aBase: hospitalized/had surgery in past two years. See online Appendix 8 for details (Note 3 in text). bBase: has regular doctor or place of care andhospitalized/had surgery in past two years. cIn past two years, medical mistake, given wrong medication or dose, lab test error, and/or delay receiving abnormaltest results. dBase: taking two or more drugs.

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(22 percent and 23 percent, respectively) to re-spond positively to all three questions,repeatingthe pattern observed with regular doctor com-munication. However, in all countries exceptSwitzerland, the United Kingdom, and the

United States, one-third or more patients an-swered no to each question concerning theirengagement in managing care.

Deficits also emerged in access to advice andfollow-up between visits for chronically ill pa-tients. Acrosscountries, 20 percent to more than40 percent of patients answered no whenasked if they could easily call their caregiver toask a question or get advice, with French andGerman patients the least likely to report easyaccess to advice by phone (Exhibit 3). In allcoun-tries, only a minority said that someone calledthem between visits to follow up on their care.

To explore how patients fared on clinical out-comes, we asked patients with hypertension,heart disease, or diabetes about their blood pres-sure control.We found that theresponses didnotalways track patterns on caremanagement inter-actions in their countries. Norway and Sweden

joined the leaders (Canada, France, NewZealand, and United States) with 83 percentand 85 percent of patients, respectively, report-ing that their blood pressure was under controlthe last time it was checked. Swiss and UK pa-tient-reported rates of control were significantly

lower than rates reported by the leadingcountries.

Those variations underscore theimportance ofassessing chronic care outcomes and not justprocess outcomes or interpersonal interactions.

However, caution is needed in interpretingpatient-reported hypertension control withoutclinical follow-up. To the extent that cliniciansin some countries are more focused on tellingpatients their results or, in the case of theUnitedStates, uninsured patients are unaware of theirconditions, patient-reported outcomes mightnot track clinical exam outcomes.

Patient-Centered Medical HomesA strategygaining international momentum to improve ac-cess, coordination, and outcomes for patientswith complex care needs is to invest in enhancedprimary care.4,12 Known primarily in the United

States as patient-centered medical homes, suchpractices not only provide primary and preven-tive care, but they also ensure timely access,know their patients medical histories, and helpcoordinate or arrange for care.

In the survey, 91100 percent of patients in allcountries said that they had a regular doctor orplace they relied on for care (Exhibit 4). How-ever, when respondents were probed aboutaccess and whether their practice team knowsthemwell and helpscoordinatecare, thepercent-age of sicker adults seen at practices with attrib-

E xh i bit 3

Patient-Centeredness, Engagement, And Chronic Care Management Among Sicker Adults In Eleven Countries, 2011

Percent of respondents who: Percent with chroniccondition who said,between visits, havehealth professional who:

Report that doctor/staff at regularplace always or often:a

Country

Spendsenoughtime withthem

Encouragesquestions,explainsthings clearly

Always/often toboth

Report shareddecisionmaking withspecialistsb

Report patientengagement incare managementfor chronic conditionc

You can

easily callto ask aquestion or

get advice

Contactsyou to seehow thingsare going

Percent reportingthat blood pressurewas controlledlast time checkedd

AUS 85% 69% 66% 64% 48% 59% 16% 79%

CAN 77 59 54 61 49 62 16 85

FRA 82 53 50 37 30 54 9 83

GER 86 64 61 50 41 55 14 78

NETH 87 54 52 67 42 70 22 74

NZ 87 67 65 72 45 71 22 84

NOR 71 31 27 40 23 63 12 85

SWE 70 41 37 48 22 73 22 84

SWI 88 77 73 80 67 68 24 69

UK 87 77 72 79 69 81 29 69US 81 71 65 67 58 77 31 85

SOURCE 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults In Eleven Countries. NOTE Significance tests are available in online Appendix 5(Note 3 in text). aBase: has regular doctor or place of care. bBase: seen specialist in past two years. See online Appendix 9 for details (Note 3 in text). cBase: has chroniccondition. See online Appendix 10 for details (Note 3 in text). dBase: has diabetes, heart disease, and/or hypertension, and had blood pressure checked in past year.

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utes of a medical home dropped sharply, rangingfrom a high of 74 percent inthe United Kingdomto about half or fewer sicker adults in severalother countries.

As detailed in Exhibit 4, patients in the variouscountries differed in terms of reporting whetherthe physician practices they used exhibited rel-atively stronger or weaker medical home attri-

butes. Patients in Switzerland and the UnitedKingdom reported that the practices they usedperformed well on such medical home attributesas access, knowing patients, and coordination.In contrast, patients in Swedenreported that thepractices they used exhibited poor performancein the last two areas.

Patients in other countries also pointed to def-icits of various different medical home attri-butes. Those in the United States, Norway, Can-ada, and Australia reported that access waslacking, while those in France and Germany re-ported relatively low rates of coordination

among their providers.M ed ic al H om es A nd C ar e E xp er ie nc es

Adults with a medical home were significantlymore positive about their care experiences thanwere those without a medical home (Exhibit 5).

Within countries there was spread of eighteen tothirty-nine percentage points between thosewith and without a medical home over such ques-tions as whether their doctor spends enoughtime with them, encourages them to ask ques-tions, and explains things clearly. The same

pattern was true for questions pertaining to en-gaging patients in managing their chronic con-ditions.

Confirming medical home patients generalperceptions that these practices help coordinatecare, in all countries except Germany, where thedifference was not statistically significant, hav-ing a relationship with a medical home was as-

sociated with reduced coordination gaps(Exhibit 5). Hallmarks of superior performanceincluded better information flow between spe-cialists and primary carepractices, availability ofrecords and tests, and the absence of dupli-cate tests.

Practices with medical home attributes alsoappearto help mitigate therisk of error. Patientswho reported having a medical home were alsoless likely to report medical errors, although intwo countries, Germany and the Netherlands,the results were not statistically significant(Exhibit 5).

Practices with medical home characteristicsmay be more connected with other providers.Patients with medical homes who were hospital-ized or had surgery were more likely to reporthaving arrangementsfor follow-up care or know-ing whom to contactwhich contributed tolower discharge gaps. Patients with medicalhomes were also more likely to say that theirdoctors were up-to-date on the care they hadreceived while hospitalized.

Perhaps not surprisingly, patients with medi-

E xh i bit 4

Medical Homes Among Sicker Adults In Eleven Countries, 2011

Percent reporting that regular doctor or place of care:

Country

Percent with aregular doctoror place of care Is accessiblea

Knowsthemb

Helpscoordinatecarec

Percent witha medicalhome

AUS 97% 79% 84% 66% 51%

CAN 96 70 80 71 49

FRA 99 91 88 60 52

GER 97 85 91 56 48

NETH 100 89 79 59 48

NZ 99 91 89 72 65NOR 99 80 76 67 53

SWE 95 83 66 42 33

SWI 99 89 96 80 70

UK 99 90 94 83 74

US 91 80 84 71 56

SOURCE 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults In Eleven Countries. NOTE Significance testsare available in online Appendix 6 (Note 3 in text). aAble to get same-/next-day appointment or always/often receives same-daycallback from regular practice in response to questions. bRegular practice always/often knows important information aboutmedical history. cRegular practice always/often helps coordinate care, or one person is responsible for all care received forchronic condition.

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E xh i bit 5

Care Experiences Among Sicker Adults With And Without Medical Homes In Eleven Countries, 2011

Patient-doctorrelationship(always/oftento all)

Patientengagementfor chroniccondition(yes to all)

Controlledbloodpressure

Coordinationgap inpast 2 years(any gap)

Medicalerrorsin past2 years(any error)

Gap inhospital/surgerydischargeplanning (any

gap)

Regulardoctornot informedabouthospital/surgery care

Carequalityin pastyear wasexcel-lent/very good

Australia

Medical home 79%a 56%a 85%a 31%a 15%a 49%a 13%a 79%a

No medicalhome 52 38 71 41 23 63 23 56

Canada

Medical home 70a 59a 88a 30a 15a 43a 11a 72a

No medicalhome 38 38 82 49 27 57 28 46

France

Medical home 59a 34a 84 49a 10a 66a 12a 49a

No medicalhome 40 24 82 57 15 82 19 38

Germany

Medical home 72a 47a 79 53 15 60 10a 35a

No medicalhome 50 33 75 59 18 63 25 27

Netherlands

Medical home 65a 54a 78 32a 16 59a 3a 44a

No medicalhome 40 29 70 42 23 74 15 26

New Zealand

Medical home 76a 51a 84 25a 19a 42a 13a 83a

No medicalhome 45 27 83 41 29 68 31 59

Norway

Medical home 36a 29a 88a 36a 22a 64a 10a 65a

No medicalhome 18 16 80 51 29 78 28 34a

Sweden

Medical home 55a 32a 86 32a 16a 59a 25a 62a

No medicalhome 28 15 82 42 22 70 40 44

Switzerland

Medical home 82a 73a 73a 20a 6a 41a 12a 72a

No medicalhome 51 51 58 30 15 67 23 57

United Kingdom

Medical home 79a 76a 70 15a 6a 17a 9a 88a

No medical

home 54 46 65 33 14 53 17 60United States

Medical home 80a 67a 90a 33a 17a 19a 9a 77a

No medicalhome 41 45 76 54 29 46 15 43

SOURCE 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults In Eleven Countries. NOTE Many of the care experience items contain multipleelements, which are summarized in always/often to all, yes to all, any gap, and any error response categories. aIndicates significant within-country differences(p < 0:05 or better).

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cal homes also were more likely to rate thequality of their care positively (Exhibit 5). Thebivariate findings of the significant positive as-sociation of having a medical home with careexperiences generally held in multivariate analy-ses that controlled for age, health, income, and,in the United States, insurance status.13

U ni t e d S t at e s : M e d i car e M ak e s A D i f f er -

ence Within the United States, gaps in coverage,frequent changes of plans, and high rates of un-insurance among thepopulation under age sixty-five put their access, continuity, and care co-ordination at risk. For patients age sixty-fiveand older, Medicare offers a more secure, stablesource of insurance and care and, with supple-ments, financial protection.

In thesurvey,US adults agesixty-fiveand olderreported significantly more positive access- andcost-related experiences than did younger USadults, including those insured all year. Theolder patients were far less likely to have gone

without care because of cost (19 percent, com-pared with 51 percent under age sixty-five) or tohave had problems paying bills (6 percent, com-pared with 35 percent under age sixty-five).

Although uninsured adults were most at risk,adults younger than sixty-five who were insuredall year reported rates of access and cost con-cerns that were double the levels reported bypeople age sixty-five or older (AppendixExhibit 11).3

Discussion And Implications

Overall, patients experiences in these elevendiverse countries point to the shared challengesof ensuring access to well-coordinated care foradults with complex care needs. To varying de-grees, coordination gaps emerged in all coun-tries, as did missed opportunities to engage pa-tients in managing their care. Information oftenfailed to flow across sites, such as during tran-sitionsfromhospitalstocommunitysettingsandbetween primary and specialist clinicians. En-suring regular medication review and timely re-ceipt of test results also emerged as issuescommon among countries.

Patients reports also reveal areas in whichcountries differ. The variations offer insightand targets as health systems within the coun-tries seek to improve.

Cross-National Patterns In all countries,patients receiving care from practices with pa-tient-reported attributes of medical homes wereless likely than others to report coordinationgaps and more likely to report positive commu-nication and care management interactions. In-terestingly, the two countries with the highestshare of patients with medical homes, Switzer-

land and the United Kingdom, have quite differ-ent delivery and insurance systems. This sug-gests that coordination is possible in quitedifferent contexts. Patient responses in theUnited Kingdom and Switzerland were oftenamong the most positive about access, co-ordination, safety, and engaging patients, andrarely at the bottom of the country range.

Compared with UK patients responses to ear-lier surveys, those who responded to this yearssurvey reported marked improvements in careaccess, management, and communication. Thissuggests thatpoliciescan havean impact.14 Inthepast decade the United Kingdom implementedpatient surveys to provide feedback to clinicians.The United Kingdom also uses performance-based payment incentives and quality frame-works that emphasize care plans and teams,while reducing waiting times.4 However, thecomparatively low rates of patient-reported dis-ease control for blood pressure may indicate a

need for increased emphasis on outcomes in ad-dition to process metrics.

Among the eleven countries, the United Statesstands out for cost burdens and cost-related ac-cess concerns, as it has in past surveys.14 Theseconcerns were concentrated in the under-sixty-five population and reflect high rates of un-insured and underinsured patients.15 Althoughper capita US spending on health care far ex-ceeds that in any of the other countries, US pa-tients also reported among the highest rates ofpatient-reported errors and coordination gaps.

At the same time, US patients were more pos-

itive than patients in other countries regardingclinicians efforts to engage them and help themmanage their care. Those positive responses mayreflect widespread endorsement and spreadinguse of the chronic care model, which originatedin the United States.16 Such efforts are likely tointensify in the future as reforms embedded inthe Affordable Care Act take hold, with paymentand information systems to support a moreteam-based, patient-centered care approach.

In contrast, sicker adults in Norway, Sweden,and, to a lesser extent, Germany and France re-ported significantlyless positive communication

and care management experiences than didsicker adults in the United States, although Nor-way and Sweden were among the leaders in highrates of patient-reported blood pressure control.Both countries are known for population healthapproaches, including nurse-led clinics inSweden.

Shared Challenges

P R ES C R IP T IO N D R UG S: Managing oftencomplex medication regimens with accountabil-ityfor care receivedacross settingspresentschal-lenges in all countries. Studies withinthe United

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States and other countries repeatedly find thatfailure to reconcile and revise medications forpatients with complex conditions, includingafter hospitalization, puts patients at risk.17 Ahigh percentage of sicker adults taking multiplemedications reported that their medicationswere not reviewed, which suggests a commonneed across the eleven countries to improve

medication management.TRANSITIONS: Gaps also emerged in a