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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 NeedsIn Eleven Countries Finds ThatCare Is Often Poorly Coordinated

ABSTRACT Around the world, adults with serious illnesses or chronicconditions account for a disproportionate share of national health carespending. We surveyed patients with complex care needs in elevencountries (Australia, Canada, France, Germany, the Netherlands, NewZealand, Norway, Sweden, Switzerland, the United Kingdom, and theUnited States) and found that in all of them, care is often poorlycoordinated. However, adults seen at primary practices with attributes ofa patient-centered medical home—where clinicians are accessible, knowpatients’ medical history, and help coordinate care—gave higher ratingsto the care they received and were less likely to experience coordinationgaps or report medical errors. Throughout the survey, patients inSwitzerland and the United Kingdom reported significantly more positiveexperiences than did patients in the other countries surveyed. Reportedimprovements in the United Kingdom tracked with recent reforms therein health care delivery. Patients in the United States reported difficultypaying medical bills and forgoing care because of costs. Our studyindicates a need for improvement in all countries through redesigningprimary care, developing care teams accountable across sites of care, andmanaging transitions and medications well. The United States inparticular has opportunities to learn from diverse payment innovationsand 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 atdifferent locations, carecoordination is imperative. Without effectivecommunication amongproviders, 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, initiativesunderwayinternationally 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 teams tomanage 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.2011.0923HEALTH AFFAIRS 30,NO. 12 (2011): –©2011 Project HOPE—The 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 Fund’sInternational 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.

December 2011 30: 12 Health Affairs 1

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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 towhich having a primary care practice with attri-butes of a patient-centered medical home influ-enced the patient’s care experience.The surveyed countries represent adiversemix

of 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).3–6

The countries also differ in insurancedesigns.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 in

Australia, Canada, France, Germany, theNether-lands, and Switzerland. In these systems, na-tional (France), provincial (Australia, Canada),or competing health insurers (Germany, theNetherlands, 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 and

privately financed insurance, supported by vary-ingmixes 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 theAffordable Care Act in 2014, the number of un-insured people will fall dramatically, and therewill be new insurance standards.Amid these distinct systems, the countries

share 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,ordisability in thepast year; reportedhavinghadsurgery 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 fromMarch through June2011 (field timesvaried 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 the adult 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, 60–80percent of the final 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 inthepast two years; and the vastmajority had seenmultiple physicians.We refer to the final samples as “sicker adults”

throughout the analysis, given their health andrecent care experiences. Exhibits 1–4 show coun-try averages. These are repeated in AppendixExhibits 3–6 with statistical tests that compareeach country to the other ten (p < 0:05).3

Primary Care Medical Home To provide aworking definition of themedical home concept,we used positive responses to four domains ofpatient experiences to create a composite indi-cator. These responseswere as follows: The adultreported having a regular doctor or place of care;the practice staff always or often knew importantinformation about the patient’s 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 sourcethat 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 survey

that 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 the direction of that poten-tial bias is unknown. To the extent that the sur-veymissed adults withmore-complex conditionsor those who aremore vulnerable because of lowincomes or lack of proficiency in the survey lan-guages, the resultsmay underestimate concerns.

Study FindingsCosts And Access 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:27percent encountered seriousproblemspayingor were unable to pay medical bills in the pastyear, comparedwith only 8 percent of Australianand Swiss patients who reported problems pay-ingbills (Exhibit 1). In those twocountries, amixof 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 likelyto report high out-of-pocket expenses or prob-lems paying for care.In addition to financial burdens, US sicker

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

Exhibit 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 obtaining

after-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.




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 suchrapid access, andmore thanone in fivewaited sixdays 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 ormore of patients in these five coun-tries reported such use, often multiple times.Canadianpatients reported thehighestuse 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-fifth tomorethan half of the sicker adults identified in thesurvey reported coordination gaps related tomedical records or tests, or communication fail-ures between providers. Among the eleven 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-cated—nearly double the rates reported in the

United Kingdom and Switzerland (Exhibit 2).Regarding communication between clinicians,French andGermanpatientswere themost likelyto 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 Norwegian

and Swedish patients also reported communica-tion gaps. Combining the two categories—pa-tients reporting that medical records were notavailable during a scheduled visit or that theirdoctors did not share information with eachother—40 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 dischargedfrom 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 not being given clear instructions aboutwhat 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 providingwritten 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 and

Swiss 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 ofNorwegianpatients and22percentof US andNewZealand patients). In seven coun-tries, including the United States, one-fifth toone-fourth of patients reported experiencing atleast one type of error in the past two years. In allcountries, the likelihood of an error increasedwith the number of doctors seen (datanot shown).Failure to review medications regularly can

also put patients at risk. Yet with the exception

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of patients in theUnited 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).Engaging Patients And Care Management

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 shareddecisionmakingabout care. The survey indicatesopportunities to improve communication andpatient engagement in all countries (Exhibit 3).Asked about interactions with their regular

doctors or care team, one-fourth to more thanhalf of sicker adults in all eleven countries saidthat their doctor did not spend enough timewiththem, 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, andUSpatientswere themostpositive, with strong majorities (65–73 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 of

responses 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, eight in tenSwiss andUKpatients reportedshared decision making with specialists.Amongpatients reporting chronic disease, the

survey found sizable gaps in guidance and sup-port inmanaging 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 instructions in the pastyear (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

Exhibit 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 62

SWE 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.




(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 theUnited States, one-third or more patients an-swered “no” to each question concerning theirengagement in managing care.Deficits also emerged in access to advice and

follow-up between visits for chronically ill pa-tients. Across countries, 20percent tomore 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 all coun-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 the responses did notalways track patterns on caremanagement inter-actions in their countries. Norway and Swedenjoined 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 variationsunderscore the importanceof

assessing 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 Homes A strategy

gaining internationalmomentum to improve ac-cess, coordination, and outcomes for patientswith complex care needs is to invest in enhancedprimary care.4,12 Known primarily in the UnitedStates 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, 91–100 percent of patients in all

countries 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 andhelps coordinate care, thepercent-age of sicker adults seen at practices with attrib-

Exhibit 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 caneasily callto ask aquestion orget 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 69

US 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 amedical homedropped sharply, rangingfrom a high of 74 percent in the United Kingdomto about half or fewer sicker adults in severalother countries.As detailed in Exhibit 4, patients in the various

countries 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 usedperformedwell on suchmedical home attributesas access, knowing patients, and coordination.In contrast, patients in Sweden reported 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 coordinationamong their providers.Medical Homes And Care Experiences

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 andwithout amedical homeover suchques-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’ general

perceptions 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 care practices, availability ofrecords and tests, and the absence of dupli-cate tests.Practices with medical home attributes also

appear to helpmitigate the risk 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 characteristics

may be more connected with other providers.Patients with medical homes who were hospital-ized or had surgery were more likely to reporthaving arrangements for follow-up careor know-ing whom to contact—which 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-

Exhibit 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 65

NOR 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.




Exhibit 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 (anygap)

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


No medicalhome 45 27 83 41 29 68 31 59

Norway


No medicalhome 18 16 80 51 29 78 28 34a

Sweden


No medicalhome 28 15 82 42 22 70 40 44

Switzerland

Medical home 82a 73a 73a 20a6a 41a 12a 72a

No medicalhome 51 51 58 30 15 67 23 57

United Kingdom

Medical home 79a 76a 70 15a6a 17a 9a 88a

No medicalhome 54 46 65 33 14 53 17 60

United States


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 inmultivariate analy-ses that controlled for age, health, income, and,in the United States, insurance status.13

United States: Medicare Makes A Differ-enceWithin the United States, gaps in coverage,frequent changes of plans, and high rates of un-insuranceamong thepopulationunderage 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 the survey,USadults age sixty-five andolder

reported significantly more positive access- andcost-related experiences than did younger USadults, including those insured all year. Theolder patients were far less likely to have gonewithout 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 ImplicationsOverall, 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-sitions fromhospitals to community settingsandbetween 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 which

countries 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 year’ssurvey reported marked improvements in careaccess, management, and communication. Thissuggests that policies canhave an impact.14 In thepast 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 aneed for increased emphasis on outcomes in ad-dition to process metrics.Among the eleven countries, the United States

stands 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 responsesmayreflect 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 significantly less positive communicationand 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▸▸PRESCRIPTION DRUGS: Managing often

complex medication regimens with accountabil-ity for care received across settingspresents chal-lenges in all countries. Studies within theUnited




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 improvemedication management.▸▸TRANSITIONS: Gaps also emerged in all

countries at the point of hospital discharge, withat least one in four patients indicating lack offollow-up instructions or arrangements or clearmedication directions. US patients reportedamong the lowest rates of gaps in coordinationof hospital discharge, perhaps reflecting inten-sified payer and policy focus on discharge plan-ning to lower readmission rates. With shorterhospital stays,18 US patients may also be sickerwhen they leave thehospital, andmore inneedofcoordination to ensure appropriate transi-tional care.Learning From Laboratories Of System

Change As the United States moves to imple-ment a complex set of payment, information,care system, and insurance reforms incorpo-rated in the Affordable Care Act of 2010, thestudy countries are implementing similar con-cepts yet adapting their approaches to theirunique histories and starting points.Germany, the Netherlands, and Switzerland,

for example, start with hospital payments thatinclude specialists and are considering expan-sion to payment “bundles” that would cover bothhospital and follow-up care.19 France and Ger-many reduce cost sharing for chronically ill pa-tients to encourage care and support practiceswith guidelines to improve chronic diseaseoutcomes.4

Canada, NewZealand, andAustralia are enact-ing payment reforms, providing more practicesupport, and investing in shared community-based teams to enhance primary care and pop-ulation health management.12 Sweden andFrance are developing centers of excellenceand referral hubs for complex care for cancer(both nations) and heart attacks (France). Re-forms in the United Kingdom continue to em-phasize reducing disparities and to build on thedecline in death rates from conditions amenable

to health care that the United Kingdom hasachieved over the past decade.20

The United Kingdom’s success has come inpart by focusing on areas with comparativelypoor performance, informed by public report-ing. Australia and Germany are similarly invest-ing in generating comparative data to improve.Multiple countries use registries to focus onpop-ulation health. Efforts within the United Statesand internationally to add patient-reported out-comes to registries and electronic health recordswill bring patients’ experiences directly intoclinical data systems.Recent US policy debates have focused on

reducing health care spending, including pro-posals to scale back benefits in public programs.Yet all of the other study countries already spendfar less than the United States and provide morecomprehensive, protective benefits. Compara-tive research finds that the higher costs in theUnited States compared with other countries arelargely due to paying higher prices and not re-lated to the generosity of insurance.18,21 As notedabove, reforms resulting from the AffordableCare Act are expected to improve coverage, low-ering cost burdens and barriers to care. Inaddressing future cost trends, US policies willneed to maintain this commitment to accessand avoid shifting costs to patientswith complexhealth care needs.Our study indicates a need—in all coun-

tries—for improvement in coordinating care forpatients with complex conditions. Necessarymeasures include redesigning primary care, de-veloping care teams accountable across sites ofcare, andmanaging transitions andmedicationswell. Given the wide differences revealed by thesurvey, all countries have opportunities to learnfromeachother.While implementinghealth carereforms and experimenting with new initiatives,the United States in particular has opportunitiesto learn from abroad—including the use of pur-chasing power to lower prices, payment innova-tions, and the use of information systems andcare system redesign efforts that are under wayin several countries included in the study. Giventhe wide differences observed in the surveys, allcountries have opportunities to learn from eachother. ▪

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This study was supported by theCommonwealth Fund. The authors thankHealth Affairs editors and reviewers fortheir comments. The views expressedare those of the authors and should notbe attributed to the CommonwealthFund, its directors, or its officers.[Published online November 9, 2011.]

NOTES

1 Cohen SB, Yu W. The concentrationand persistence in the level of healthexpenditures over time: estimatesfor the U.S. population, 2007–2008.Rockville (MD): Agency for Health-care Research and Quality; 2010 Dec.(Statistical Brief No. 309).

2 Grumbach K, Grundy P. Outcomes ofimplementing patient centeredmedical home interventions: a re-view of the evidence from prospec-tive evaluation studies in the UnitedStates [Internet]. Washington (DC):Patient-Centered Primary Care Col-laborative; [updated 2010 Nov 16;cited 2011 Oct 18]. Available from:http://www.pcpcc.net/files/evidence_outcomes_in_pcmh.pdf

3 To access the Appendix, click on theAppendix link in the box to the rightof the article online.

4 Thomson S, Osborn R, Squires D,Reed SJ, editors. Profiles of twelvecountry health care systems, 2011.New York (NY): CommonwealthFund; 2011 Nov.

5 Schoen C, Osborn R, Doty MM,Squires D, Peugh J, Applebaum S. Asurvey of primary care physicians ineleven countries, 2009: perspectiveson care, costs, and experiences.Health Aff (Millwood). 2009;28(6):w1171–83. DOI: 10.1377/hlthaff.28.6.w1171.

6 Protti D. Comparison of informationtechnology in general practice in 10countries. Healthc Q. 2007;10(2):107–16.

7 Schoen C, Osborn R, Squires D,Doty MM, Pierson R, Applebaum S.How health insurance design affectsaccess to care and costs, by income,in eleven countries. Health Aff(Millwood). 2010;29(12):2323–34.

8 The Commonwealth Fund providedcore support, with cofunding to in-

clude countries from the GermanNational Institute for Quality Meas-urement in Health Care; Haute Au-thorité de Santé and Caisse Natio-nale d’Assurance Maladie desTravailleurs Salariés (France); DutchMinistry of Health, Welfare, andSport and the Scientific Institute forQuality of Healthcare at RadboudUniversity Nijmegen; NorwegianKnowledge Centre for the HealthServices; Swedish Ministry of Healthand Social Affairs; and the SwissFederal Office of Public Health.Support to expand samples wasprovided by the UK Health Founda-tion; the Bureau of Health Informa-tion (Australia); and the HealthCouncil of Canada, Health QualityCouncil of Alberta, Ontario HealthQuality Council, and Québec HealthCommission.

9 This was a rapid-response survey.Field times ranged from one to threemonths; most were two months. In-terviewers called up to eight times tomake contact. Response rates were:Australia, 24 percent; Canada,42 percent; France, 28 percent;Germany, 29 percent; the Nether-lands, 21 percent; New Zealand,22 percent; Norway, 16 percent;Sweden, 21 percent; Switzerland,30 percent; United Kingdom,28 percent; and United States,26 percent.

10 Weights were adjusted for age, sex,region, education, and additionalvariables consistent with countrystandards. US weights included raceand ethnicity.

11 For the survey, country currency wasconverted to US dollars using ex-change rate equivalents.

12 Willcox S, Lewis G, Burgers J.Strengthening primary care:

achievements and recent reforms inAustralia, England, and the Nether-lands. New York (NY): Common-wealth Fund; 2011 Nov.

13 Regression results are available fromthe first author on request.

14 Schoen C, Osborn R, How SK,Doty MM, Peugh J. In chronic con-dition: experiences of patients withcomplex health care needs, in eightcountries, 2008. Health Aff (Mill-wood). 2009;28(1):w1–16. DOI:10.1377/hlthaff.28.1.w1.

15 Schoen C, Doty MM, Robertson R,Collins S. Affordable Care Act re-forms could reduce the number ofunderinsured by 70 percent. HealthAff (Millwood). 2011;30(9):1762–71.

16 Bodenheimer T, Wagner EH,Grumbach K. Improving primarycare for patients with chronic illness.JAMA. 2002;288(14):1775–9.

17 Gandhi TK, Weingart SN, Borus J,Seger AC, Peterson J, Burdick E,et al. Adverse drug events in ambu-latory care. N Engl J Med. 2003;348(16):1556–64.

18 Squires DA. The US health system inperspective: a comparison of twelveindustrialized nations. New York(NY): Commonwealth Fund;2011 Jul.

19 Struijs JN, Baan CA. Integrating carethrough bundled payments—lessonsfrom the Netherlands. N Engl J Med.2011;364(11):990–1.

20 Nolte E, McKee M. Variations inamenable mortality—trends in 16high-income nations. Health Policy.2011 Sep 12. [Epub ahead of print].

21 Anderson GF, Reinhardt UE, HusseyPS, Petrosyan V. It’s the prices, stu-pid: why the United States is so dif-ferent from other countries. HealthAff (Millwood). 2003;22(3):89–105.




ABOUT THE AUTHORS: CATHY SCHOEN, ROBIN OSBORN,DAVID SQUIRES, MICHELLE DOTY, ROZ PIERSON &SANDRA APPLEBAUM

Cathy Schoen isthe senior vicepresident for policy,research, andevaluation at theCommonwealthFund.

In this month’s Health Affairs,Cathy Schoen and coauthorspresent the results of theCommonwealth Fund 2011International Health Policy Surveyof Sicker Adults in ElevenCountries, including the UnitedStates. Although care is oftenpoorly coordinated in all of thecountries, the authors found thatadults seen at primary carepractices with attributes of apatient-centered medical home—where clinicians are accessible,know patients’ medical history, andhelp coordinate care—gave higherratings to the care they received.They also were less likely toexperience coordination gaps orreport medical errors, compared tothose seeking care at practiceswithout those attributes.

“Although the health caresystems in these eleven countriesare quite different, the countriesare beginning to resemble oneanother in negative ways, withcommunication and coordinationshortfalls posing serious challengesto sicker adults’ receiving qualitycare,” Schoen says. “For thisreason, we were heartened to seethat the medical home modelmakes a significant positive impacton patients’ satisfaction with thecare they receive.”

Schoen is the senior vicepresident for policy, research, andevaluation at the CommonwealthFund. She also serves on theNational Academy of Sciences

advisory panel on MeasuringMedical Care Risk in Conjunctionwith the New Supplemental IncomePoverty Measure. Schoen received amaster’s degree and an all-but-dissertation in economics fromBoston College.

Robin Osborn is thevice president anddirector of theInternationalProgram in HealthPolicy andInnovation,CommonwealthFund.

Robin Osborn is the vicepresident and director of theInternational Program in HealthPolicy and Innovation at theCommonwealth Fund. She receivedher master of businessadministration degree fromColumbia University.

David Squires is asenior researchassociate in theInternationalProgram in HealthPolicy andInnovation.

David Squires is a seniorresearch associate in theCommonwealth Fund’sInternational Program in HealthPolicy and Innovation. He holds amaster’s degree in bioethics fromNew York University.

Michelle Doty isvice president ofsurvey research andevaluation,CommonwealthFund.

Michelle Doty is vice president ofsurvey research and evaluation atthe Commonwealth Fund. Shereceived a doctorate in publichealth from the University ofCalifornia, Los Angeles.

Roz Pierson is vicepresident of publicaffairs at HarrisInteractive.

Roz Pierson is vice president ofpublic affairs as well as the policyand health policy lead for HarrisInteractive, a research andcommunications firm. She has adoctorate in communicationresearch from Stanford University.

Sandra Applebaumis a senior researchmanager at HarrisInteractive.

Sandra Applebaum is a seniorresearch manager at HarrisInteractive. She holds a master’sdegree in applied social researchfrom the City University of NewYork.

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