No reader of THCB will be surprised that the cross-national series which the Commonwealth Fund has sponsored for several years now (and for which my old colleague and friend at Harris, Kinga Zapert has been running the surveys) continues to find that sick people here have it worse than sick people in other countries. Their latest work was published in Health Affairs yesterday and it’s called Taking The Pulse Of Health Care Systems: Experiences Of Patients With Health Problems In Six Countries. Here’s the press release if you don’t want to read the whole thing.
The headlines have been taken by the finding that patients in the US were more likely to say that they’d experienced a medical error (34% here versus between 30% and 22% elsewhere). But no one really has got the medical error situation under control, and it’s likely that patient reporting isn’t such a great measure of medical errors in reality. After all, Brent James has shown us that clinician reporting is a lousy guide to whether mistakes have been made. And in general all countries need to do better on care management of sick people, including treatment planning and clinician co-ordination.
But of course the study continues to find the the US is a real outlier when it comes to the financial impact on patients of being sick.
• Half of U.S. adults reported that they had gone without care because of costs in the past year• In contrast, just thirteen percent of U.K. adults reported not getting needed care because of cost• One-third of U.S. patients reported out-of-pocket expenses greater than $1,000 in the past year• U.K. patients were the most protected from high cost burdens, with two-thirds having no out-of-pocket expenses. The variations were notable given the study’s design focus on sicker adults with recent intensive use of medical care. (My emphasis)
And while we continue to hear reams of rubbish about the terrible impacts of waiting lists in Canada, none of the America-first crowd in Health Care seem too bothered by the confirmation that speedy access to primary care is none too good here, and ends up increasing emergency room use.
Access—including after-hours access—and waiting times to see a doctor when sick differed markedly across the countries:• Canadian and U.S. adults who needed medical care were the least likely to report fast access (same day) to doctors (30 percent or fewer of U.S. or Canadian patients) (My emphasis)• In contrast, majorities of patients in New Zealand (58 percent) and Germany (56 percent) reported that they were able to get same-day appointments, as did nearly half of patients in Australia (49 percent) and the United Kingdom (45 percent)• Majorities of patients in Germany (72 percent), New Zealand (70 percent), and the United Kingdom (57 percent) also reported easy after-hours (nights, weekends, or holidays) access to a doctor• In contrast, majorities of patients in the United States (60 percent), Australia (58 percent), and Canada (53 percent) said that it was very or somewhat difficult to get after-hours care• The four countries with comparatively more rapid access to physicians—Australia, Germany, New Zealand, and the United Kingdom—also had lower rates of emergency room use, with Germany having the lowest rates• One-fifth of Canadians and one-fourth of U.S. patients who reported going to the ER said that it was for a condition that could have been treated by their regular doctor if available. (My emphasis)
I know this is just piling on, but for the gazillionth time let me remind you that the biggest difference between the US and the rest of these countries is that they cover their entire populations and do it for remarkably less per head than we do. And in virtually no other country are people financially destroyed just because they are sick.
There’s an awful lot wrong with health care everywhere, but my guess is that if there’s one reason that foreigners are saying Vive La Difference, it’s that one.
The authors, though, find a few other ways to put the boot in:
In past patient surveys among the five English-speaking countries, the United States has stood out for having relatively short waiting times for specialized care. Based on patients’ reports in this study, Germany also provides rapid access to such care. Understanding how Germany has achieved access to physicians, after-hours care, and specialized care while spending much less than the United States spends as a percentage of national income could help inform U.S. policy.Symptoms of inadequate insurance coverage and more fragmented care in the United States emerged throughout the survey. The United States outspends the other countries, spending 14.6 percent of national income compared with Germany’s 10.9 percent, Canada’s 9.6 percent, Australia’s 9.1 percent, New Zealand’s 8.5 percent, and the United Kingdom’s 7.7 percent.Yet the United States often ranks last or tied for last for safety, efficiency, and access. With one-third of U.S. patients reporting medical, medication, or lab errors and a similar share citing duplicate tests or medical record delays, our findings indicate widespread performance deficiencies that put patients at risk and undermine care. Moreover, a recent study finds that the United States is not systematically a leader in clinical outcomes.Confirming spending data from the Organization for Economic Cooperation and Development (OECD), the United States also stands out for its patient cost burdens, with consequences for access.U.S. physician visit rates are already low by OECD standards.To the extent that U.S. insurance continues to move toward higher front-end patient deductibles, these rates could go up, as increasing numbers of insured patients become “underinsured,” lacking access or adequate financial protection.Contrasts between the United States and Germany, in particular, indicate that it is possible to organize care and insurance to achieve timely access without queues, while ensuring that care is affordable at the point of service. There are clear opportunities for the United States to learn from other countries’ insurance systems.