The Commonwealth Fund Blog

A Common Challenge: Seamless and Patient-Centered Care for Adults with Complex Care Needs

November 9, 2011

Tags: international health policy health spending access to care patient-centered care

David Squires Cathy Schoen Michelle Doty Robin Osborn By David Squires, Cathy Schoen, Michelle M. Doty, and Robin Osborn

People coping with serious illnesses or chronic conditions often see the problems of their health care systems up close. In the 2011 Commonwealth Fund International Survey—the results of which were published today in Health Affairs—adults with health problems in 11 countries (Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States) reported on their recent health care experiences. The survey found that in all countries, care is often poorly organized, medical errors are not uncommon, and, in many countries, particularly the U.S., recommended care can be unaffordable. But patients from all countries who had a "medical home"—that is a primary care practice that helps them navigate the delivery system and provides easy access to needed care—had significantly better experiences.

Among the 11 countries surveyed, the U.S. stands out for its cost and affordability problems. More than 40 percent of adults with chronic conditions or other serious illnesses reported that they did not get medical care in the past year because it was too expensive, and a quarter reported serious difficulty paying medical bills. These problems were most common among those under age 65, both insured and uninsured, suggesting that Medicare helps protect the elderly from financial vulnerability. In contrast, in the U.K. only 11 percent reported cost-related barriers to care and just 1 percent had difficulty paying medical bills.

But in the U.S., costs weren't the only barrier to care. Although per capita U.S. spending on health care far exceeds that in any of the other countries, U.S. adults also reported among the highest rates of errors and coordination gaps.

At the same time, U.S. adults were more positive than patients in other countries about their clinicians' efforts to engage them and help them manage their care. These positive responses perhaps reflect widespread endorsement and spreading use of the chronic care model, which originated in the United States. Efforts to improve chronic care are likely to intensify with the spread of Affordable Care Act reforms, such as new payment and information systems that support a team-based, patient-centered approach to care.

We found that in all countries, providers often fail to communicate with each other or coordinate care, according to patients' reports. Yet in each country patients who have a "medical home" are far less likely to encounter duplication of care, delays, and failures to share important information.

Sicker adults were also less likely than many of their counterparts in other countries to be able to get a same- or next-day appointment when they were sick and easily access care in the evenings, weekends, or holidays without going to the emergency department. The U.S. stands out as the only wealthy nation with a large uninsured population. 

Even with these wide variations among health systems, these nations face similar challenges. No one system has completely solved the puzzle of providing seamless, coordinated, and patient-centered care across providers for patients with complex needs. As they experiment with reforms to meet these challenges, all of these countries have opportunities to learn from each other.

Recent U.S. policy debates have focused on reducing health care spending, including proposals to scale back benefits in public programs. Yet, all the other countries in the survey already spend far less on health care than the United States and provide more comprehensive, protective benefits. Comparative research finds that the higher costs in the United States compared with other countries are largely due to the higher prices for health care services and not related to the generosity of insurance.

As the U.S. moves to implement the complex set of payment, information, care system, and insurance reforms that make up the Affordable Care Act, it will need to maintain its commitment to ensuring access to care and avoid shifting costs to patients with complex health care needs.

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Cristin McQueen, RN, MSN, FNP-BC of Matrix Medical Network says:
November 16, 2011

I experienced the palpable relevancy of this issue as my elderly father passed away this week from complications of iatrogenic, recurrent C. difficile infection. Although the intrinsic issues of his rapid dehydration in the setting of renal insufficiency and poor cardiopulmonary and hepatic status contributed to his demise ultimately, it was the extrinsic problems of lack of a medical home, let alone a PCP, that made his last 4 months of life so very emotionally difficult for him and my whole family. (His PCP, an internist and nephrologist, dropped him after 20+ years as he was phasing out his IM practice in favor of his renal specialty) My father's "retired" PCP said to me, "It's hard to practice internal medicine these days," referencing that he couldn't continue see his internal medicine patients in the hospital, "...because nobody wants to pay." Meanwhile, my father, my family, even me - a family nurse practitioner - struggled to procure a coordinated, patient-centered flow of care for him from home to ED to hospital to subacute rehab (nursing home) to home health care, and then back into the cycle again on his 3rd recurrence of C. difficile as an outpatient. Also meanwhile, his hospital procedures and expenses mounted exorbitantly under the disjointed care of revolving hospitalists, who would often preface their updates to me with, "I just came on service for your father, and he is previously unknown to me....." Out of the hospital and into a rehab and then the community health system the frustrating, disjointed care continued, including trying to secure an 85-year old man a new PCP in the midst of serious chronic health problems. It was a very sad ending-state of medical affairs for a man who served his country in WWII and later received commendation from the Joint Chief of Staffs for his work at the Pentagon, before turning his life's work to serving his county Health Department until his retirement in his 70's. I have been concerned about our noncontinuous, fee-for-service healthcare system that is especially harsh to our vulnerable populations for sometime now, especially since starting my practice as a family NP and assuming primary care work. But now I've had a wake-up call that goes to bed with me every night even more so; and I'm evermore determined that healthcare reform and redesign is our only option if we are to remain a civilized society.