International Survey Of Older Adults Finds Shortcomings In Access, Coordination, And Patient-Centered Care
By Robin Osborn, Donald Moulds, David Squires, Michelle M. Doty and Chloe Anderson
Health Affairs, November 2014 (online)
Industrialized nations face the common challenge of caring for aging populations, with rising rates of chronic disease and disability. Our 2014 computer-assisted telephone survey of the health and care experiences among 15,617 adults age sixty-five or older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States has found that US older adults were sicker than their counterparts abroad. Out-of-pocket expenses posed greater problems in the United States than elsewhere. Accessing primary care and avoiding the emergency department tended to be more difficult in the United States, Canada, and Sweden than in other surveyed countries. One-fifth or more of older adults reported receiving uncoordinated care in all countries except France. US respondents were among the most likely to have discussed health-promoting behaviors with a clinician, to have a chronic care plan tailored to their daily life, and to have engaged in end-of-life care planning. Finally, in half of the countries, one-fifth or more of chronically ill adults were caregivers themselves.
Comparative US Performance And Challenges Going Forward
Despite having Medicare coverage, older US adults remained much more likely to face financial barriers to care than their counterparts in other developed countries. This may be surprising, as other studies have found that Medicare offers more stable and protective insurance than other forms of coverage in the United States, including employer-sponsored private coverage. However, it is still clearly less protective than the universal coverage offered in the health systems of other countries surveyed. This finding likely reflects limitations in Medicare coverage, including substantial deductibles and copayments, especially for pharmaceuticals, which are often more expensive in the United States than elsewhere. The absence of limitations on catastrophic expenses and long-term care coverage likely play a role as well.
Financial barriers aside, elderly Americans also face comparatively poor access to primary care and after-hours care, relatively high dependence on the ED, and large gaps in care coordination. Yet the survey also captures areas where the experience of US older adults is favorable. Both comparatively and objectively, Americans reported good access to specialists. The US health care system also performed relatively well when it came to hospital discharge planning and on the more patient-centered measures of health promotion, self-management support for chronically ill patients, and support for end-of-life planning.
Finally, the US elderly population is sicker than the comparable population in other surveyed nations, reporting a much higher incidence of chronic disease. This higher disease burden will pose critical challenges for US policy makers in years to come. The United States already significantly outspends all of the other countries in the survey—often by a two-to-one margin—despite having the youngest population. Although the growth in health care costs has slowed in recent years in all of these countries, these considerations suggest that the United States will face growing cost pressures. It will be hard to maintain the current low-growth trajectory unless the United States successfully implements delivery and payment system reforms that reduce the cost of care and finds a way to narrow the health gap between itself and other countries.
Richard Gottfried, Chair, Committee on Health, New York State Assembly, made the following observation: “The lesson: Living 65 years with American insurance companies leaves you sicker. Then, transitioning to American social insurance gives you quicker access to specialists.”
(Personal communication, 11/19/14)
U.S. Seniors’ Health Poorest, Global Survey Shows
By Steven Reinberg
HealthDay, November 19, 2014
Dr. Steffie Woolhandler, co-founder of Physicians for a National Health Program, said American seniors are sicker because of the inadequate care they received before they turned 65.
“The health care system for the under-65 population is full of gaps, and lots of people fall through the cracks,” she said.
Woolhandler, who is also a professor of health at CUNY School of Public Health at Hunter College in New York City, added that Medicare is also leaving many Americans underinsured and that the Affordable Care Act will not make a major difference.
“We need to be providing much more comprehensive coverage to everyone, including lower co-pays and deductibles,” she suggested.
By Don McCanne, MD
This international comparison of health care in older adults in eleven nations is the latest in the series sponsored by the Commonwealth Fund. For the United States, it is unique in that it compares only patients over 65 in our public Medicare program with older patients in other nations that already have universal health care systems.
Perhaps the most remarkable finding for the United States is that patients enter the Medicare program sicker than older patients in other nations, but, once there, they have better access to health care than those younger than 65. But even our Medicare program leaves our elderly exposed to greater financial barriers to care than do the systems of other nations.
This study once again shows what the United States needs is obvious. We need to improve Medicare so that it provides better coverage, and then we need to expand it to cover everyone.