1. Senior Vice President, The Commonwealth Fund
Patients with Complex Care Needs: Coordination, Safety and Medical Homes
Findings from the Commonwealth Fund 2011 International Health Policy Survey of Sicker Adults in Eleven Countries and Health Affairs article, Nov. 2011
Webinar: January 11, 2012
Cathy Schoen
Senior Vice President, The Commonwealth Fund

2. Key Findings
Care is often poorly coordinated for patients with complex care needs – but wide differences emerge across country
Medical homes make a difference
In all countries sicker adults with a “medical home” have more positive care experiences and are less likely to experience coordination gaps or medical errors
Swiss and the United Kingdom patients most likely to have medical homes; have among the lowest rates of access concerns, coordination gaps or errors across countries
United States’ chronically ill patients stand out for access problems because of cost and difficulty paying medical bills
U.S. also among highest for errors and coordination gaps
Survey of “Sicker Adults”, 11 Countries (see last page for details)
Australia, Canada, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland, U.K., and U.S.
March-June 2011 Phone survey of 18,000 adults who reported fair/poor health, recent hospital, or surgery, or serious illness

3. Health Spending per Capita, 2009 Adjusted for Differences in Cost of Living
% GDP
* 2008
Source: OECD Health Data 2011 (June 2011).

4. Cost-Related Access Problems in the Past Year, Sicker Adults 2011
Percent of adults who went without care because of cost in past year *
* Did not see doctor when sick, get recommended care, or fill prescription or skipped doses because of costs.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

5. Out-of-Pocket Spending and Problems Paying Medical Bills in Past Year
Spent more than US$1,000
OOP Costs
Serious Problems Paying or Unable to Pay Medical Bills
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

6. Access to Doctor or Nurse Last Time Sick or Needed Care
Same- or next-day appointment
Waited six days or more
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

7. After-Hours Care and Emergency Room Use
Difficulty Getting After-Hours Care Without Going to the ER
Used ER in Past Two Years
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

8. Waited Less Than a Month to See Specialist
Percent
Base: Saw or needed to see a specialist in the past 2 years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

9. Experienced Coordination Gaps in Past Two Years
Percent
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

10. Gaps in Hospital or Surgery Discharge Planning in Past Two Years
Percent
* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

11. Experienced Medical, Medication, or Lab Test Errors in Past Two Years
Percent*
* Reported medical mistake, given wrong medication or dose, lab test error, or delay receiving abnormal test results.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

12. Patient Engagement in Care Management for Chronic Condition
Percent reported professional in past year has:
AUS
CAN FR
GER
NETH NZ
NOR
SWE
SWIZ UK US
Discussed your main goals/ priorities 63 67 42 59 62 51 36 81 78 76
Helped make treatment plan you could carry out in daily life 61 53 49 52 58 41 40 74 80 71
Given clear instructions on symptoms and when to seek care 66 56 64 44 84 75
Yes to all three 48 30 45 23 22 69
Q1705; q1710; q1730
Base: Has chronic condition.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

13. Patients with a Regular Doctor vs. Medical Home
Percent
Patients with a medical home have a regular practice who is accessible, knows their medical history, and helps coordinate their care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

14. Experienced Coordination Gaps in Past Two Years, by Medical Home
Percent*
Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.
* Test results/records not available at time of appointment, doctors ordered test that had already been done, providers failed to share important information with each other, specialist did not have information about medical history, and/or regular doctor not informed about specialist care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

15. Hospital or Surgery Discharge Gap in Past Two Years, by Medical Home
Percent*
Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.
* Last time hospitalized or had surgery, did NOT: 1) receive instructions about symptoms and when to seek further care; 2) know who to contact for questions about condition or treatment; 3) receive written plan for care after discharge; 4) have arrangements made for follow-up visits; and/or 5) receive very clear instructions about what medicines you should be taking.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

16. Medical, Medication, or Lab Test Errors in Past Two Years, by Medical Home
Percent*
Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.
* Reported medical mistake, medication error, and/or lab test error or delay in past two years.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

17. Patient Engagement in Care Management for Chronic Condition, by Medical Home
Percent reporting positive patient engagement in managing chronic condition*
Q1705; q1710; q1730
Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.
* Health care professional in past year has: 1) discussed your main goals/priorities in care for condition; 2) helped make treatment plan you could carry out in daily life; and 3) given clear instructions on symptoms and when to seek care.
Base: Has chronic condition.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

18. Rated Quality of Care in Past Year as “Excellent" or “Very Good,” by Medical Home
Percent
Patients with a medical home have a regular practice who is accessible, knows them, and helps coordinate their care.
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

19. 19
U.S. Adults: Affordability, Access, and Coordination Experiences in the Past Year, by Age and Insurance
Percent
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

20. Cross-Cutting Themes and Implications
Room for improvement in all countries
Improving care coordination and system integration
Primary care “medical homes” make a difference in all countries
Patients in the U.K. and Switzerland often have more positive experiences despite very different systems
U.S. is an outlier on access and affordability
Concerns concentrated in the under-65 population; Medicare more positive experiences
Other countries spend far less yet provide more comprehensive insurance and protective benefits
Policies need to maintain Affordable Care Act commitment to access and affordability; avoid shifting costs to patients
Opportunities to learn as we confront often similar challenges in diverse health care systems

21. 2011 International Health Policy Survey: Description
Telephone survey of representative samples of sicker adults ages 18 and older conducted from March to June 2011
Sicker adults included: fair or poor health; had surgery or been hospitalized in past 2 years; or received care for serious or chronic illness, injury, or disability in past year
Final Samples 18,000 in 11 Countries
1,500 Australia, 3,958 Canada, 1,001 France, 1,200 Germany, 1,000 Netherlands, 750 New Zealand, 753 Norway, 4,804 Sweden, 1,500 Switzerland, 1,001 U.K., and 1,200 U.S.
Conducted by Harris Interactive and country contractors
Results published in Health Affairs
C. Schoen, R. Osborn, D. Squires, et al. “ New 2011 Survey of Patients with Complex Care Needs in Eleven Countries Finds Care is Often Poorly Coordinated”, Health Affairs, Web First, 11/9/2011, Print December 2011 Vol. 30(12):

22. 2011 Survey Profile of Sicker Adults
Percent
AUS
CAN FR
GER
NETH NZ
NOR
SWE
SWIZ UK US
Age 50 or older 57 50 54 60 58 63 62 56
Has 2+ chronic conditions (out of 8) 44 41 34 42 35 26 37 45 53
Health care use in past 2 years:
Hospitalized 51 43 40 46 48
Surgery 36 39 38
Saw 4+ doctors 32 21 23 24 19 6 16
Taking 4+ prescription medications regularly 28 30 31 27 29
Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

23. Acknowledgments and Cofunders23
Thanks to coauthors David Squires, Michelle M. Doty, Roz Pierson, and Sandra Applebaum, and to Harris Interactive, Inc., and contractors for conducting the survey. Published in Health Affairs as: “New 2011 Survey Of Patients With Complex Care Needs In Eleven Countries Finds Care Is Often Poorly Coordinated,” Web First, November 9, 2011.
Australia: Bureau of Health Information
Canada: Health Council of Canada, Ontario Quality Council, Quebec Health Commission, Health Quality Council of Alberta
France: Haute Authorité de Santé (HAS), Caisse Nationale de l’Assurance Maladie des Travailleurs Salariés (CNAMTS)
Germany: German National Institute for Quality Measurement in Health Care
Netherlands: Dutch Ministry of Health, Welfare and Sport, and Scientific Institute for Quality of Healthcare, Radboud University Nijmegen
Norway: Norwegian Knowledge Centre for the Health Services
Sweden: Swedish Ministry of Health and Social Affairs
Switzerland: Federal Office of Public Health
United Kingdom: Health Foundation