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International Comparisons

Common Concerns Amid Diverse Systems: Health Care Experiences In Five Countries

PROLOGUE: Researchers worldwide have exhaustively chronicled the inefficiency of the U.S. health care system. The most expensive and technologically advanced health care system in the world yields health outcomes comparable to those of countries with much lower health spending. Some have pointed out structural misallocations of health care assets that hobble the system’s ability to respond to the changing needs of the U.S. population. Molly Coye (Health Affairs, Nov/Dec 2001), for example, has noted "highly variable patterns of care, widespread failure to implement recognized best practices and standards of care, and the persistent inability of provider systems to achieve substantive changes in patterns of practice."

The paper that follows reports findings from the 2002 Commonwealth Fund International Health Policy Survey of Sicker Adults in the United States, Canada, the United Kingdom, Australia, and New Zealand. This study reports the recent experiences of sicker adults in each country with respect to care coordination, physician-patient interaction, medical errors, prescription drug issues, and access to needed care. Interestingly, despite clear structural differences among the systems, findings in all five countries reveal consistent dissatisfaction among surveyed populations with general health system quality, stemming from problems associated with medical errors, inadequate patient-physician communication, and insufficient coordination of care. Robert Blendon and colleagues conclude that sizable dividends (improved health and reduced costs) could be garnered from targeting health reform interventions in each country to such subpopulations of sicker adults, particularly those using multiple physicians and medications.

Blendon is a professor of health policy and political analysis at the Harvard School of Public Health. Cathy Schoen is vice-president for health policy, research, and evaluation at the Commonwealth Fund. Catherine DesRoches is a senior research associate at the Harvard School of Public Health. Robin Osborn is assistant vice-president and director of international health policy at the Commonwealth Fund, and Kinga Zapert is a vice-president of Harris Interactive.

Abstract

 
This article reports on a comparative survey of sicker adults in Australia, Canada, New Zealand, the United Kingdom, and the United States. The study finds that despite differences among the health care systems, large proportions of citizens across the five countries report dissatisfaction with their health care system and serious problems including medical and medication errors, faulty patient-physician communication, and poor care coordination. The most crucial policy implication of these findings is that a focus on a small population of intensive health system users could have the potential to both control costs and improve care.

Focusing on the experiences of sicker adults in the United States, Australia, Canada, New Zealand, and the United Kingdom, the 2002 Commonwealth Fund International Health Policy Survey of Sicker Adults assesses sicker adults’ views of these countries’ health care systems and priorities for policymakers. The survey captures their recent experiences with care coordination, physician-patient communication, medical errors, prescription drug problems, and difficulties getting medical care when needed.

International quality agendas. Concerns with quality and patients’ experiences are high on the policy agendas of these five countries. The study is part of an ongoing effort to promote cross-national learning and collaboration.² In the United States, despite health care spending levels that lead the world, recent reports on medical error and system performance issued by the Institute of Medicine have sparked an array of public and private initiatives to improve care and safety.³ The United Kingdom has made a major investment in quality through an infusion of new public resources derived from tax increases, in an effort to revamp its National Health Service (NHS) to reduce waiting times, improve care, and produce a more patient-centered care system.⁴ In Canada, funding increases for Canada’s Medicare since 2000 have followed an earlier decline in the 1990s, and the country is now awaiting a response to recommendations for reforms to address concerns about resource shortages, waiting lists, and drug coverage.⁵ Australia has taken the lead on patient safety, is supporting public policies to enhance private insurance supplements of public insurance, and has implemented innovative care models for chronically ill populations in coordinated care trials.⁶ New Zealand also is pursuing efforts to improve access and the organization of services within its care system.⁷

The survey series. The 2002 survey is the fifth in a series, begun in 1998, of these five English-speaking countries. Survey populations have included the general public, the elderly, physicians, and now sicker adults. Results are presented at an annual meeting attended by the health ministers of each of the five countries. The results are also used by decisionmakers in each country.⁸

This survey’s focus on sicker adults highlights the challenges these and other advanced industrialized countries share as they seek to redesign medical care delivery systems to make care more effective, efficient, safe, and responsive to patients. Survey findings point to common concerns with varying performance, indicating opportunities to learn from cross-national initiatives.

Survey Methods

Top Survey Methods Survey Findings Commonalities And Differences NOTES

 
Screening interviews. The survey screened initial random samples of adults age eighteen or older who met at least one of four criteria: reported their health as fair or poor; reported that they had had serious illness, injury, or disability that required intensive medical care in the past two years; or reported that in the past two years they had undergone major surgery or had been hospitalized for something other than a normal, uncomplicated delivery. Starting with screening interviews with 2,500–2,900 adults in the five countries, this process resulted in a final sample of 750 or more noninstitutionalized "sicker adults" in each country. This final survey sample represents one-fourth to one-third of those initially contacted (Exhibit 1). The percentages of adults identified who met any one of the four screening criteria were remarkably similar across the five countries, except for the lower proportion of New Zealand adults rating their health as fair or poor. This screening method yielded a study group of sicker adults with either ongoing health care needs or recent, more intensive use of the medical care system (Exhibit 1).

Sampling error. All surveys are subject to sampling error. The margin of sampling error in each country for similarly sick adult groups is approximately plus or minus four percentage points at the 95 percent confidence level or higher. Results were compared between countries using a T test, except where the overall distribution of the variable is shown in the exhibit, when a chi-square test was used. Text and exhibits indicate where differences between countries and groups are significant. Reading rows from left to right, the exhibits compare each country with those following it, indicating where country pairs differ significantly.

Survey Findings

Top Survey Methods Survey Findings Commonalities And Differences NOTES

 
System views. The survey first asked sicker adults about their satisfaction with the health care system overall, with follow-up questions to probe for their main concerns. To assess overall satisfaction, the survey used a standard four-point satisfaction scale borrowed from the Eurobarometer, a general population survey conducted in fifteen European countries.⁹ Sizable minorities of sicker adults in each country had negative views of their country’s health care system: The proportion saying that they were "not very" or "not at all" satisfied ranged from nearly a third in the United Kingdom (31 percent) to more than two out of five adults in New Zealand (48 percent) and the United States (44 percent) (Exhibit 2). Sicker adults in New Zealand and the United States were significantly more likely than those in the other three countries were to report being dissatisfied. However, in no country did the proportion saying they were very satisfied top 25 percent.

In the other four countries, shortages, waiting times, and inadequate government funding led the list of top concerns, with varying emphasis. More than half of sicker Canadians named shortages of health professionals or hospital beds as the leading problem, followed by waiting times. New Zealanders and Britons named waiting times most frequently. In Australia, shortages and waiting times tied as the two top problems.

Recommendations. When asked what is the single most important thing that government could do to improve care, respondents in all but the United States were most likely to call for increased public spending on health care, with about a third endorsing this action. Other responses in these countries indicated support for increased investment in the supply of health professionals or hospitals. Notably, these concerns were echoed by physicians in these four countries when surveyed in 2000, with more than half saying that there were too few hospital beds and more than 30 percent, that there were too few specialists.¹⁰

U.S. opinions were more divided. The single policy action endorsed most frequently by U.S. respondents was to improve coverage of services or people. However, only one-fifth named this policy step; an equal proportion said that they were "not sure" what the government should do (data not shown).

Quality of care. The principal focus of the survey was quality of care. To assess views on the direction of recent changes in the performance of the health care system, the survey asked respondents whether they thought that the quality of care they had received had gotten better or worse over the past two years or had remained the same. Two-thirds or more in all five countries saw little recent change. However, Canadians were significantly more likely than those in the other four countries were to report that quality had gotten worse (Exhibit 2). With the exception of Canada, similar shares of adults reported declines or improvements in the quality of care they had received.

Coordination of care. Patients with chronic health problems or recent hospital or surgical experiences are at risk for breakdowns in the coordination of their care, absent teams or well-organized care systems. A sizable majority of respondents had been cared for by three or more physicians during the past two years (Exhibit 3). Overall, their experiences indicate frequent problems with coordination of care.

Although the percentage of adults reporting coordination failures varied among countries, the frequency of such problems in all five countries indicates common experiences with duplication of effort or delays. These experiences may also fuel the public’s perception of waste in the health system captured in Exhibit 2.

Patients also encountered conflicting information from different physicians and health professionals. One-fifth to one-quarter of respondents in each of the five countries reported that they received conflicting information about their care from different health professionals in the past two years.

Care coordination problems were particularly frequent among people seeing multiple physicians. Those seeing three or more physicians were more than twice as likely as those seeing fewer physicians were to report receiving conflicting information. Similarly, those seeing three or more physicians were about twice as likely to report duplicate tests by different health care professionals and delays in care when medical records or tests did not reach the office in time in all countries except Australia, which repeated the pattern but to a lesser degree.

Pharmaceuticals. The sharp rise in drug spending and trends toward reliance on multiple medications has increased the importance of patient-doctor communication about prescription drugs.¹¹ The survey revealed heavy reliance on medications among sicker adults: Two-thirds or more of respondents in each country said that they rely on prescription medications on a regular basis (Exhibit 4). U.S. adults were significantly more likely to report that they regularly take four or more prescription drugs than were adults in any of the other four countries.

The survey found that medication-related side effects, which pose problems for some sicker adults, are not always discussed between doctors and patients. Among all respondents, including those not currently taking medications regularly, 17–19 percent said that they stopped taking a prescription medication without a doctor’s advice because of side effects, and about one of ten reported that they had experienced serious side effects that the doctor did not tell them about. Few reported having difficulty understanding the instructions for a medication. Compared with adults in the other four countries, U.S. adults were the most likely to say that they skipped doses of medications to make them last longer, a problem found to be widespread among the U.S. elderly in a recent eight-state study.¹²

Patient safety: medication and medical errors. Medical errors have become a highly visible quality-of-care issue, both in the media and in the professional literature of many countries. To compare safety issues across five different health care systems, the survey asked sick patients about medication errors and a more general question about any medical mistakes or errors (Exhibit 5). About one in ten sick patients in each country reported a time in the past two years when they were given the wrong medication or wrong dose by a doctor, hospital, or pharmacist. Reports of medical mistakes were more frequent.

Other studies have found that the number of doctors seen, the number of prescription drugs taken, and the probability of an adverse event are correlated.¹³ Similar to the earlier study, this survey finds that the incidence of reported medical errors increased among those who saw three or more physicians. Such patients reported errors at about twice the rate of those seeing only one or two physicians.

Rates of medication errors also rose with the number of medications taken regularly. At least one of seven respondents who were taking four or more medications regularly said that they had been given the wrong dose or wrong medication in the past two years (Exhibit 5).

Doctor-patient communication. For patients with ongoing care needs, making care more patient-centered by involving patients in care decisions and clearly communicating treatment goals have the potential of improving care. Yet in the survey at least half of respondents reported that their regular physician does not ask for their ideas or opinions about treatment and care (Exhibit 6). Sizable proportions of respondents said that their physicians do not make clear the specific goals for treatment. Moreover, between 28 percent (Canada) and 43 percent (U.K.) of sicker adults said that their doctor does not keep them motivated to do the things they need to do. On all measures in this series, sicker adults in the United Kingdom were significantly more likely than those in the other four countries were to report that these conversations were not taking place.

Considerable emotional strain often accompanies serious or chronic illnesses. Yet the majority of respondents in the five countries said that their regular doctor had not discussed the emotional burden of coping with their illness in the past two years (Exhibit 6). British respondents were the least likely to report emotional support from their physician. Although physicians are doing marginally better at talking about exercise, diet, weight, smoking, and other lifestyle issues, one-third or more of adults in each country reported no discussion of these issues in the past two years. Again, British respondents were the most likely to report that these conversations had not taken place.

Despite evidence of communication failures, the majority of sicker adults in all five countries rated their physician highly (excellent or very good) on questions about care relationships: listening to their health concerns, treating them with dignity and respect, being accessible, spending enough time with them, or diagnosing their problems correctly (Exhibit 6). Ratings of "excellent" or "very good" tended to be highest in New Zealand, with Australia a close second and significantly lower ratings in both the United States and the United Kingdom. Sicker U.S. and U.K. adults were also more likely than their counterparts were to give their physician a negative (fair or poor) rating on diagnosis.

In New Zealand, high ratings of personal physicians coexisted with high levels of dissatisfaction with the health care system overall (Exhibit 1). Analysis of the interaction of care experiences and system views in New Zealand indicate that New Zealanders who were dissatisfied with the care system were significantly more likely (typically twice the rate or more of those who were satisfied with the system) to have experienced medication or medical errors, care coordination problems, and medication side effects and to have encountered difficulties accessing the care system, including waits or access problems related to cost (data not shown). This pattern also held in the other four countries.

Access to care and waiting times. The five countries vary greatly in insurance systems; availability of resources such as physicians, specialists, and hospitals; and recent histories of public investment in their health care systems.¹⁴ Sicker adults’ responses to questions about access to care tended to reflect these variations in countries’ insurance and resources. These findings repeat patterns observed in the 1998 and 2001 five-nation surveys.¹⁵

Seeing specialists. Half of Canadians said that it was difficult to see a specialist when needed, citing waits for appointments as the dominant reason (Exhibit 7). Difficulty in seeing specialists was also reported by more than one in three respondents in Australia, New Zealand, and the United Kingdom, with waiting times listed as the primary reason. Despite the fact that the United States has more practicing specialists per 1,000 people than the other four countries, two of five U.S. respondents also reported difficulties seeing a specialist when needed. U.S. adults, along with adults in New Zealand and Australia, cited costs as one of the main reasons for these difficulties. Costs of specialty care were not an issue in Canada or the United Kingdom. It was only in the United States that sicker adults cited referral denials or delays as a leading reason for difficulties seeing a specialist.

Physician access. Regarding waits to see a physician, respondents in New Zealand were the least likely to report big problems, and Canadian, U.K., and U.S. respondents were the most likely (Exhibit 7). These responses may reflect expectations as well as actual differences in waiting times. The 2001 survey in the five countries asked about the number of days adults had to wait to see a doctor when sick and found that the majority of patients in New Zealand and Australia (69 percent and 62 percent) saw a doctor within one day when sick, with longer waits in the other three countries.

Delayed surgery. Compared to waits for hospital admissions or doctor appointments, comparatively few sicker adults reported big problems with delay of scheduled surgery or other medical procedures because of cancellation (Exhibit 7).

Cost barriers. Access problems are also related to cost. Sicker adults in the United States were most likely to say that they had not filled a prescription or followed up on recommended tests or treatment because of costs, and U.K. respondents were the least likely to report these problems (Exhibit 7). New Zealanders and U.S. adults were the most likely to say that they did not get needed medical care because of cost. At least one of four sicker U.S. adults reported forgoing a needed medical service because of cost. Sicker adults in the United Kingdom were significantly less likely to report forgoing needed care because of costs than were adults in the other four countries.

In general, access questions related to costs were among the only measures in the survey on which care experiences varied significantly by income. On questions about coordination of care, medical or medication errors, or communication with physicians, the study found few or no significant differences by income in the five countries (data not shown).

Commonalities And Differences

Top Survey Methods Survey Findings Commonalities And Differences NOTES

 
The small proportions of all five countries’ populations that are sicker account for the majority of health care expenditures in any given year.¹⁷ This survey indicates that these sicker adults are likely to be at high risk for deficiencies in care coordination, communication failures, and medical care errors. As countries seek to improve care quality, effectiveness, and safety, the survey finds notable areas of common concern as well as varying performance across the five nations.

A limitation of this cross-national study is that we are unable to assess how much of these differences can be attributed to variations in cultural expectations. Despite this limitation, the similarities in problems of coordination, communication, medication problems, and errors are striking.

In all five countries sicker adults’ experiences indicate that failure to coordinate care can result in duplicate tests, delays in care, wasted patient and medical staff time, and conflicting information. Deficiencies in patient-doctor communication can compound such concerns because of failure to involve patients in decision making. The survey indicates frequent failures of physicians during patient visits to exchange information and answer questions, to discuss care goals and options, and to review medication regimens. Although the United Kingdom stands out in this regard, reports from all five countries suggest that each country is missing opportunities to improve care and decrease the possibility of errors.

United Kingdom. Access concerns also exist in all five countries, but sources and types of barriers vary widely. These system differences influence public opinion and expectations of policy leaders. Sicker British adults reported problems with waiting times and other nonfinancial barriers to care, but they were the most satisfied with their health care system.

Canada. Shortages of physicians or other resources and waiting times also top the list of public concerns in Australia, Canada, and New Zealand. Sicker Canadians stand out as the most likely to report difficulties in seeing specialists, and a substantial proportion perceived that quality of care had declined in recent years. Levels of discontent in Canada likely reflect high expectations and recent memories of more ready access to care. Until the early 1990s Canadians expressed the greatest satisfaction with their national health care system, but ratings plummeted with restrictions in national expenditures for health care during the mid-1990s.¹⁸ The sharp increase in the level of discontent in Canada underscores the high value the public places on their health care system. Canadians are now awaiting a policy response to the report from the Royal Commission on the Future of Health Care in Canada.

New Zealand. New Zealand adults expressed some of the highest levels of dissatisfaction with their system overall, citing concerns with waiting times for hospital care and endorsing increased public funding for health care. New Zealand has undergone a series of major health reforms over the past decade.¹⁹ The public response to system changes might account for some of this discontent. Concerns also might reflect capacity constraints. New Zealand’s health spending as a percentage of gross domestic product (GDP) remains below the Organization for Economic Cooperation and Development (OECD) median.²⁰ New Zealanders, however, give their physicians high ratings and report few problems with accessing doctor’s offices.

Australia. Sicker adults in Australia also reported long waiting times and shortages as their top problems. However, Australia was generally in the middle in terms of the range of problems faced by the five countries. It was neither the best nor the worst on any measure.

United States. Sicker U.S. adults were most likely to be concerned about costs and coverage and to report access barriers due to costs. They stand out for forgoing medical care and not getting recommended follow-up treatment because of costs, including skipping medications. This unique exposure to financial burdens when sick reflects basic U.S. insurance patterns. Although U.S. per capita spending and the percentage of GDP spent on health leads the world, forty-one million Americans remain uninsured, and those with insurance tend to face higher out-of-pocket costs than do insured populations in other countries.²¹ It is also surprising, given the much higher level of spending, that the United States does not rank higher on most measures in this survey compared to the other five countries. Notably, it ranked poorly on care coordination, medical errors, overall rating of doctors, and getting questions answered. The high rates of duplicate tests and coordination failures in the United States may contribute to higher costs as well as negative patient care experiences.

Our findings indicate that as countries seek to redesign their care systems, interventions that target patients who see multiple physicians or depend on multiple medications could be particularly effective. Tracking systems, shared electronic medical records, or electronic prescribing of medications offer potential payoffs. Better monitoring of prescriptions could help to prevent medication-related adverse interactions, side effects, and prescription errors and could work toward controlling high pharmaceutical costs. Because sicker U.S. adults are more likely than their counterparts in the other four countries are to see multiple physicians and to be taking multiple medications, efforts to improve care coordination in the United States could be particularly fruitful.

Sicker patients, especially those seeing multiple doctors and taking multiple medications, are bellwethers for how well a health care system is working. The most important policy implication of this study is that a focus on a small population of intensive users of the health care system could have the potential for controlling costs and improving care for all citizens.

Editor's Notes

 
An earlier version of this work was presented at the Commonwealth Fund’s international symposium, Reconciling Rising Health Care Costs and Getting Value for Money, 23–25 October 2002, in Washington, D.C. The authors thank Karen Davis and three anonymous reviewers for many thoughtful comments that improved this paper. The views expressed are those of the authors and should not be attributed to the Commonwealth Fund or its directors or officers.

NOTES

Top Survey Methods Survey Findings Commonalities And Differences NOTES

 

1. G.F. Anderson and J.R. Knickman, "Changing the Chronic Care System to Meet People’s Needs," Health Affairs (Nov/Dec 2001): 146–160.
2. Commonwealth Fund, 2002 International Symposium on Health Care Policy, "Reconciling Rising Health Care Costs and Getting Value for Money," Washington, D.C., 23–25 October 2002.
3. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the Twenty-first Century (Washington: National Academies Press, 2001); and L.T. Kohn, J.M. Corrigan, and M.S. Donaldson, eds., To Err Is Human: Building a Safer Health Care System (Washington: National Academies Press, 1999).
4. "Budget 2000 Government States: Reform Is Price of NHS Cash Boost," FinancialTimes, 22 March 2000, 31.
5. R.J. Romanow, Building on Values: The Future of Health Care in Canada—Final Report (Ottawa: Canadian Government Publishing, November 2002).
6. S. Willcox, "Promoting Private Health Insurance in Australia," Health Affairs (May/June 2001): 152–161; and Commonwealth Department of Health and Ageing Care, "The Australian Coordinated Care Trials: Summary of the Final Technical National Evaluation Report of the First Round of Trials" (Canberra: Department of Health and Ageing, 2001).
7. N. Devlin, A. Maynard, and N. Mays, "New Zealand’s New Health Sector Reforms: Back to the Future?" British Medical Journal (12 May 2001): 1171–1174.
8. For the other surveys, see K. Donelan et al., "The Cost of Health System Change: Public Discontent in Five Nations," Health Affairs (May/June 1999): 206–216; C. Schoen et al., "Health Insurance Markets and Income Inequality: Findings from an International Health Policy Survey," Health Policy 51, no. 2 (2000): 67–85[Medline]; K. Donelan et al., "The Elderly in Five Nations: The Importance of Universal Coverage," Health Affairs (May/ June 2000): 226–235; R.J. Blendon et al., "Physicians’ Views on Quality of Care: A Five-Country Comparison," Health Affairs (May/June 2001): 233–243; and R.J. Blendon et al., "Inequities in Health Care: A Five-Country Survey," Health Affairs (May/June 2002): 182–191.
9. Eurobarometer public opinion polls are conducted on behalf of the European Commission. See German Social Science Infrastructure Service, "The Eurobarometer Survey Series," 18 November 2002, www.gesis.org/en/data_service/eurobarometer (13 February 2003).
10. Blendon et al., "Physicians’ Views on Quality of Care."
11. G. Anderson, V. Petrosyan, and P.S. Hussey, Multinational Comparisons of Health Systems Data, 2002 (New York: Commonwealth Fund, October 2002).
12. D. Safran et al., "Prescription Drug Coverage and Seniors: How Well Are States Closing the Gap?" 31 July 2002, www.healthaffairs.org/WebExclusives/Safran_Web_Excl_073102.htm (10 February 2003).
13. J.L. Wolff, B. Starfield, and G. Anderson, "Prevalence, Expenditures, and Complications of Multiple Chronic Conditions in the Elderly," Archives of Internal Medicine 162, no. 20 (2002): 2269–2276.[Abstract/Free Full Text]
14. Anderson et al., Multinational Comparisons.
15. Donelan et al., "The Cost of Health System Change"; Schoen et al., "Health Insurance Markets"; and Blendon et al., "Inequities in Health Care."
16. In the United States only 5 percent of those with a hospitalization waited four months or more, compared with 23 percent in Australia, 26 percent in New Zealand, 27 percent in Canada, and 38 percent in the United Kingdom. Blendon et al., "Inequities in Health Care."
17. B.G. Druss et al., "Comparing the National Economic Burden of Five Chronic Conditions," Health Affairs (Nov/Dec 2001): 233–241.
18. Donelan et al., "The Cost of Health System Change."
19. Blendon et al., "Inequities in Health Care."
20. Anderson et al., Multinational Comparisons.
21. Ibid.

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