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4 Public Health and Medical Care Systems
Pages 106-137

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From page 106...
... . Cost sharing is common in the United States, and high out-of-pocket expenses make health care services, pharmaceuticals, and medical supplies increasingly unaffordable (Commonwealth Fund Commission on a High Performance System, 2011; Karaca-Mandic et al., 2012)
From page 107...
... household income (Commonwealth Fund Commission on a High Performance System, 2011)
From page 108...
... Wagner and colleagues (1996) were among the first to document the importance of coordination in managing chronic illnesses.
From page 109...
... , as are a host of effective medical treatments for acute and chronic illness care (Cochrane Library, 2012)
From page 110...
... health disadvantage, such as infant mortality and other adverse birth outcomes, HIV infection, heart disease, and diabetes.
From page 111...
... , the high consumption of health care resources may also be the product of the U.S. health disadvantage (reverse causality)
From page 112...
... In a 2010 Commonwealth Fund survey, only 70 percent of U.S. adults reported being confident or very confident that they would receive the most effective treatments (e.g., drugs, tests)
From page 113...
... developed a health care decommodification index based on the following three variables: private health expenditure as a percentage of gross domestic product, private hospital beds as a percentage of total bed stock, and the percentage of the population covered by the health care system. She found that the United States had a lower decommodification score (9.0)
From page 114...
... 114 TABLE 4-1  Cost-Related Access Problems in the Past Year Among U.S. Patients with Complex Chronic Conditions, 2011 Percentage of Respondents Reporting Access Problems in Selected Countries New United United Problem Austria Canada France Germany Netherlands Zealand Norway Sweden Switzerland Kingdom States Difficulty  8  8  5  6 14 11  7  4  8  1 27 paying or unable to pay medical bills Cost-related 30 20 19 22 15 26 14 11 18 11 42 access problems Did not visit a 17  7 10 12  7 18  8  6 11  7 29 doctor when had a medical problem Did not get 19  7  9 13  8 15  7  4 11  4 31 recommended test, treatment, or follow-up Did not fill a 16 15 11 14  8 12  7  7  9  4 30 prescription or skipped doses SOURCE: Data from Schoen et al.
From page 115...
... .7 Physician density grew in the United States by only 0.5 per 1,000 people between 2000 and 2009, a lower growth rate in physician density than that reported by any peer country but France.8 Access to physicians varies by geography, a particular problem in the United States with its large rural expanses.9 Primary Care  Although the United States does well in providing access to many specialists, access to primary care physicians and a regular health care provider is more limited than in many other countries (OECD, 2011b; Schoen et al., 2009b, 2011; Starfield et al., 2005; World Health Organization, 2008b)
From page 116...
... . In another Commonwealth Fund survey, U.S.
From page 117...
... Responses to the Commonwealth Fund surveys suggest that U.S. patients with complex care needs are more likely than those in many other countries to face delays in seeing a physician or nurse within 1-2 days, especially after normal office hours, making it necessary to rely on an emergency department (Schoen et al., 2011)
From page 118...
... . According to the OECD, the United States has the third highest rate of mammography screening among peer countries, surpassed only by the Netherlands and Finland, and it has the highest cervical cancer screening rate among peer countries (and all OECD countries)
From page 119...
... Evaluating the quality of chronic illness care is complex because of the multifactorial influences on care management and coordination. The Commonwealth Fund Commission on a High Performance Health System (2008)
From page 120...
... This interdependence is illustrated by two barriers to trauma care services in the United States -- lack of health insurance and the geography of the United States -- both of which may affect survival and rehabilitation (Greene et al., 2010)
From page 121...
... health disadvantage, such as obesity or diabetes, because comor bidity from chronic illnesses increases the risk of death from injuries (Morris et al., 1990)
From page 122...
... Cardiovascular Care  U.S. patients appear more likely than those in peer countries to have their blood pressure and serum cholesterol levels checked (Davis et al., 2010; Schoen et al., 2004; Thorpe et al., 2007)
From page 123...
... . In a comparison of 5-year mortality rates following acute myocardial infarction among U.S.
From page 124...
... data for peer countries indicate that the United States has the highest asthma hospitalization rate among persons age 15 and older, the U.S. admission rate for uncontrolled diabetes in the same age group is below the OECD average (see Figures 4-3 and 4-4)
From page 125...
... could be averted by better health care,15 Nolte and McKee concluded that the United States had the highest amenable mortality 15  This measure, which has been used in a number of studies (Bunker et al., 1994; Commonwealth Fund Commission on a High Performance System, 2011) , relies on certain assumptions about attributable mortality and does not adjust for disease prevalence (Gay et al., 2011)
From page 126...
... Medical Errors U.S. patients surveyed by the Commonwealth Fund were more likely to report certain medical errors and delays in receiving abnormal test results than were patients in most other countries (Schoen et al., 2011)
From page 127...
... . The only detailed data to compare care delivery practices across countries come from surveys conducted each year by the Commonwealth Fund.
From page 128...
... 128 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE BOX 4-3 Quality of Care: Survey Findings from Commonwealth Fund Surveys Strengths: United States at or Better Than Average • Attention to clinical detail Practice knows important information about medical history Pharmacist/physician reviews and discusses medications Tracking adverse events Regular self-assessment of outcomes and patient satisfaction • Patient-centered communication Encourages questions Discusses goals and priorities Explains treatment options Involves patient in decision as much as wanted Helps make daily treatment plan Gives clear instructions about warning symptoms • Hospital discharge planning  Instructions about symptoms to watch for and when to seek further carea Who to contact for questions about condition or treatmenta Written care plan for care after dischargea Arrangements made for follow-up visits Clear instructions about medications to takea Weaknesses: United States Worse Than Average • Coordination of care Wasted time Wasted time a "major problem" for primary care physician Unnecessary treatment Duplicate testingb No tracking system to ensure results reach clinician No system for physician to send reminders Not using nonphysician staff to coordinate care Not using written guidelines • Medical errors Medical mistake made in treatment Given wrong medication or wrong dose Given incorrect test results on diagnostic test Delays in being notified of abnormal results
From page 129...
... aMore than half of surveyed countries reported a higher prevalence of problems than in the United States. bHalf or fewer surveyed countries reported a higher prevalence of problems.
From page 130...
... However, U.S. respondents are more likely than those in the other surveyed countries to have problems in four key areas that could affect the quality of care outside the hospital, particularly management of chronic illnesses: confusion and poorly coordinated care, inadequate information systems to access needed clinical data, miscommunication between providers and between patients and providers, and medical errors.
From page 131...
... Fig4-5.eps NOTE: Based on surveys of patients with chronic illnesses conducted by the Commonwealth Fund. SOURCE: Adapted from Schoen et al.
From page 132...
... Compared to people living in comparable countries, Americans do better than average in being able to see a physician within 1-2 days of a request, but they find it more difficult to obtain medical advice after business hours or to get calls returned promptly by their regular physicians. There appear to be differences in the quality of hospital and ambulatory care across countries.
From page 133...
... The same surveys that describe coordination problems also suggest that U.S. primary care physicians perform as well as those in other countries in some aspects of care coordination, such as being attentive to clinical details, using reminders to monitor test results, and giving patients medication lists and written instructions.
From page 134...
... However, it is possible that the health disadvantage arises from shortcomings in care outcomes that are not currently measured and from gaps in insurance, access, and coordination. Even the measures that are available for myocardial infarction and stroke are limited to short follow-up periods after the acute event, and outcomes may deteriorate thereafter.
From page 135...
... . The Netherlands, which ranks highly on many surveys by the Commonwealth Fund, has historically had shorter life expectancy than some other comparable countries.
From page 136...
... The Commonwealth Fund gives equal weight to each measure; some weighting is probably warranted, but an empirical basis is lacking to know which characteristics patients value more highly or are more predictive of health outcomes. Even the proper domains for assessing the performance of health sys 24  Such data are lacking even within the United States.
From page 137...
... . Another such effort is that of the Commonwealth Fund, which established a Commission on a High Performance Health System in 2005 that regularly issues a "national scorecard" based on five dimensions: quality, access, efficiency, equity, and long, healthy, and productive lives (Commonwealth Fund Commission on a High Performance Health System, 2011)


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