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Patients Report Barriers To Primary Care,
Lab Test Errors Or Delays, International Survey In Five Nations Reveals

U.S. and Canadian Adults Wait Longer to See Doctors
U.S. Patients Report Highest Out-of-Pocket Costs and Foregone Care Due to Costs

New York City, October 28, 2004—A new international survey of patients’ experiences with doctors in five nations finds access concerns in all countries, but also wide variation in waits to see a doctor when sick. U.S. and Canadian adults are the least likely to see a doctor the same day when sick and most likely to wait multiple days for care. Use of emergency rooms for non-emergencies was most frequent in countries with lowest rates of same-day access to doctors. Patients in all five nations report lab test errors and delays in receiving results. U.S. patients are most likely to have high out-of-pocket health care costs and to forego care because of costs, compared to the other four countries, Australia, Canada, New Zealand, and the United Kingdom.

The Commonwealth Fund survey of patients in five countries, published today as a Health Affairs Web exclusive, found shortfalls in all countries but also country variations in delivering accessible, safe, high-quality and patient-centered care.

“Health care leaders in all five countries should be concerned about missed opportunities, errors, and gaps in primary health care, which is the core of any health system,” Fund President Karen Davis said of the report, Primary Care and Health System Performance: Adult Experiences in Five Countries. “The good news is that these deficits can be improved through targeted policy interventions, which some countries have already undertaken by investing in electronic medical records and prescribing systems, and redesigned primary care practices."
The article, by Commonwealth Fund Vice President Cathy Schoen and colleagues at the Fund and Harris Interactive, is based on the 2004 Commonwealth Fund International Health Policy Survey, conducted by Harris researchers between March and May 2004.

Access Difficulties and ER Use

U.S. and Canadian patients were the least likely to report getting same-day appointments the last time they were sick and needed care, with rates well below same-day access in Australia and the New Zealand, the country leaders. U.S. and Canadian adults were also the most likely to encounter waits of six days or more, a waiting time rare in Australia or New Zealand.

Same-day access to a physician appears linked to lower rates of ER use for non-emergencies. Residents of Canada and the U.S., the two countries with the least timely appointments, were the most likely to say they used the emergency room (ER) for conditions that could have been cared for by their doctor if available. In Australia and New Zealand, where a majority of patients received same-day care, adults used the ER for non-emergencies at half the rates reported in the U.S. or Canada.

Difficulty in getting care on nights, weekends, and holidays was a significant concern in all five countries. Although problems were most widespread in the U.S., significant numbers in the other countries reported difficulty getting after-hours care (AU= 54%; CA=59%; NZ=33%; UK=43% US=63%)

About half of patients with recent ER experience rated care excellent or very good in all countries. Yet, patients who had been to the ER in the last two years frequently cited deficiencies in the care they received. Nearly half of patients in Canada (48%), about one-third in the U.K. (36%) and the U.S. (34%) and nearly three of 10 in Australia and New Zealand said they waited two hours or more before being treated. Of patients who went to the ER in pain, more than one in four said that ER staff did not do everything they could to help control their pain (AU=30%, CA=34%, NZ=33%, UK=24%, US=36%).

While wide majorities of patients in all five countries have a regular doctor or place to get care, U.S. patients stood out for short-term relationships with their physicians, signaling a lack of care continuity.

Erroneous Test Reporting, Gaps in Physician/Patient Communication

Up to 15% of patients in the five countries who had a test in the past two years reported getting incorrect test results or delays in being notified of abnormal test results. The U.S. had the highest rate of such problems, nearly double that of the lowest, the U.K. In addition, 16 to 28% of patients who had a lab test in the past two years said that they did not receive results or that results were not clearly explained to them. (AU=16%, CA= 28%, NZ=22%, UK=21%, US=20%)

Doctors also often fail to review prescription medications or explain the side effects, raising risks of drug problems for patients. Among those on regular medications, two-fifths to over half of patients in the study countries said their doctor had not reviewed medications with them or explained side effects in the past two years. (AU=42%; CA=39%; NZ=42%; UK=55% US=41%)

The survey also found missed opportunities for doctors to discuss important health issues and promote preventive care. In the past two years, between half to nearly three-quarters of patients in the five countries reported not receiving advice or counseling on weight, nutrition, or exercise. (AU=62%, CA=55%, NZ=67%, UK=72% US=48%). Three-fifths or more said they had not been asked by their doctors whether emotional issues may be affecting their health (AU=67%, CA=62%, NZ=71%, UK=72%, US=63%). Half to as many as three-fifths of patients across the countries said they do not receive reminders from their doctors about preventive care.

The U.S. stands out for having the best rates of preventive care such as pap tests for women ages 25 to 64 (AU=78%, CA=77%, NZ=81%, UK=77%, US=89%) and mammograms for women ages 50 to 64 (AU=80%, CA=79%, NZ=81%, UK=77%, US=86%), based on women’s reports of tests within the past three years.

U.S. Patients Face High Out-of-Pocket Costs and Care Foregone Due to Costs

One fourth of U.S. patients reported more than $1,000 in out-of-pocket medical costs in the past year, compared to 4% to 14% of patients in the other countries. Overall, U.K. followed by Canadian residents were the most protected against out-of-pocket costs.

U.S. patients are also more likely than those in other countries to go without needed care because of cost. Two of five U.S. patients report one or more cost-related access problems—either not seeing a doctor when sick, not getting a recommended test or follow-up care, not filling a prescription or skipping doses due to cost—compared to one-tenth to one-third of patients in the other four countries.

Adults with lower incomes were more likely to report access problems in all countries, though here again U.S. patients stood out. Over half (57%) of U.S. adults with below average incomes went without needed care due to costs in the past year compared to just 12% of their counterparts in the U.K.

Patient dissatisfaction with their country’s health system is widespread, with 47 to 63 percent thinking fundamental changes are needed. Further, 13 percent to 33 percent say their nation’s health system should be rebuilt completely (AU=23%, CA=14%, NZ=19%, UK=13%, and US=33%). Trends over the last six years show that U.S. respondents’ dissatisfaction in 2004 is back to 1998 levels, after moderating somewhat in 2001.

“The challenge in all five countries is finding the right combination to improve primary care to move to a high performance care system. The United States’ lack of a strong patient-centered or primary care orientation emerges throughout the survey and underscores the importance of examining international strategies that could be adapted and instituted at home,” Cathy Schoen, Vice President of the Commonwealth Fund and lead author of the study concludes.

Methodology: The survey was conducted by telephone by Harris Interactive and its subcontractors with nationally representative cross-sections of adults ages 18 and over in Australia, Canada, New Zealand, the United Kingdom, and the United States between March 29 and May 17, 2004. Interviews were completed with about 1,400 adults in each country. In the United Kingdom, additional samples in specific geographic areas were interviewed in addition to the core 1,400 random sample for follow-up analyses by countries within the United Kingdom.

The article can be read at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.487.

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Separately, Health Affairs is publishing a second paper that assesses the role of pharmacy benefit managers in implementing the new Medicare drug benefit. This paper is the latest in an ongoing series of Health Affairs Web exclusives that explore implications of the new Medicare law.

You can read the article at
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.504.

Health care consultant Robert Atlas writes that PBMs are likely to be an important part of making the new drug benefit work, because they will administer drug benefits of Medicare Advantage plans, potentially offer stand-alone prescription drug plans, and operate the government fallback plan in regions that have no more than one private drug plan. Whether they will participate as stand-alone prescription drug plans remains unclear, because that would require them to accept risk, something PBMs are unaccustomed to doing.

For information on this paper, contact Jon Gardner at 301-347-3930, or jgardner@projecthope.org.

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research.

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©2004 Project HOPE–The People-to-People Health Foundation, Inc.