In global struggle to care for aging populations, plenty of room for improvement

Photo: Chester Paul Sgroi via Flickr

Photo: Chester Paul Sgroi via Flickr

Compared with other industrialized nations, patients age 65 or older in the U.S. are generally in poorer overall health and have more challenges paying out-of-pocket expenses than their counterparts in other industrialized nations, according to a new study in the November 2014 issue of Health Affairs. (Remember, AHCJ members get free access to Health Affairs.)

Older adults in 11 nations – Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States – were asked by telephone about their health and health care delivery. Among the 15,617 adults, age 65 or older, who participated in the 2014 Commonwealth Fund International Health Policy Survey of Older Adults, 20 percent of respondents in every country except France reported problems with care coordination. Access to primary care was most challenging in Canada, the U.S., and Sweden.

The health and payment systems in these countries vary considerably — from single payer to privately funded to an amalgam of benefits, cost-sharing, and subsidies. In the United States, near universal health coverage for seniors is available under Medicare. Some low-income older adults, the dual-eligibles, also receive Medicaid.

The United States had the highest rates of chronic conditions among the 11 countries: 87 percent of respondents reported at least one of seven conditions, and 68 percent had two or more conditions. In contrast, only one-third of older adults in the United Kingdom reported having multiple chronic conditions. 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.

French respondents were the least likely to have seen four or more doctors in the past year or to have been hospitalized in the past two years, while German respondents were among the most likely to report these experiences.

Seniors in most nations struggle with medication management — more than half of U.S. older adults (53 percent) and about 40 percent of older patients in eight other countries reported taking four or more medications. French and Swiss respondents were the least likely to report this rate of medication use.

When it comes to out-of-pocket expenses, nearly 20 percent of U.S. seniors said they skipped a medical visit, test or doctor-prescribed treatment, did not fill a prescription or skipped doses because of high cost. Additionally, just over one-fifth (21 percent) of those in the U.S. spent $2,000 or more in out of pocket costs. In comparison, fewer than 10 percent of older adults in other countries spent $2,000 or more out of pocket or experienced access barriers because of medical costs.

For those needing same or next-day physician appointments, residents of Germany, France and New Zealand were seen the fastest; Canadians, Swedes, and Americans had the longest wait times. When they did visit a provider, older adults in the U.S. most commonly reported that medical records or tests results were unavailable or that tests were duplicated (23 percent). In other countries that figure was 17 percent or less. Communication problems exist in all countries, but were least prevalent in France (6 percent) and most common in Norway (43 percent). French participants also reported very few instances of receiving conflicting information from different providers (2 percent); 16 percent of those in the U.S. said this was a problem.

On the plus side, the United States was at or near the top in the reported frequency with which doctors discussed diet or exercise (76 percent) and stress (29 percent) with their patients. Respondents in the United States also most frequently reported having had a conversation about advance care planning (78 percent) and having named a health care proxy in writing (67 percent) and were among the most likely to report having a written plan regarding the end-of-life treatment they wanted (55 percent). A majority (58 percent) of chronically ill respondents in the U.S. also reported discussing care goals and receiving clear instructions about when to seek further care; fewer than half of patients in 9 other countries received this type of advice.

Although these nations are experimenting with approaches to care for their aging populations, researchers concluded that no health system consistently offers older adults accessible, coordinated, and patient-centered care:

“As industrialized countries recognize the increased demands that will be placed on their already stressed health care system by an aging population, they are all experimenting with policy reforms and delivery system innovations to improve care and quality of life.”

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