Thursday, November 20, 2014

International comparison of patients over 65 - impact of Medicare

Health Affairs
November 2014 (online)
International Survey Of Older Adults Finds Shortcomings In Access,
Coordination, And Patient-Centered Care
By Robin Osborn, Donald Moulds, David Squires, Michelle M. Doty and
Chloe Anderson


Industrialized nations face the common challenge of caring for aging
populations, with rising rates of chronic disease and disability. Our
2014 computer-assisted telephone survey of the health and care
experiences among 15,617 adults age sixty-five or older in Australia,
Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden,
Switzerland, the United Kingdom, and the United States has found that US
older adults were sicker than their counterparts abroad. Out-of-pocket
expenses posed greater problems in the United States than elsewhere.
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. One-fifth or more of older adults reported receiving
uncoordinated care in all countries except France. US respondents were
among the most likely to have discussed health-promoting behaviors with
a clinician, to have a chronic care plan tailored to their daily life,
and to have engaged in end-of-life care planning. Finally, in half of
the countries, one-fifth or more of chronically ill adults were
caregivers themselves.

Comparative US Performance And Challenges Going Forward

Despite having Medicare coverage, older US adults remained much more
likely to face financial barriers to care than their counterparts in
other developed countries. This may be surprising, as other studies have
found that Medicare offers more stable and protective insurance than
other forms of coverage in the United States, including
employer-sponsored private coverage. However, it is still clearly less
protective than the universal coverage offered in the health systems of
other countries surveyed. This finding likely reflects limitations in
Medicare coverage, including substantial deductibles and copayments,
especially for pharmaceuticals, which are often more expensive in the
United States than elsewhere. The absence of limitations on catastrophic
expenses and long-term care coverage likely play a role as well.

Financial barriers aside, elderly Americans also face comparatively poor
access to primary care and after-hours care, relatively high dependence
on the ED, and large gaps in care coordination. Yet the survey also
captures areas where the experience of US older adults is favorable.
Both comparatively and objectively, Americans reported good access to
specialists. The US health care system also performed relatively well
when it came to hospital discharge planning and on the more
patient-centered measures of health promotion, self-management support
for chronically ill patients, and support for end-of-life planning.

Finally, the US elderly population is sicker than the comparable
population in other surveyed nations, reporting a much higher incidence
of chronic disease. This higher disease burden will pose critical
challenges for US policy makers in years to come. The United States
already significantly outspends all of the other countries in the
survey—often by a two-to-one margin—despite having the youngest
population. Although the growth in health care costs has slowed in
recent years in all of these countries, these considerations suggest
that the United States will face growing cost pressures. It will be hard
to maintain the current low-growth trajectory unless the United States
successfully implements delivery and payment system reforms that reduce
the cost of care and finds a way to narrow the health gap between itself
and other countries.


Richard Gottfried, Chair, Committee on Health, New York State Assembly,
made the following observation: "The lesson: Living 65 years with
American insurance companies leaves you sicker. Then, transitioning to
American social insurance gives you quicker access to specialists."

(Personal communication, 11/19/14)


November 19, 2014
U.S. Seniors' Health Poorest, Global Survey Shows
By Steven Reinberg

Dr. Steffie Woolhandler, co-founder of Physicians for a National Health
Program, said American seniors are sicker because of the inadequate care
they received before they turned 65.

"The health care system for the under-65 population is full of gaps, and
lots of people fall through the cracks," she said.

Woolhandler, who is also a professor of health at CUNY School of Public
Health at Hunter College in New York City, added that Medicare is also
leaving many Americans underinsured and that the Affordable Care Act
will not make a major difference.

"We need to be providing much more comprehensive coverage to everyone,
including lower co-pays and deductibles," she suggested.


Comment by Don McCanne

This international comparison of health care in older adults in eleven
nations is the latest in the series sponsored by the Commonwealth Fund.
For the United States, it is unique in that it compares only patients
over 65 in our public Medicare program with older patients in other
nations that already have universal health care systems.

Perhaps the most remarkable finding for the United States is that
patients enter the Medicare program sicker than older patients in other
nations, but, once there, they have better access to health care than
those younger than 65. But even our Medicare program leaves our elderly
exposed to greater financial barriers to care than do the systems of
other nations.

This study once again shows what the United States needs is obvious. We
need to improve Medicare so that it provides better coverage, and then
we need to expand it to cover everyone.

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