The New Health Dialogue

It is not every day the U.S. loses to the Dutch. Heck, even when our wooden-shod friends were favored in soccer over the U.S. in group play at the Olympics this summer, the U.S. came from behind to tie.

But when it comes to the quality of health care services, particularly taking care of people with chronic disease, the Netherlands runs way ahead of us.

So do Australia, New Zealand, France, Germany, the United Kingdom and Canada.

The Commonwealth Fund and Harris Interactive's 2008 survey of access and efficiency of health care services offered to chronically ill adults in eight industrialized countries provides yet more evidence that we in the U.S. do a terrible job of caring for patients with ongoing conditions. Despite far outspending the other seven countries surveyed, and despite high cost sharing even for insured patients, the U.S. was the hands-down survey loser. It's another reminder that our anachronistic system is designed to respond to acute, episodic illnesses, not prevent complications or deterioration of patients with chronic conditions.

The researchers surveyed about 10,000 people, most of whom were either in poor health or had experienced a serious illness or surgery in the previous two years. The Netherlands didn't top every category, but the United States almost always brought up the rear. Examples:

Skipping Care Because of Cost

• Chronically ill U.S. adults were most likely to report forgoing needed care because of costs. More than 54 percent reported at least one cost-related access problem, like not filling a prescription or not visiting a doctor when sick. Twenty-nine percent of the U.S. patients surveyed were uninsured during the year.
• The Dutch and the U.K. were the least likely to go without care

Can't Get Access to Timely Care

• U.S. patients are the least likely to receive same or next-day access to care (a point we'd like to emphasize to all those skeptics of health reform out there who are always complaining that we'd have to wait for care)
• The Dutch have no problem receiving same-day care, and have superb access during evenings and weekends

U.S. Uses ERs More

• Chronically ill adults used hospital ERs more in the U.S., Canada and Australia than in the other five countries

More Medical Errors in U.S.

• Lab and diagnostic test errors and delays in hearing about abnormal test results were significantly higher for U.S. patients than in other countries

Complaints About Wasted Time and Duplicate Tests

• U.S. patients were significantly more likely to report wasted time because of poorly organized care and unavailable medical records or test results lead to unnecessary duplication of tests
• The Dutch (and the U.K.) were the least likely to report time wasted and reported significantly better coordinated care

A couple of the things the United States does relatively well: timely access to specialist care and decent instructions after hospital discharge. Apparently, the French are particularly uninterested in touchy-feely post-surgery conversations, with 71percent of French patients reporting deficits in discharge instructions (e.g., after new medications are prescribed, there is a failure to warn of potential adverse drug interactions).

This was a powerful survey with important lessons:

1. Our primary care system —to use a clinical term — stinks. U.S. patients lack rapid access and ability to get care after hours.
2. We need medical homes. The absence of a strong primary care infrastructure and inadequate coordination of care leads to poor care. Just ask the people who have the most interaction with our health care system.
3. Insurance matters. U.S. patients either forgo care due to costs or can't afford to follow recommended care. What is so pathetic about this truth is that we are WAY outspending our foreign friends on health care.

Why are the Dutch winning the health care game? They have comprehensive insurance benefits and a strong primary care infrastructure. I'm not trading in my "Sex in the City"-inspired footwear for wooden shoes, but I'd still like us to follow in their health care footsteps.