Thursday, November 5, 2009

Survey of Primary Care Physicians in 11 Countries

Survey Highlights:

  • Access and Barriers to Care – 58 percent of U.S. physicians report their patients often have difficulty paying for medications or other out-of-pocket costs, compared to between 5 percent and 37 percent in other countries. U.S. physicians are also four times as likely as physicians in Australia, the Netherlands, Sweden and the U.K. to report major problems with the time they or their staff spend getting patients needed medication or treatment due to insurance coverage restrictions. About half (48 percent) of U.S. physicians report this is a major problem, compared to just 6 percent in the U.K. Twenty-eight percent of U.S. doctors report their patients often face long waits to see a specialist – a rate similar to that reported by Australian (35 percent) and U.K. (22 percent) physicians, the lowest rates in the survey. Three-quarters of Canadian and Italian physicians reported long waits.
  • After-Hours Care Outside the Emergency Room – Most U.S. primary care doctors say they have no arrangement for access to care after normal office hours except for directing patients to a hospital emergency room. Just 29 percent of U.S. doctors have an arrangement for patients to see a doctor or nurse after hours, a drop from 40 percent in the 2006 Commonwealth Fund survey. In contrast, 97 precent of doctors in the Netherlands and 89 percent of those in New Zealand and the U.K report after-hour provisions, as do more than three of four doctors in France (78 percent) and Italy (77 percent).
  • Health Information Technology – While 46 percent of U.S. primary care doctors report using EMRs – up from 28 percent in 2006 – they and their Canadian counterparts lag well behind the Netherlands (99 percent), New Zealand (97 percent), the U.K. (96 percent), Australia (95 percent), Italy (94 percent), Norway (97 percent),and Sweden (94 percent).
  • Financial Incentives to Improve Quality – Every country in the survey, to some degree, uses financial incentives to improve primary care, preventive care, or disease management. Primary care physicians in the United States, however, are among the least likely to report that they receive financial incentives for quality improvement, such as bonuses for achieving high patient satisfaction ratings, increasing preventive care, use of teams or managing patients with chronic disease or complex needs. Only one-third of U.S. physicians reported receiving any financial incentives for the six quality improvement measures in the survey. Rates were also low in Sweden and Norway. In contrast, significant majorities of doctors in the U.K (89 percent), the Netherlands (81 percent), New Zealand (80 percent), Italy (70 percent) and Australia (65 percent) report some type of extra financial incentive or target support to improve primary care capacity.
  • Use of Care Teams and Systems to Care for Patients with Chronic Illness –Teams that include health professionals such as nurses serve an important role in managing care, especially for chronic conditions. The survey results indicate that use of teams is widespread in Sweden (98 percent), the U.K, (98 percent), the Netherlands (91 percent), Australia (88 percent), New Zealand (88 percent), Germany (73 percent) and Norway (73 percent), but much lower in the United States (59 percent), Canada (52 percent) and France (11 percent). Only in Italy did more than half of physicians (63 percent) say they routinely provide written instructions to chronically ill patients for managing care at home.
  • Quality Reporting and Feedback – Many countries have been investing in information on performance to provide incentive and benchmarks. The authors note that "information that peers have met with success is often instrumental to guide and drive innovation." Asked about comparative information systems, doctors in the U.K. are most likely to routinely receive and review data on clinical outcomes (89 percent), followed by Sweden (71 percent), New Zealand (68 percent) and the Netherlands (65 percent). Less than half of doctors in other surveyed countries – including the U.S. at 43 percent – report such reviews. U.K physicians (65 percent) were by far the most likely to report they receive data on how they compare to other practices and, along with Sweden and New Zealand doctors, the most likely to have information on patient experiences. Notably, U.S. doctors lagged well behind these leading countries on feedback on both clinical quality and patient experiences.
  • Tracking Medical Errors –The study finds that half or more primary care doctors in Canada, France, Germany, Italy and the Netherlands report not yet having a process to identify "adverse events" and take action. Just one in five U.S. primary care physicians say they have a process that works well to identify risks and take follow-up actions; one-third said they have no process. At 56 percent, U.K. physicians were most likely to say they have processes they think work well, followed by Sweden (41 percent), New Zealand (32 percent) and Australia (32 percent).

The authors conclude that national policies have been instrumental in achieving round-the-clock access, information systems and advance primary care teams in leading countries. They note that "overall, the survey highlights the lack of national policies focused on U.S. primary care. Unless primary care practices are part of more integrated care systems, they are on their own facing multiple payers with uncoordinated policies."

Davis noted that key national reforms could make a significant difference by:

  • Covering everyone, with benefits that emphasize primary care and prevention and remove financial barriers and support primary care physicians as well as their patients;
  • Providing financial incentives focused on value and health outcomes;
  • Supporting primary care practices and their capacity to serve as "medical homes" with 24-hour access, use of teams of health professionals and continuity of care;
  • Accelerating the adoption and use of health information technology, including electronic medication prescribing, to reduce risks of errors;
  • Simplifying insurance to reduce complexity and paperwork for doctors and their staff; and
  • Investing in information systems with quality reporting and feedback to spread improved care and safety.

Journal: Health Affairs Web Exclusive, Nov. 4, 2009, w1171–w1183
Contact: Cathy Schoen, M.A., Senior Vice President, Research and Evaluation, The Commonwealth Fund,
Summary Writer(s): Deborah Lorber


A study of more than 10,000 primary care physicians in 11 countries finds the United States lags far behind in terms of access to care, the use of financial incentives to improve the quality of care, and the use of health information technology. In other countries, national policies have sped the adoption of such innovations.

The Issue

Research shows that strong primary care is associated with good health outcomes and lower costs. It also can help meet the challenges presented by aging populations and the rising incidence of chronic disease. Across the globe, countries are working to redesign their primary care systems by investing in information technology, round-the-clock access, teamwork, integration, and quality improvement. They also are working to reform delivery systems and payment policies. This study surveyed primary care physicians in 11 countries to find out what is happening on the front lines of health care.

Key Findings

  • More than half (58%) of U.S. physicians—by far the most of any country surveyed—said their patients often have difficulty paying for medications and care. Half of U.S. doctors spend substantial time dealing with the restrictions insurance companies place on patients’ care.
  • Only 29 percent of U.S. physicians said their practice had arrangements for getting patients after-hours care—so they could avoid visiting a hospital emergency room. Nearly all Dutch, New Zealand, and U.K. doctors said their practices had arrangements for after-hours care.
  • Only 46 percent of U.S. doctors use electronic medical records, compared with over 90 percent of doctors in Australia, Italy, the Netherlands, New Zealand, Norway, Sweden, and the United Kingdom.
  • Twenty-eight percent of U.S. physicians reported their patients often face long waits to see a specialist, one of the lowest rates in the survey. Three-quarters of Canadian and Italian physicians reported long waits.
  • While all the countries surveyed use financial incentives to improve the quality of care, primary care physicians in the U.S. are among the least likely to be offered such rewards; only one-third reported receiving financial incentives. Rates were also low in Sweden (10%) and Norway (35%), compared with large majorities of doctors in the U.K. (89%), the Netherlands (81%), New Zealand (80%), Italy (70%), and Australia (65%).
  • Patients with chronic illness require substantial time with physicians, education about their illness, and coaching about treatment, diet, and medication regimens. Care teams composed of clinicians and nurses have been shown to be effective in providing care to people with chronic conditions and in improving outcomes. The use of such teams is widespread in Sweden (98%), the U.K. (98%), the Netherlands (91%), Australia (88%), New Zealand (88%), Germany (73%), and Norway (73%). It is less prevalent in the U.S. (59%) and Canada (52%), with France (11%) standing out on the low end.

Addressing the Problem

The advanced health information technology and extensive use of quality incentives and care teams reported by Australian, Dutch, and New Zealand doctors reflect national payment and information system policies focused on primary care. Lacking such policies, the U.S. lags far behind its peers in these areas—even as it spends far more on health care overall. In addition, insurance coverage restrictions make it difficult for many U.S. physicians to provide their patients with timely access to care.

About the Study

The authors surveyed more than 10,000 primary care physicians in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. Data were collected by mail, by telephone, and over the Internet between February and July 2009.

The Bottom Line

Despite spending more on health care than other countries, an international survey finds the United States lags behind on important measures of access, quality, and use of health information technology. There are opportunities to learn as other countries move ahead to enhance the primary care foundations of their health care systems.


C. Schoen, R. Osborn, M. M. Doty, D. Squires, J. Peugh, and S. Applebaum, A Survey of Primary Care Physicians in 11 Countries, 2009: Perspectives on Care, Costs, and Experiences, Health Affairs Web Exclusive, Nov. 5, 2009, w1171–w1183.

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