Fifty-eight percent of primary care doctors in the U.S. report their patients often have difficulty paying for medications and care, and half of U.S. doctors spend substantial time dealing with restrictions insurance companies place on their patients' care, according to findings from the 2009 Commonwealth Fund International Health Policy Survey published online today in the journal Health Affairs.
The responses of U.S. doctors also stand out in the 11-country survey because the vast majority (69%) report that their practices do not have provisions for after-hours care, forcing patients to seek care in emergency departments. U.S. doctors were also far less likely to use health information technology that helps reduce errors and improve care-only 46 percent of U.S. doctors use electronic medical records compared to 99 percent of doctors in the Netherlands and 97 percent of doctors in New Zealand and Norway.
Many of the areas in which the U.S. lags would be addressed by proposed health reform legislation currently under consideration in Congress. "We spend far more than any of the other countries in the survey, yet a majority of U.S. primary care doctors say their patients often can't afford care, and a wide majority of primary care physicians don't have advanced computer systems to access patient test results, anticipate and avoid medication errors, or support care for chronically ill patients," said Commonwealth Fund Senior Vice President Cathy Schoen, lead author of the article. "The patient-centered chronic care model originated in the U.S., yet other countries are moving forward faster to support care teams including nurses, spending time with patients, and assuring access to after-hours. The study underscores the pressing need for national reforms to close the performance gap to improve outcomes and reduce costs."
The survey of 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 describes a U.S. primary care system that is under stress and highlights areas where the U.S. can learn from other countries. Notably, the U.S. could look to improve by using financial incentives to improve quality and efficiency, expanding access to health care and simplifying insurance, expanding the use of health information technology to prevent medical errors, and using a medical home approach to primary care where patients have options for care at any time of day or night, teams of health care providers to manage conditions, and continuity of care.
"Access barriers, lack of information, and inadequate financial support for preventive and chronic care undermine primary care doctors' efforts to provide timely, high quality care and put the U.S. far behind what many other countries are able to achieve," said Commonwealth Fund President Karen Davis. "Our weak primary care system puts patients at risk, and results in poorer health outcomes, and higher costs. The survey provides yet another reminder of the urgent need for reforms that make accessible, high-quality primary care a national priority."
Survey Highlights:
Access and Barriers to Care - More than half of U.S. physicians (58%) report their patients often have difficulty paying for medications or other out-of-pocket costs, compared to between 5 percent and 37 percent in the other countries.
U.S. physicians are also 4 times or more as likely as physicians in some other countries-Australia, 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%) 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%) and U.K. (22%) 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 report any arrangement for patients to see a doctor or nurse after hours, a drop from 40 percent in the 2006 Commonwealth Fund International Health Policy Survey. In contrast, nearly all doctors in the Netherlands (97%), and large majorities in New Zealand (89%) and the U.K (89%) report after-hour provision, as do more than three of four doctors in France (78%) and Italy (77%).
Health Information Technology - While nearly half (46%) of U.S. primary care doctors report using electronic medical records (EMRs)-up from 28 percent in 2006-U.S. primary care practices, along with Canadian doctors, continue to lag well behind other leading countries. EMRs are nearly universal in the Netherlands (99%), New Zealand (97%), the U.K. (96%), Australia (95%), Italy (94%), Norway (97%), and Sweden (94%).
In addition to basic EMRs, the survey asked about a range of 13 possible computer functions, including electronic medication prescribing and alerts for medication errors, ordering lab tests and viewing test results, and support and prompts for preventive care and follow-up care with patients. Here country results varied widely, ranging from nearly all to half of doctors reporting at least nine of 14 possible computerized functions in New Zealand (92%), Australia (91%), the U.K. (89%), Italy (66%), and the Netherlands (54%), to one fourth or fewer practices in the U.S. (26%), Canada (14%), France (15%), and Norway (19%).
Notably, in the United States, advanced information capacity was concentrated in larger group practices and those affiliated with integrated care systems. In contrast, in the seven countries with near universal use of EMRs, there was little or no difference in advanced health information technology use by practice size. The authors note that in these countries national policies and standards have supported wide adoption of information technology in primary care practices.
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 U.S., 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%), the Netherlands (81%), New Zealand (80%), Italy (70%) and Australia (65%) report some type of extra financial incentive or target support to improve primary care capacity.