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March 28, 2022

Primary care around the world: How does the US fare?

Daily Briefing

When compared with adults in 10 other high-income countries, U.S. adults were the least likely to have a regular place of care or a longstanding relationship with a primary care provider (PCP), according to a recent report from The Commonwealth Fund.

U.S. primary care trails behind other wealthy countries

For the report, researchers evaluated the primary care system in the United States against 10 other high-income countries, including issues such as access to care and the coordination of services. In the analysis, they relied on findings from the Commonwealth Fund's 2019 and 2020 International Health Policy Surveys, as well as the Commonwealth Fund's 2020 International Profiles of Health Care Systems report.

Ultimately, the report found that U.S. adults were the least likely to maintain a longstanding relationship with a regular physician, place of care, or PCP, Fierce Healthcare reports. Overall, however, individuals in countries with better access to primary care were much less likely to delay or neglect care. 

"A strong primary care system yields better health outcomes," said Munira Gunja, a co-author and senior researcher at the Commonwealth Fund's International Program in Health Policy Innovations. "Research has shown the importance of primary care in order to help prevent long-term chronic health problems and lower mortality rates."

In addition, the report suggested that individuals in the United States had the least access to home visits and after-hours care. In comparison, the report found that nearly all primary care facilities in Germany, New Zealand, Norway, and the Netherlands offered both home care visits and after-hours care.

"Making sure primary care is accessible outside standard practice hours can help patients avoid emergency department trips for non-urgent care," the authors wrote.

Notably, just half of U.S. PCPs reported sufficient coordination between specialists and hospitals. For example, less than half of U.S. PCPs claimed that they were typically aware when another provider modified a patient's care plan or medication regimen.

"The U.S. has a lot to learn from other countries on the importance of investing in a primary care system that is sufficient and ensuring that they have an adequate supply of primary care physicians," Gunja said, adding that "subsidizing medical education may help incentivize students to go into primary care."

According to the report, U.S. PCPs were the most likely to screen for social service needs. However, U.S. adults were still more likely to worry about having their social needs met when compared with adults in Sweden, Norway, the Netherlands, and Germany.

"Across all the countries," the authors wrote, "it is still relatively uncommon for PCPs to assess patients' social needs, including for housing, food security, transportation, and ability to pay for basic needs like utilities, as well as to screen for exposure to domestic violence or feelings of social isolation or loneliness."

According to the authors, the shortcomings of primary care in the United States are the result of decades of underinvestment in primary care. To address these shortcomings, they recommended several steps for policymakers, including decreasing the wage gap between generalist and specialist physicians, investing in telehealth to expand access to primary care, incentivizing providers to improve the continuity of care, acknowledging the importance of social service needs, and facilitating communication between patients' providers.

"Without a solid foundation in primary care, we don't have a solid healthcare system—period," said Commonwealth Fund President David Blumenthal. "Especially now, in the era of Covid-19, the U.S. needs to invest in strengthening our primary care system," he added. (Kreimer, Fierce Healthcare, 3/15; The Commonwealth Fund, Primary Care in High-Income Countries report, 3/15)

 

 

Advisory Board's take

Why details and context are critical to health care comparisons abroad

The Commonwealth Fund's analysis is a good starting point to understand relative strengths and deficiencies of primary care in the U.S. and abroad. However, looking at the U.S.'s primary care landscape in aggregate is too high-level to inform targeted action. We recommend looking a level or two deeper to identify specific primary care business models in the U.S. as the comparators. Only when you dig into the many pockets of primary care in the U.S. are you able to make meaningful comparisons to other models.

Primary care abroad benefits from a defined scope and identity

Most non-U.S. countries that the survey looks at squarely position primary care as the "front door" of the health system. The publicly funded nature of these countries' health systems means that the taxpayer is ultimately the health care payer—so they have built their primary care systems to consistently excel at managing disease in the community and limit downstream demand.

Because increasing access and decreasing costs are the primary, and sometimes conflicting goals, most countries use some combination of the following tools in their primary care systems as a whole:

  • Gatekeeping—in most, but not all, countries assessed here, a patient must obtain a PCP referral to see a specialist.
  • Compulsory enrollment—most patients are required to have a registered family doctor, and many countries such as the UK go as far as automatically enrolling patients in a certain geographic area with a PCP. The patient can of course choose to enroll in a different practice, but as a baseline, they are on some PCP's panel.
  • Cheap or free to access—perhaps you will pay a small co-pay to see a PCP in Switzerland or Germany, but financial exposure to the patient is generally small regardless of primary care services rendered, especially compared to the U.S.
  • Broad coverage and portability—because insurance coverage elsewhere is not tied to employment, but often guaranteed on a large provincial, state, or national basis, your average citizen is never really "out of network." That means that a patient can more easily keep their family doctor from childhood or PCP across multiple jobs.
  • Independence from health systems—other countries often have stricter versions of the Stark Law that makes it difficult for health systems to legally own and operate PCP practices as referral engines.

The U.S.' primary care 'system' is more of a landscape of choice

While it's a stretch to say other countries have monolithic primary care systems, they are indeed more monolithic than what the U.S. operates with. The level of heterogeneity of primary care models in the U.S. is orders of magnitude larger than anything happening in other countries—traditional PCPs, HMO models, PCPs that specialize in a single consumer type, concierge or retail, direct-to-consumer disruptors, Big Tech, health-system-owned clinics, the list goes on. And this doesn't even account for the numerous payer type or PCP employment models that are out there.

But this, of course, is by design. Because choice is the U.S.' supreme health care value, its primary care landscape is more complex and does not have a universally accepted role or function. Rather, there are many roles and many functions, each of which targets a specific consumer base. Take a company like Iora or ChenMed—the best comparisons there might be PCP networks in the U.K. or Family Health Teams in Ontario. But for a small, independent practice of a few PCPs, it might be best to look to Germany or the Netherlands.

Parting thoughts

We firmly believe in the power of examining health care globally. We have an entire research subscription based around that belief. But comparisons like the Commonwealth Fund's are only instructive when they capture the context behind health care system performance and measure the elements that are comparable.

And to be clear, primary care across the world is full of challenges. Patients still go to ED when it's not clinically appropriate. PCPs internationally still complain about not getting discharge information when their patients go to the hospital. There is opportunity to improve across the board. Isolating the factors that make an international example successful are key. Sometimes, they are structural factors as we highlighted above with primary care. But many times, they're individually influenceable and ripe of best practice adoption.

It's easy to dunk on the U.S. for its primary care performance when you aggregate a $200B part of the health ecosystem. It's more valuable to target the analysis to make apples-to-apples comparisons and then determine what each primary care stakeholder needs to improve.  

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