Finger on the Pulse: The State of Primary Care in the U.S. and Nine Other Countries

Introduction

For many people, primary care is their first point of contact with the health system, and decades of evidence shows it is critical for population health, health equity, and the overall efficiency of health care systems.¹ Primary care is also uniquely positioned to screen for social needs and provide integrated behavioral health services.² Ensuring people have access to high-quality, comprehensive primary care is vital to good health outcomes and positive experiences with the health system at large.

Despite the importance of primary care, health systems around the world are facing challenges at the patient and provider level. Many countries struggle to ensure access to care, or first contact; continuity of care; comprehensiveness of care; and coordination of care. These four core components of high-quality primary care are essential to better overall health outcomes.³ Factors like workforce shortages, physician burnout, and dwindling access for patients, driven in part by underinvestment and growing administrative burdens, pose significant barriers to care.⁴

To better understand how patient care can be improved in a changing primary care landscape, this brief compares the state of primary care in the United States with nine other high-income nations. It updates an earlier Commonwealth Fund study comparing primary care performance in the U.S. with nine peer countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United Kingdom. Our data come from the Commonwealth Fund’s 2022 International Health Policy Survey of Primary Care Physicians and the 2023 International Health Policy Survey of adults age 18 and older. The 2022 and 2023 surveys asked different questions of the participating physicians and responding adults, so this edition includes new measures on access to telehealth, preparedness to treat behavioral health conditions, and care coordination. For more details on our methods, see “How We Conducted This Study.”

Findings

First Contact or Accessibility

Having a regular doctor or place of care is key to preventive care, the early detection and treatment of disease, and chronic disease management.⁵ Patients with a usual source of care are more likely to receive immunizations, blood pressure screenings, and cancer screenings. Regular contact with a primary care physician is also associated with fewer barriers to health care and more positive attitudes about the health system, which may contribute to improved engagement and better coordination of care.⁶

Adults in the U.S. and Canada are the least likely to report having a regular doctor, and there are growing numbers of U.S. adults without a usual source of care over the past decade.⁷ In both countries, younger adults ages 18 to 42 were significantly less likely to have a regular doctor or place of care than adults over age 43 (data not shown). In the U.S., younger adults are less likely to have continuous health insurance.⁸ Much like in the U.S., the tradition of having one family doctor is fading in Canada, as younger people become more transient and seek care through different means, such as walk-in clinics or telehealth.⁹

Telehealth, or the delivery of care remotely by audio or video, is a key to ensuring convenient access to primary care, particularly for people in remote or rural areas.¹⁰ Telehealth can allow physicians to easily share information for better clinical education and facilitate diagnosis or prevention by enabling patients to seek care in a timelier fashion than if they had to travel to an appointment in person.¹¹ However, telehealth was used in the majority of patient encounters in only two of 10 surveyed countries (data not shown), with one in 10 physicians in New Zealand and over a quarter of U.K. physicians reporting high telehealth use. On the other end, just 2 percent of physicians in the U.S., Australia, Sweden, and Germany reported “high” telehealth use.

Because telehealth had been introduced within the U.K.’s National Health Service (NHS) prior to the COVID-19 pandemic, the NHS had much of the infrastructure in place. Patients and physicians were also already familiar with virtual care settings. Research shows that telehealth utilization and satisfaction — both for patients and physicians — has remained high long after the pandemic peaked.¹²

Home visits by doctors improve health outcomes and are a vital for reaching people who are homebound.¹³ Physicians in the U.S. were significantly less likely to report making frequent or occasional home visits than physicians in other surveyed countries, where over two-thirds reported doing so. Lower U.S. rates could be attributed to a smaller supply of physicians overall, but factors like lack of financial incentives, time, and training, as well as safety and liability concerns, could also be at play.¹⁴ In Germany, where all physicians reported making frequent or occasional home visits, physicians and many specialists are legally required to offer home visits.¹⁵

Continuity of Care

Having a longstanding relationship with a primary care physician deepens patient trust and is associated with lower total health care costs and hospitalizations.¹⁶ Yet only about two of five adults in the U.S. and Australia reported having been with their primary care physician for at least five years, a significantly lower proportion than in the other countries we analyzed.

Offering primary care services outside regular operating hours expands access to health care, particularly for caregivers or people with jobs that limit their ability to receive care during regular business hours. It can also lower improper use of emergency departments and increase patient satisfaction.¹⁷

In four of the nine surveyed countries, over two-thirds of physicians reported having arrangements for patients to be seen outside of regular hours, meaning weekends or after 6:00 p.m. during the week. Just over half of physicians in the U.S. reported seeing patients outside regular hours.

Comprehensiveness of Care

Screening for the drivers of health, like housing instability or food insecurity, allows physicians to understand the social and economic circumstances that affect their patients’ health.¹⁸ It is also an initial step in addressing those needs.

About a third of physicians in the U.S. and Germany reported that their practices usually screen or assess patients for at least one social need. In the U.S., there is concerted effort by policymakers and payers to make screening more common and standardized.¹⁹ This is particularly important given that compared to other surveyed countries, the U.S. has higher rates of material hardship, such as food insecurity and financial instability, along with a weaker social safety net. Across all other countries, a quarter of physicians or less reported usually screening patients for at least one social need.

After screening for social needs, primary care physicians can coordinate with community-based social services to address the needs identified. In every country, more than half of physicians reported challenges connecting patients’ care with social services.

Coordination challenges included internal, practice-related factors like the amount of paperwork required, not having a system or enough staff to make referrals, or lacking information about services available in the community. Some challenges were also external, including lack of follow-up from the social service organizations about which services patients received or needed.

Across all surveyed countries, more than 90 percent of physicians reported that their practices were well prepared to manage care for patients with behavioral health needs. Despite falling toward the bottom of the pack compared to other countries, previous research has shown that in the U.S., most primary care physicians treat behavioral health issues, and, in fact, most primary care visits are for behavioral health needs.²⁰

Announced in January 2023, Medicaid programs will now be able to cover interpersonal consultations, where primary care providers consult with behavioral health specialists to develop treatment plans for their patients.²¹ The Centers for Medicare and Medicaid Services also announced a multistate integrated care pilot model, where community-based behavioral health providers will form integrated teams of physical health providers and community-based social supports to treat patients.²² Wide implementation of integrated care is imperative for expanding equitable access to behavioral health services, since it can reduce the need for additional appointments or visits and improve outcomes across age groups and diagnoses.²³

Coordination of Care

Coordination between physicians and other care providers is essential to ensuring patients’ needs and preferences are communicated at the right time to the right people.²⁴

Two-thirds of U.S. adults reported that their regular doctor helped coordinate their care by assisting them with getting appointments, following up to make sure patients received recommended care, and ensuring other doctors had important information about them.

Patient care plans, which are collaboratively designed care processes tailored to the specific health priorities and social context of a patient, have been found to improve health outcomes.²⁵ Coordinating and communicating about patient care plans is critical for ensuring all physicians are aware of patient preferences and are providing effective treatment, all while reducing the burden on patients.

In the U.S., the decentralized and fragmented nature of the health system makes care coordination complicated.²⁶ Only four in 10 U.S. physicians reported usually receiving information about changes to their patient’s care or medication plans from specialists or hospitals. In Germany, just one in five physicians report coordinating care. By contrast, in the U.K. and New Zealand, over two-thirds of physicians reported regularly receiving this critical information.

Conclusion

Our analysis reveals primary care systems around the world are facing challenges. Consistent with prior research, we found the U.S. trails its peers, particularly in access to and continuity of care. Patients in the U.S. are among the least likely to have access to primary care outside of regular business hours or a longstanding relationship with their primary care physician.²⁷ Experts point to a few likely causes. Primary care physicians in the U.S. are paid less than specialists, and investment in primary care overall is low and decreasing over time.²⁸ Furthermore, fewer practitioners are entering the field at a time when the health care needs of patients are growing, inequities are widening, and we are asking more of the primary care physicians we do have.²⁹

There are several options for federal and state policymakers seeking to strengthen primary care in the United States:

• Invest in primary care. The U.S. spent 4.7 percent of its total health care spending on primary care in 2021 compared to an average of 14 percent in other high-income countries.³⁰ Greater financial support for primary care, including physicians and their care teams, would give providers greater resources to expand access through telehealth, home visits, and after-hours appointments, and make care more comprehensive by addressing behavioral health and social needs. More than 20 states have increased investment in primary care in recent years, and there are opportunities for supportive federal policy action, like updating the Medicare physician fee schedule.³¹
• Grow the primary care workforce. The U.S. has the largest wage gap between generalist and specialist physicians, as well as the highest medical tuition fees, among the countries included in this analysis.³² Facing lower salaries and large student loans, fewer physicians are going into primary care, and even fewer choose to practice primary care in underserved communities. Policymakers can narrow this wage gap and increase federal funding for workforce development by pushing for more competitive compensation and loan repayment programs, particularly those that encourage physicians to practice in rural and underserved areas, such as Teaching Health Center Graduate Medical Education Program and the National Health Services Corps. Similarly, Australia has a well-established Workforce Incentive Program to financially incentivize physicians to practice in rural or remote areas.³³
• Reform payment for primary care. The U.S. pays for primary care largely through volume-based, fee-for-service payments, which incentivizes physicians to deliver more services while limiting which services they can provide. Moving to population-based payments, which provide upfront, predictable payment, would enable and incentivize physicians to offer a more comprehensive set of services — such as care coordination or addressing social needs — and give them greater flexibility to deliver the right care at the right time.³⁴ Federal and state policymakers can develop new primary care payment reform models, or scale existing ones, to increase flexibility and hold physicians accountable for patient outcomes.
• Facilitate better coordination between primary care and other physicians. Our findings also show there is a disconnect in the patient–provider relationship when it comes to care coordination. In the U.K., for example, the majority of physicians believe that patient care is being coordinated, but just half of patients feel their care was coordinated. In the U.S., federal and state policymakers can financially incentivize communication between primary care physicians, specialists, and hospitals by, in part, expanding interoperability between electronic health records (EHRs) and ensuring all stakeholders, including patients, feel their care plans are being coordinated and communicated with all providers.³⁵
• Reduce the administrative burden on primary care physicians. Primary care physicians are facing unprecedented burnout and administrative burden across the globe.³⁶ Policymakers can take steps to reduce the many requirements primary care physicians uniquely face in reporting, prior authorizations, billing, and documentation. This could improve care, reduce burnout, and minimize hurdles to providing care, enabling physicians to spend more time with patients.³⁷ Additional strategies to streamline administrative work, reduce physician workload, and improve care delivery include redesigning health care processing technology — like electronic health records and other electronic administrative tasks — with the input of physicians.³⁸