International survey of physicians in 11 countries reveals US lagging in access, quality, HIT use

New York, NY, November 5, 2009 — 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.

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%), the U.K, (98%), the Netherlands (91%), Australia (88%), New Zealand (88%), Germany (73%) and Norway (73%). Use of teams was far less frequent in the United States (59%), Canada (52%), and France (11%) based on primary care physician reports.

Use of evidence-based guidelines for chronic disease was high in all countries for diabetes, asthma, and hypertension but notably lower for depression. Yet, providing written instructions for patients to manage care at home is not yet routine in any country ? gaps exist in all. Only in Italy did more than half of physicians (63%) say they routinely provide written instructions to chronically ill patients for managing care at home.

Quality Reporting and Feedback ? Many countries in the survey have also 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%), followed by Sweden (71%), New Zealand (68%), and the Netherlands (65%). Less than half of doctors in other surveyed countries?including the U.S. at 43 percent?report such reviews.

U.K physicians (65%) 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%), New Zealand (32%), and Australia (32%).

Looking across survey results, the authors conclude that national policies have been instrumental in the leading countries to achieve round-the-clock access, information systems, and advance primary care teams. 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.”

U.S. In Perspective: Pressing Need for Reforms

Following survey findings that point out lagging U.S. performance, Commonwealth Fund President Karen Davis noted that key national reforms could make a significant difference by:

  • Covering everyone, with a set of benefits that emphasizes primary care and prevention and which 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;
  • Investing in information systems with quality reporting and feedback to spread improved care and safety.

Country-specific information and an online tool to create charts and tables using Commonwealth Fund international survey data from 2006-2009 are available at


Harris Interactive, Inc. and country contractors conducted the physician surveys by a combination of mail, phone and internet (the method varied by country) from February through July 2009. The final study includes 1,016 primary care doctors in Australia, 1,401 in Canada, 502 in France, 715 in Germany, 844 in Italy, 614 in Netherlands, 500 in New Zealand, 774 in Norway, 1,450 in Sweden, 1,062 in the U.K., and 1,442 in the U.S. The Commonwealth Fund provided core support for the study and partnered with the Health Foundation (U.K.), Australian Commission of Safety/Quality, Health Council of Canda, Ontario Quality Council and Quebec Health Commission for expanded samples. Other country were funded by: German Institute for Quality and Efficiency, Haute Authorité de Santé and Caisse Nationale d’Assurance Maladie des Travailleurs Salariés, Italian Association of Primary Care Doctors (FIMMG), Dutch Ministry of Health, Welfare and Sport and Scientific Institute of Quality of Health Care Radboud University, Norwegian Knowledge Center, and the Swedish Ministry of Health. For sample sizes of 1,000 and 500, the margin of sample error are +/- 3 percent and +/-4 percent respectively, at the 95 percent confidence level.

The Commonwealth Fund is a private foundation supporting independent research on health policy reform and a high performance health system.

Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at

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