A survey of primary care physicians in eleven countries, 2009: perspectives on care, costs, and experiences.

Abstract

This 2009 survey of primary care doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States finds wide differences in practice systems, incentives, perceptions of access to care, use of health information technology (IT), and programs to improve quality. Response rates exceeded 40 percent except in four countries: Canada, France, the United Kingdom, and the United States. U.S. and Canadian physicians lag in the adoption of IT. U.S. doctors were the most likely to report that there are insurance restrictions on obtaining medication and treatment for their patients and that their patients often have difficulty with costs. We believe that opportunities exist for cross-national learning in disease management, use of teams, and performance feedback to improve primary care globally.

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A Survey Of Primary Care
Physicians In Eleven Countries,
2009: Perspectives On Care,
Costs, And Experiences
Doctors say problems exist across all eleven countries, although some
nations are doing a better job than others.
by Cathy Schoen, Robin Osborn, Michelle M. Doty, David Squires, Jordon
Peugh, and Sandra Applebaum
ABSTRACT: This 2009 survey of primary care doctors in Australia, Canada, France, Ger-
many, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the
United States finds wide differences in practice systems, incentives, perceptions of access
to care, use of health information technology (IT), and programs to improve quality. Re-
sponse rates exceeded 40 percent except in four countries: the United States, Canada,
France, and the United Kingdom. U.S. and Canadian physicians lag in the adoption of IT.
U.S. doctors were the most likely to report that there are insurance restrictions on obtaining
medication and treatment for their patientsand that their patientsoften have difficulty with
costs. We believe that opportunities exist for cross-national learning in disease manage-
ment, use of teams, and performance feedback to improve primary care globally. Health Aff
(Millwood). 2009;28(6):w1171–83 (published online 5 November 2009; 10.1377/hlthaff
.28.6.w1171)]
P
shows that strong primary care is associated with good outcomes and lower
costs.1–3Agingpopulations,prevalenceofchronicdisease,andincreasingabilityto
deliver complex care outside the hospital have prompted international efforts to
redesign primary care to improve outcomes and efficiency. Consequently, primary
rimary care clinicians in most countries provide the foundation
for health care systems and serve as the linchpin that improves access, con-
nects care, and provides continuity for patients and families. Research
C a r e& C o s t s
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CathySchoen(cs@cmwf.org)isaseniorvicepresident,ResearchandEvaluation,attheCommonwealthFundin
NewYorkCity.RobinOsbornisavicepresident,InternationalPrograminHealthPolicyandPractice,atthe
CommonwealthFund;MichelleDoty,anassistantvicepresident,SurveyResearch;andDavidSquires,aprogram
associate,InternationalProgram.JordonPeughisavicepresident,GovernmentandAcademicResearch,at
KnowledgeNetworksinNewYorkCity.SandraApplebaumisaresearchmanageratHarrisInteractive,alsoin
NewYorkCity.
DOI 10.1377/hlthaff.28.6.w1171 ©2009 Project HOPE–The People-to-People Health Foundation, Inc.
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care practicesoftenfacenewrequirementsforaccountabilityaswellasincentives
to improve.
Tovaryingdegrees,healthsystemsareinvestingininformationtechnology(IT),
round-the-clock access, providers working in teams, integration, and quality im-
provement.Reformsindeliverysystemsandpaymentpoliciesseektospurinnova-
tions for managing chronic conditions and supporting frail elderly or disabled
people living in the community.
Primary care physicians’ experiences and perspectives in a period of rapid
change offer a unique view from the front lines. To track developments in coun-
tries with diverse health systems, this 2009 study surveyed primary care physi-
ciansinelevencountries:Australia,Canada,France,Germany,Italy,NewZealand,
the Netherlands, Norway, Sweden, the United Kingdom, and the United States.
This survey, the twelfth in a series that informs a symposium of health ministers
and policy experts, focused on access, chronic care management, health IT, and fi-
nancial and information incentives—key areas that have been targets of reforms.
Eleven-Country Context
The countries studied represent a mix of primary care and insurance systems
(Exhibit 1). The United States is distinct in its reliance on internal medicine and
pediatricsforprimarycareanditshighlydecentralizedreferralsystems.Theother
countries rely extensively on general or family practice (GP/FP) physicians, often
augmented by use of primary care nurses for preventive or chronic care and coun-
seling.4InAustralia,Italy,theNetherlands,NewZealand,Norway,andtheUnited
Kingdom, patients register with primary care physicians, who typically serve as
“gatekeepers” for referral for more specialized care. Other countries encourage
registration through financial incentives for patients or providers, or both.5
Primary care practices, except in Sweden, generally operate as private prac-
tices. A majority of Swedish doctors work as public employees (local health cen-
ters),butreformshavebeenmovingtoprivatecontractsandamixofprepayment,
or capitation, and fees.4Insurers in Australia, Canada, France, Germany, and the
United States generally pay fee-for-service (FFS). The other countries use a blend
of capitation and fees for visits, targeted care, or performance incentives. The U.S.
systemincludesexamplesofsalary,mixedFFS andcapitation,andintegratedsys-
tems.6
Insurance systems differ across countries in patient cost sharing. In contrast to
the United States, Canada, the Netherlands, and the United Kingdom have no or
little cost sharing for medical care. France requires no cost sharing for specific
chronic illnesses. Germany limits costs as a share of income. Norway and Sweden
limit annual out-of-pocket costs. In Australia, primary care visits are often “bulk-
billed” with no patient charge, and ceilings limit overall cost exposure. New Zea-
land has been reducing patient fees. Italy’s national benefits cover primary care in
full, with copayments for outpatient drugs and specialists.4
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Inrecentyears,allbuttheUnitedStateshaveinitiatednationalreforms,includ-
ing financial andinformationincentives, focusedonprimary care to strengthenor
transform the capacity to provide a foundation for high-quality, efficient care.
Study Design And Methods
?Sampling. Primary care physicians in each country were sampled and sur-
veyed using a common questionnaire that builds on a 2006 primary care physician
surveyconductedinsevencountries.7ThedefinitionofprimarycareincludedGPand
FP physicians in all countries and also general internists and pediatricians in Ger-
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EXHIBIT 1
Country Information, Survey Sample, And Practice Size Among Primary Care
Physicians In Eleven Countries, 2009
Country informationSurvey sample and practice size
Primary care doctor role and payment
a
SamplePractice size
b
Required
to register
Gatekeeper
for referralsPayment
Unweighted
N
Response
rate
<2 FTE
doctors
2 to <5
FTE doctors
5 or more
FTE doctors
ITAYesYes Mix capitation/
fees/incentives
84461%48% 33% 19%
NORc
YesYesMix FFS/
capitation
774 561064 26
AUS No YesFFS1,0165211 47 41
GERd
NoNational
incentives
FFS71550 50462
NETYesYesMix capitation/
FFS
61450 56 394
NZYesYes Mix capitation/
FFS
50050 165925
SWEd
NoNational
incentives
Most salary;
private: mix
capitation/FFS
1,4504873457
USNoNoFFS 1,442392732 38
CANd
No National
incentives
FFS1,401 35 24 3241
UKYes YesMix capitation/
incentives
1,062 20125730
FRAd
NoNational
incentives
FFS5027 72 262
SOURCES: See below.
NOTES: Countries are listed in descending order by response rate. FTE is full-time equivalent. FFS is fee-for-service.
aCommonwealth Fund. Description of health care systems: Australia, Canada, Denmark, France, Germany, Italy, the
Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. New York (NY):
Commonwealth Fund; forthcoming, 2009 Nov.
bCommonwealth Fund International Health Policy Survey of Primary Care Physicians, 2009.
cNorway does not require registration but strongly encourages and offers incentives; 98 percent are registered.
dCanada does not require referral but has provider incentives to discourage self-referrals. France, Germany, and Sweden use
incentives for patients and providers.
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many and the United States.8Practicing physicians were chosen randomly from
public andprivatelists.9Exhibit1showsfinal samplesizesandresponserates.
Harris Interactive Inc. and subcontractors in each country collected data by a
combinationofmail,online,andtelephoneduringFebruary–July2009.10Mailsur-
veys were conductedinCanada, Germany, Netherlands, Norway, Sweden, andthe
UnitedStates.AustraliaandNewZealandusedphonerecruitmentandsurveysby
mail. Italy recruitedby mail andcompletedsurveys online. French andU.K. inter-
viewswereby phone.11Thelow responseratesinthelatter twoofthesecountries,
as well as in the United States and Canada, indicate the need for caution in inter-
preting results as representative of all physicians.
In general, final samples closely matched initial characteristics available from
lists of physicians. However, differences in data collection and response rates
introduce an unknown bias.
The analysis weighted final samples to reflect the distribution of physicians by
age, country region, sex, and primary care specialty.12For samples of 1,000 and
500, the margin of sample error is 3–4 percent at the 95 percent confidence level.
Exhibits indicate where differences are significant (p < 0.05).
?Practice size. The countries differ significantly in practice size (Exhibit 1).
GrouppracticeismorethenorminSweden,theUnitedKingdom,Norway,andAus-
tralia;groupstendtobelargestinSweden.ItalianandFrenchdoctorsweretheleast
likelyandSwedishdoctorsthemostlikelytosaythattheyincludenonphysiciancli-
niciansintheir practices.13
Study Findings
?Health IT. The survey asked about basic electronic medical records (EMRs)
and thirteen other computerized functions (Exhibit 2). To assess multifunctional
capacity,wecreatedasummaryvariablecountingthenumberoffunctionsandcate-
gorizedsystemsaslow (0–3),middle(4–8),or high (9–14).13
The survey found a striking spread across countries in the adoption of EMRs
and the range of electronic functions (Exhibit 2). In Australia, Italy, the Nether-
lands, New Zealand, Sweden, and the United Kingdom, EMRs are nearly univer-
sal, and half or more practices reported at least nine functions surveyed. Physi-
ciansinCanada,theUnitedStates,andFrancelagbehindinbasicEMRsaswellas
multifunctional support, following patterns observed in other studies.14Even
though EMR use is nearly universal in Norway, its functional capacity is low, as is
that of Germany.
The varied responses indicate different emphases in building capacity. For ex-
ample, among the seven countries with near-universal EMRs, the majority of phy-
siciansreportedelectronicaccesstolabresults,yetfewerthanhalfofDutch,Nor-
wegian, and U.K. doctors can order tests electronically. Across countries, most
doctorswithEMRsreportedelectronicclinicalnotes,routineelectronicprescrib-
ing,andcomputerizedalertsaboutpotentialproblemswithdrugdosesorinterac-
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tions (except in Norway). Answers varied for other functions.13
Decisionsupportappearsgenerallylesswelldeveloped.Computerizedremind-
ersfortreatmentguidelines,trackinglaboratorytests,andpromptstoprovidepa-
tients with test results were the least frequently reported, including in countries
with multifunctional capacity.
Notably, the seven countries with near-universal EMRs have succeeded in
spreading multifunctional capacity to smaller as well as larger practices (Exhibit
2). Their national policies and standards have supported spread of multifunc-
tional capacity.15In contrast, U.S. multifunctional capacity remains concentrated
inlarger practices. HalfofU.S. practices with high-functioncapacity were associ-
ated with integrated care systems such as Kaiser (data not shown).
?Access.Primarycarepracticesprovideanentrypointintothehealthcaresys-
tem as well as a key source of prevention, essential care, and continuity. Asked
whethertheirpracticehadanarrangementwherepatientscouldbeseenafterhours
withoutgoingtoanemergencyroom(ER),nearlyallDutch,NewZealand,andU.K.
doctorssaid“yes,”comparedtojust29percentofU.S.physicians—thelowestinthe
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EXHIBIT 2
Health Information Practice Capacity Among Primary Care Physicians In Eleven
Countries, 2009
Use EMR
in practice
(% yes)
Electronic information
functions (0–14) in practice
Percent high functionality (9–14)
by practice size (no. of FTE doctors)
Low
(0–3)
Middle
(4–8)
High
(9–14) <22 to <55 or more
AUS
CAN
FRA
95b,c,d,f,k
37c,d,e,f,g,h,i,j,k
68e,f,g,h,i,j,k
3%
65
39
6%
21
47
91%b,c,d,e,f,h,i,j,k
14c,d,e,f,g,h,i,j,k
15d,e,f,g,h,i,j,k
82%
6
14
90%L
18L
16
94%L
17L
–m
GER
ITA
NET
72e,f,g,h,i,j,k
94f,h,k
99g,h,i,j,k
14
4
1
50
30
45
36e,f,g,h,i,j,k
66f,g,h,i,j,k
54g,h,i,j,k
31
65
53
41L
64
55
–m
72
–m
NZ
NOR
SWE
97i,k
97i,k
94j,k
2
15
4
6
66
47
92h,i,j,k
19i,j,k
49j,k
83
15
20
92L
19
49L
98L
21
52L
UK
US
96k
46
0
51
11
23
89k
26
83
7
89
25L
92L
40L
SOURCE: Commonwealth Fund International Health Policy Survey of Primary Care Physicians, 2009.
NOTES: Count of fourteen functions includes the following: electronic ordering of medications and tests, computer access to
test results and medication lists, computer alerts/prompts, and decision support; computerized reminder systems for
prevention and follow-up care; computerized ability to list patients by diagnosis, lab results, and medications; and electronic
entry of notes and medical histories. For details by function, see Technical Appendix Table 2, online at http://content.health
affairs.org/cgi/content/full/hlthaff.28.6.w1171/DC2. Significant differences between countries for low/high functionality
indicated for distribution of summary variable rather than individual responses. Underlined row headings indicate a response
rate below 40 percent. Reading from top to bottom starting with Australia, the letter indicates significant differences with
countries below at p < 0.05, as indicated:bDifferent from CAN.cDifferent from FRA.dDifferent from GER.eDifferent from ITA.
fDifferent from NET.gDifferent from NZ.hDifferent from NOR.iDifferent from SWE.jDifferent from UK.kDifferent from US.
LIndicates significant within-country differences with <2 full-time-equivalent (FTE) doctors (p < 0.05).
mVery small sample size (under 30) of practices with 5 or more FTE doctors.
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