– The United States still trails behind other similarly developed nations in primary care access, with the latest data from The Commonwealth Fund finding suboptimal home care access and care coordination.
These findings build on previous research The Commonwealth Fund has done to compare the US healthcare system to other similarly developed nations: Sweden, Canada, Switzerland, Australia, France, Germany, New Zealand, the United Kingdom, the Netherlands, and Norway. In the past, the US has trailed these other wealthy nations in healthcare quality and patient care access, and this latest assessment is no different.
“Evidence shows that a strong foundation of primary care yields better health outcomes overall, greater equity in health care access and outcomes, and lower per capita health costs,” the researchers wrote. “But in the United States, decades of underinvestment and a low provider supply, among other problems, have limited access to effective primary care.”
For instance, patients in the US are among the least likely to have a regular doctor or a place to go for care, with 89 percent of adults reporting as much. The only country for which this rate is lower is Sweden, with 87 percent of patients saying they have a regular doctor or place to go for care.
Although 89 percent is a sizeable portion—nine in 10 patients have a regular doctor—other nations fare better. In Norway, every patient has a regular doctor or place to go for care, and 99 percent of those in the Netherlands said the same. For the remaining nations included in the study, between 90 and 97 percent of adult patients said they had access to a regular doctor or source of care.
More tellingly, patients in the US don’t have a deep relationship with their doctors; only 43 percent of American patients said they have known their primary care provider for a long time. Up to 70 percent of patients in other countries (Germany and the Netherlands) said they have a longstanding relationship with their primary care providers.
“Prior research shows that patients who have a long-term relationship with their PCP are less likely to go to the emergency department,” the researchers pointed out. “Primary care continuity is also associated with improved care coordination and increased patient satisfaction.”
But unlike the leading nations, the US doesn’t have a good policy for making this care continuity and PCP access happen. Save for some managed care programs, patients don’t have automatic enrollment with a PCP—they have to do this themselves, and it’s a task that often falls through the cracks.
Conversely, Norway automatically registers patients with a PCP, and the UK enables enrollment with a general practitioner, or GP, of the patient’s choice.
Even when American patients have a good relationship with a PCP, care access is arduous, with patients reporting few non-traditional care access modalities. Patients in the US are the least likely to have access to primary care home visits, with only 37 percent reporting as much. In Canada, the nation with the second most-limited home care access, 70 percent of patients can get PCP visits at home.
Meanwhile, this is a universal or near-universal benefit in Sweden (95 percent), France (96 percent), Germany (97 percent), Norway (97 percent), the UK (97 percent), and the Netherlands (100 percent).
The researchers said primary care provider shortages, limited financial incentives, lack of time, and training could be hampering home visit access in the US.
Moreover, patients in the US don’t even have widespread access to their primary care providers after typical office hours. Only 45 percent of patients in the US said they could access their primary care provider after hours.
This was a more common hurdle in other developed nations; 47 percent of patients in Canada said the same of after-hours visits, as did 56 percent of patients in Switzerland. Still, other countries have made this near-ubiquitous. More than 90 percent of patients in the Netherlands, Norway, New Zealand, and Germany said they have after-hours PCP access.
The report did find that primary care providers in the US are more likely to conduct social determinants of health screenings than other nations. A total of 30 percent of US primary care providers said they screen for social determinants of health, like housing security, food security, and access to transportation.
Some nations were not far behind. Twenty-nine percent of French primary care providers said they conduct SDOH screenings, as well as 25 percent of German PCPs. Meanwhile, only 9 percent of primary care providers in the Netherlands said they conduct social determinants of health screenings.
Additionally, nine in 10 patients in the US said they got high-quality information about social services and SDOH interventions, and 37 percent of PCPs have social workers employed within their offices.
However, the researchers posited that higher rates of SDOH screenings are more indicative of a failing social safety net in the US than more comprehensive primary care. Patients living in the US are more likely to experience SDOH, the researchers reasoned, and primary care providers are seeing the ill effects and urgently identify a need for SDOH intervention.
“Such screenings were most common in the U.S. and France and least common in the Netherlands and Norway — a difference that, at least for the U.S., may be attributable to chronic underinvestment in social services that support healthy living conditions and population health,” the researchers pointed out.
“Patients in the Netherlands and Norway are less likely than those in the U.S. to say they worry about getting their social needs met,” the researchers said, although they did not display that data.
There were some key areas where US healthcare was middling. The US was mid-to-high-level on mental healthcare access within the PCP practice, while half of PCPs said they see good care coordination across themselves and subspecialists. US primary care also ranked in the middle for care coordination with the emergency department; half of PCPs said they are notified when their patients visit the ED.
The researchers said these findings should provide a roadmap for both primary care quality improvement and further comparative research.
“In its efforts to improve primary care, the United States can learn a lot from what other high-income countries are doing,” they concluded. “But there are also ample lessons to be learned from lower-income countries, such as Costa Rica, whose health system is anchored by robust, community-oriented primary health care.”