The U.S. lags behind other leading industrial democraties in primary care, according to a new study from the Commonwealth Fund. The report, A Survey of Primary Care Physicians in 11 Countries, 2009: Perspectives on Care, Costs, and Experiences, surveyed doctors in Australia, Canada, France, Germany, Italy, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. It found the U.S. falls behind significantly in access to care, the use of payment incentives to improve health care quality, and utilization of health information technology.  

Health IT. The U.S. lags behind every surveyed country except for Canada in health IT adoption. In the Netherlands, New Zealand, Norway, the U.K., Australia, Italy, and Sweden, over 90 percent of doctors use health IT, while in the U.S., only 46 percent of doctors use health IT. (It's worth noting that the U.S. has prioritized funding for health IT through economic stimulus package, and approximately $1.2 billion in grants has gone out to health IT development and implementation since data collection for this study concluded in July 2009.)

Cost. About half of U.S. doctors reported insurance restrictions were an obstacle to obtaining the treatment and medication their patients needed. More than half of U.S. doctors said their patients had difficulty paying for medication and care, more than any other surveyed country. Patients who struggle to pay for medical care are less likely to comply with treatment recommendations, and more likely to stay sick or get sicker. Millions of Americans go bankrupt every year because of medical debt. 

Access. Only 29 percent of U.S. physician practices had arrangements to get patients reliable after-hours care -- which means many patients rely on costly visits to a hospital emergency room. In the Netherlands, New Zealand, the U.K., France, and Italy, more than 75 percent of physician practices had alternative arrangements. (Some examples of after-hours care arrangements include on-call clinicians and after-hours clinics.)

Financial incentives. The report found that other countries rely predominately on general practitioners or family practice physicians, in conjunction with primary care nurses. Primary care nurses counsel patients about healthy lifestyle choices, and help coordinate care of chronic conditions. In some countries, such as the Netherlands and the U.K., primary care doctors serve as gatekeepers for referrals to specialists. Elsewhere, patients and providers have financial incentives to rely on primary care. The U.S. offers few financial incentives to primary care doctors. Compared to 89 percent in the U.K. and 70 percent Italy, only 36 percent of U.S. doctors report receiving financial incentives. In many ways our payment system is geared to favor specialists with higher pay, and it discourages medical students with huge debts to go into the lower paying medical fields associated with primary care. We're facing a shortage of primary care physicians. On the other hand, one area the U.S. prevailed in was the wait time to see a specialist -- only 28 percent of doctors reported long waiting times for their patients to see a specialist, compared to more than 75 percent in Canada and Italy. However, the U.K. reported an even lower level of wait times to see a specialist -- only 22 percent.

Good primary care is the foundation for good health care. Research into primary care shows that good primary care leads to healthier populations, better health outcomes and lower costs. The U.S. has examples of both excellent and woefully inadequate primary care. The lack of a "strong primary care backbone" is the main difference between the U.S. and other countries, notes the Health Populi blog. Our reliance on internal medicine and pediatrics for primary care, coupled with very decentralized referral systems, makes the United States system of primary care uniquely different from the other surveyed countries. But as the study shows, that isn't necessarily a good thing.