US Primary Care Seen Lagging in Key Markers

Howard Wolinsky

March 15, 2022

If the nation's primary care system were a patient, it would be in critical condition, researchers have found.

In delivery of primary care, including access and coordination, the US trails well behind 10 other wealthy countries, according to a new report from the Commonwealth Fund.

The document, released March 15, concludes that the shortcomings in the US system ― from a lack of a relationship with a primary care physician to unequal access to after-hours care ― "disproportionately affect Black and Latinx communities and rural areas, exacerbating disparities that have widened during the COVID-19 pandemic."

Munira Gunja, MPH

"This report really shows that the US is falling behind. We know that a strong primary care system yields better health outcomes. We have a lot to learn from other high-income countries," co-author Munira Z. Gunja, MPH, a senior researcher for the Commonwealth Fund's International Program in Health Policy and Practice Innovations, told Medscape Medical News. "At baseline, we really need to make sure that everyone has health insurance in this country so they can actually use primary care services, and we need to increase the supply of those services."

The report draws from the Commonwealth Fund's 2019 and 2020 International Health Policy Surveys and the 2020 International Profiles of Health Care Systems. Among the main points:

  • US adults are the least likely to have a regular physician or place of care or a long-standing relationship with a primary care provider: 43% of American adults have a long-term relationship with a primary care doctor, compared with highs of 71% in Germany and the Netherlands.

  • Access to home visits or after-hours care ― excluding emergency department visits ― is lowest in the United States (45%). In the Netherlands, Norway, New Zealand, and Germany, the rate is 90% to 96%.

  • Half of primary care providers in the United States report adequate coordination with specialists and hospitals ― around the average for the 11 countries studied.

"Dismal Mess"

Experts reacted to the report with a mix of concern and frustration ― but not surprise.

"The results in this report are not surprising, and we have known them all for a number of years now," Timothy Hoff, PhD, a health policy expert at Northeastern University, Boston, told Medscape Medical News. "Primary care doctors remain the backbone of our primary care system. But there are too few of them in the United States, and there likely will remain too few of them in the future. This opens the door to other and more diverse forms of innovation that will be required to help complement the work they do."

Hoff, author of Searching for the Family Doctor: Primary Care on the Brink (Johns Hopkins University Press, 2022), added that comparing the United States to smaller countries like Norway or the United Kingdom is "somewhat problematic."

"Our system has to take care of several hundred million people, trapped in a fragmented and market-based delivery system focused on specialty care, each of whom may have a different insurance plan," he said. "Doing some of the things very small countries with government-funded insurance and a history of strong primary care delivery do in taking care of far fewer citizens is not realistic."

Jeffrey Borkan, MD, PhD, chair and professor in the Department of Family Medicine at the Alpert Medical School of Brown University, Providence, Rhode Island, said the most shocking finding in the report is that despite spending far more on healthcare than any other country, "we cannot manage to provide one of the least expensive and most efficacious services: a relationship with a primary care doctor."

Arthur Caplan, PhD, director of the Division of Medical Ethics at New York University Langone Medical Center, New York City, called primary care in this country "a dismal mess. It has been for many years. This is especially so in mental health. Access in many counties is nonexistent, and many primary care physicians are opting into boutique care."

R. Shawn Martin

R. Shawn Martin, CEO of the 133,000-member American Academy of Family Physicians, said, "None of this surprises me. I think these are trendlines; we have been following this for many, many years here at the Academy."

Martin added that he was disappointed that the recent, large investments in sharing and digitizing information have not closed the gaps that hinder the efficient and widespread delivery of primary care.

The findings in the report weren't all bad. More primary care providers in the United States (30%) screen their patients for social needs such as housing, food security, and transportation ― the highest among all 11 nations studied.

Also, Commonwealth Fund said the proportion of patients who said they received information on meeting their social needs and screening for domestic violence or social isolation was low everywhere. However, the percentage in the United States, Canada, and Norway was the highest, at 9%. Sweden had the lowest rate for such screenings, at 1%.

The researchers noted that social determinants of health account for as much as 55% of health outcomes. "In some countries, like the United States, the higher rates of receiving such information may be a response to the higher rates of material hardship, along with a weaker safety net," the report states.

Gunja and her colleagues suggested several options for changes in policies, including narrowing the wage gap between primary care providers and higher-paid specialists; subsidizing medical school tuition to give students incentives to enter primary care; investing in telehealth to make primary care more accessible; and rewarding and holding providers accountable for continuity of care.

"The US had the largest wage gap and highest tuition fees among the countries we studied," Gunja told Medscape.

Researchers noted that US patients could benefit from the introduction of incentives such as those paid in New Zealand to primary health organizations, which receive additional funding per capita to promote health and coordinate care.

But Caplan was skeptical that those measures would do much to correct the problems.

"We have no will to fix this ongoing, scandalous situation," he said. "Specialist care still pays inordinately large salaries. Nurses and physician extenders are underused. Academic prestige does little to reward primary care. Plus, patients are not pressing for better access. Sorry, but I see no solutions pending in the current climate. Obamacare barely survived."

The authors have disclosed no relevant financial relationships.

Commonwealth Fund. March 15, 2022. Full text

Howard Wolinksy is a medical writer in Chicago.

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