New York, NY, December 7, 2015—Twenty-four percent of U.S. primary care doctors say their practices are not well prepared to manage care for patients with multiple chronic illnesses and 84 percent are not well prepared for severely mentally ill patients, according to findings from the Commonwealth Fund’s 2015 International Health Policy Survey published in the December issue of Health Affairs.

The article, “Primary Care Physicians In Ten Countries Report Challenges Caring for Patients With Complex Health Needs,” analyzes survey responses from more than 11,000 primary care doctors in Australia, Canada, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States. It highlights concerns among many doctors that their practices are not fully prepared to care for patients with more than one chronic illness, serious mental health problems, and other challenges. Prior research has shown that despite being a younger nation overall, the U.S. has a higher share of patients with multiple chronic illnesses than any of the other nine nations surveyed.

“It’s concerning that one in four U.S. primary care doctors don’t think their practices are prepared for the sickest patients, especially when we have so many Americans with multiple chronic illnesses who may get sicker as they age,” said Robin Osborn, lead author of the study and vice president of the International Program in Health Policy and Practice Innovations at The Commonwealth Fund. “To be sure there is affordable, high-quality health care for sick and complex patients, we need to continue to strengthen primary care in the U.S.”

According to the survey, doctors across the 10 countries questioned the preparedness of their practices to manage patients with challenging illnesses or those needing long-term home care or social services. In Sweden, 34 percent of doctors said their practices were not well prepared to care for those with multiple chronic illnesses, while doctors in Germany and the Netherlands were the most confident in their ability to care for the sickest, with only 12 percent saying they did not feel fully prepared.

All Nations Face Challenges Coordinating Care

Doctors in all of the nations surveyed reported that their practices struggled to coordinate care and communicate with other health and social service providers—both keys to managing complex patients.

The survey found that primary care doctors are often not notified when their patients are discharged from the hospital:

• In the U.S., one in three primary care doctors said they were always notified when a patient was discharged from the hospital (31%) and when a patient was seen in the emergency department (32%).
• In the Netherlands, which does best in this area, 69 percent of doctors reported they were always notified at discharge and 68 percent reported they were always told about a patient’s ED visit.
• Doctors in Sweden have the most trouble with communication. Only 8 percent said they were always notified when a patient was discharged and 6 percent were notified after an ED visit.

Communication with home care (e.g., nursing or personal care) providers and social service (e.g., housing, meals, or transportation) providers is also often lacking:

• About half (52%) of U.S. primary care doctors said their practice routinely communicated with patients’ home care providers. Only 43 percent frequently coordinated with patients’ social service providers, among the lowest in the survey.
• Norway had the highest percentage of doctors reporting routine communication with home care providers (63%), while doctors in New Zealand had the lowest percentage (28%).
• Doctors in the U.K. had the best care coordination with patients’ social service providers (65% frequently coordinated) while Sweden and the Netherlands had the least success (42% frequently coordinated).

“Primary care is the hub of patients’ health care experiences. If it isn’t strong and working efficiently, patients won’t get the best possible care,” said Commonwealth Fund President David Blumenthal, M.D. “Taking steps to encourage doctors, nurses, and social service providers to work together in teams, making it easier for patients to get care on nights and weekends, and facilitating better communication between providers are essential to creating better primary care.”

Access to Care and Support for Chronically Ill Patients

There is a wide variation in how countries provide primary care, with some making it easier for patients to get care outside of the office and providing more support for chronically ill patients.

• Only 39 percent of primary care doctors in the U.S. had arrangements for patients to get after-hours care without going to the ED—the lowest rate in the survey. In contrast, 94 percent in the Netherlands, 92 percent in New Zealand, and 89 percent in the U.K. made after-hours care available to patients.
• Primary care practices in the Netherlands and the U.K. are the most likely to be able to make home visits—more than 80 percent frequently do, compared to only 6 percent in the U.S.
• While 96 percent of U.K. primary care practices and 92 percent of Dutch practices report using nurses or case managers to monitor and support chronically ill patients, only 27 percent in Germany do so.

Health Information Technology: A Bright Spot for the U.S. and Canada

According to the survey, after lagging behind most other countries, the U.S. has made substantial improvements in use of health information technology, which can support better care coordination.

• Adoption of electronic medical records in the U.S. is up 15 percent in the past three years, and use has tripled since 2006.
• Fifty-seven percent of U.S. primary care practices communicate with patients via email.
• Sixty percent of U.S. practices allow patients to access their medical record electronically, the highest percentage of any country in the survey.
• Forty-two percent of U.S. primary care doctors can electronically exchange information with doctors outside of their practices, an important step in health information technology’s meaningful use, up from 33 percent in 2012.
• Electronic medical records adoption has also substantially improved in Canada, rising from 56 percent in 2012 to 73 percent in 2015.

However, the survey found that only 52 percent of U.S. primary care doctors were satisfied with their electronic medical record in 2015—the second-lowest rate among the surveyed countries, after Sweden (37% satisfied).

Moving Forward

All of the nations surveyed are grappling to find ways to care for their aging populations with complex health care needs. Strengthening primary care is an essential response to this challenge.

In the U.S., the Affordable Care Act includes some provisions that are encouraging investment in new ways of providing and paying for health care, such as medical homes and accountable care organizations. However, the authors note that “these and related efforts are nascent, and delivery systems can be slow to change.” They conclude the U.S. “may need to do more to strengthen primary care, with policymakers keeping an open mind about new ideas including those that have demonstrated effectiveness in other countries.”

METHODS

The 2015 Commonwealth Fund International Health Policy Survey of Primary Care Doctors surveyed nationally representative random samples of primary care doctors. Samples of practicing physicians were drawn from government or private lists of primary care doctors in each country. Primary care doctors were defined as general practice or family physicians in all countries, as well as internists and pediatricians in the United States, Germany, and Switzerland, recognizing that their role, training, and scope of practice vary across countries. A common questionnaire was reviewed by experts in each country, adjusted for country-specific wording, and translated as needed to ensure comparability across countries. SSRS, a survey research firm, and country contractors interviewed doctors by phone, online, or mail between March and June 2015.

Final sample quantities ranged from 503 to 2,905. Data were weighted, based on the known population parameters in each country, to ensure they were representative of the primary care physician population. Response rates ranged from 19 percent in Germany to 47 percent in Sweden. Although nonrespondents might differ from respondents, data were weighted to account for differential nonresponse along known geographic and demographic parameters in each country.