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Finger on the Pulse: The State of Primary Care in the U.S. and Nine Other Countries

Doctor spreads out a sheet on a hospital bed

A doctor prepares her office at the Pontgibaud health house in central France on November 24, 2022. Analysis of the Commonwealth Fund 2022 International Health Policy Survey of Primary Care Physicians finds that 91 percent of physicians in France reported they have arrangements to see patients outside of normal hours. Photo: Jeff Pachoud/AFP via Getty Images

A doctor prepares her office at the Pontgibaud health house in central France on November 24, 2022. Analysis of the Commonwealth Fund 2022 International Health Policy Survey of Primary Care Physicians finds that 91 percent of physicians in France reported they have arrangements to see patients outside of normal hours. Photo: Jeff Pachoud/AFP via Getty Images

Toplines
  • In the U.S. and many other nations, access to comprehensive primary care is hindered by underinvestment, workforce shortages, and physician burnout

  • Survey data from 10 high-income countries show that U.S. adults were the least likely to have a longstanding relationship with a primary care provider, and U.S. providers were least likely to make home visits

Toplines
  • In the U.S. and many other nations, access to comprehensive primary care is hindered by underinvestment, workforce shortages, and physician burnout

  • Survey data from 10 high-income countries show that U.S. adults were the least likely to have a longstanding relationship with a primary care provider, and U.S. providers were least likely to make home visits

Introduction

For many people, primary care is their first point of contact with the health system, and decades of evidence shows it is critical for population health, health equity, and the overall efficiency of health care systems.1 Primary care is also uniquely positioned to screen for social needs and provide integrated behavioral health services.2 Ensuring people have access to high-quality, comprehensive primary care is vital to good health outcomes and positive experiences with the health system at large.

Despite the importance of primary care, health systems around the world are facing challenges at the patient and provider level. Many countries struggle to ensure access to care, or first contact; continuity of care; comprehensiveness of care; and coordination of care. These four core components of high-quality primary care are essential to better overall health outcomes.3 Factors like workforce shortages, physician burnout, and dwindling access for patients, driven in part by underinvestment and growing administrative burdens, pose significant barriers to care.4

To better understand how patient care can be improved in a changing primary care landscape, this brief compares the state of primary care in the United States with nine other high-income nations. It updates an earlier Commonwealth Fund study comparing primary care performance in the U.S. with nine peer countries: Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United Kingdom. Our data come from the Commonwealth Fund’s 2022 International Health Policy Survey of Primary Care Physicians and the 2023 International Health Policy Survey of adults age 18 and older. The 2022 and 2023 surveys asked different questions of the participating physicians and responding adults, so this edition includes new measures on access to telehealth, preparedness to treat behavioral health conditions, and care coordination. For more details on our methods, see “How We Conducted This Study.”

Highlights

  • Although 86 percent or more of respondents in all 10 countries reported having a regular doctor or place to go for care, adults in the U.S., Sweden, and Canada had the lowest rates, and U.S. adults were the least likely to have a longstanding relationship with a primary care provider.
  • Less than a third of U.S. primary care providers reported making home visits compared to more than two-thirds in all other surveyed countries.
  • Physicians in the U.S. and Germany were most likely to screen their patients for social needs, such as housing, financial, and food insecurity.
  • Less than four in 10 physicians in the U.S., Sweden, the Netherlands, and Germany reported adequate coordination with specialists and hospitals regarding changes to their patients’ care.

Findings

First Contact or Accessibility

Gumas_finger_on_the_pulse_primary_care_Exhibit_01

Having a regular doctor or place of care is key to preventive care, the early detection and treatment of disease, and chronic disease management.5 Patients with a usual source of care are more likely to receive immunizations, blood pressure screenings, and cancer screenings. Regular contact with a primary care physician is also associated with fewer barriers to health care and more positive attitudes about the health system, which may contribute to improved engagement and better coordination of care.6

Adults in the U.S. and Canada are the least likely to report having a regular doctor, and there are growing numbers of U.S. adults without a usual source of care over the past decade.7 In both countries, younger adults ages 18 to 42 were significantly less likely to have a regular doctor or place of care than adults over age 43 (data not shown). In the U.S., younger adults are less likely to have continuous health insurance.8 Much like in the U.S., the tradition of having one family doctor is fading in Canada, as younger people become more transient and seek care through different means, such as walk-in clinics or telehealth.9

Gumas_finger_on_the_pulse_primary_care_Exhibit_02

Telehealth, or the delivery of care remotely by audio or video, is a key to ensuring convenient access to primary care, particularly for people in remote or rural areas.10 Telehealth can allow physicians to easily share information for better clinical education and facilitate diagnosis or prevention by enabling patients to seek care in a timelier fashion than if they had to travel to an appointment in person.11 However, telehealth was used in the majority of patient encounters in only two of 10 surveyed countries (data not shown), with one in 10 physicians in New Zealand and over a quarter of U.K. physicians reporting high telehealth use. On the other end, just 2 percent of physicians in the U.S., Australia, Sweden, and Germany reported “high” telehealth use.

Because telehealth had been introduced within the U.K.’s National Health Service (NHS) prior to the COVID-19 pandemic, the NHS had much of the infrastructure in place. Patients and physicians were also already familiar with virtual care settings. Research shows that telehealth utilization and satisfaction — both for patients and physicians — has remained high long after the pandemic peaked.12

Gumas_finger_on_the_pulse_primary_care_Exhibit_03

Home visits by doctors improve health outcomes and are a vital for reaching people who are homebound.13 Physicians in the U.S. were significantly less likely to report making frequent or occasional home visits than physicians in other surveyed countries, where over two-thirds reported doing so. Lower U.S. rates could be attributed to a smaller supply of physicians overall, but factors like lack of financial incentives, time, and training, as well as safety and liability concerns, could also be at play.14 In Germany, where all physicians reported making frequent or occasional home visits, physicians and many specialists are legally required to offer home visits.15

Continuity of Care

Gumas_finger_on_the_pulse_primary_care_Exhibit_04

Having a longstanding relationship with a primary care physician deepens patient trust and is associated with lower total health care costs and hospitalizations.16 Yet only about two of five adults in the U.S. and Australia reported having been with their primary care physician for at least five years, a significantly lower proportion than in the other countries we analyzed.

Gumas_finger_on_the_pulse_primary_care_Exhibit_05

Offering primary care services outside regular operating hours expands access to health care, particularly for caregivers or people with jobs that limit their ability to receive care during regular business hours. It can also lower improper use of emergency departments and increase patient satisfaction.17

In four of the nine surveyed countries, over two-thirds of physicians reported having arrangements for patients to be seen outside of regular hours, meaning weekends or after 6:00 p.m. during the week. Just over half of physicians in the U.S. reported seeing patients outside regular hours.

Comprehensiveness of Care

Gumas_finger_on_the_pulse_primary_care_Exhibit_06

Screening for the drivers of health, like housing instability or food insecurity, allows physicians to understand the social and economic circumstances that affect their patients’ health.18 It is also an initial step in addressing those needs.

About a third of physicians in the U.S. and Germany reported that their practices usually screen or assess patients for at least one social need. In the U.S., there is concerted effort by policymakers and payers to make screening more common and standardized.19 This is particularly important given that compared to other surveyed countries, the U.S. has higher rates of material hardship, such as food insecurity and financial instability, along with a weaker social safety net. Across all other countries, a quarter of physicians or less reported usually screening patients for at least one social need.

Gumas_finger_on_the_pulse_primary_care_Exhibit_07

After screening for social needs, primary care physicians can coordinate with community-based social services to address the needs identified. In every country, more than half of physicians reported challenges connecting patients’ care with social services.

Coordination challenges included internal, practice-related factors like the amount of paperwork required, not having a system or enough staff to make referrals, or lacking information about services available in the community. Some challenges were also external, including lack of follow-up from the social service organizations about which services patients received or needed.

Gumas_finger_on_the_pulse_primary_care_Exhibit_08

Across all surveyed countries, more than 90 percent of physicians reported that their practices were well prepared to manage care for patients with behavioral health needs. Despite falling toward the bottom of the pack compared to other countries, previous research has shown that in the U.S., most primary care physicians treat behavioral health issues, and, in fact, most primary care visits are for behavioral health needs.20

Announced in January 2023, Medicaid programs will now be able to cover interpersonal consultations, where primary care providers consult with behavioral health specialists to develop treatment plans for their patients.21 The Centers for Medicare and Medicaid Services also announced a multistate integrated care pilot model, where community-based behavioral health providers will form integrated teams of physical health providers and community-based social supports to treat patients.22 Wide implementation of integrated care is imperative for expanding equitable access to behavioral health services, since it can reduce the need for additional appointments or visits and improve outcomes across age groups and diagnoses.23

Coordination of Care

Gumas_finger_on_the_pulse_primary_care_Exhibit_09

Coordination between physicians and other care providers is essential to ensuring patients’ needs and preferences are communicated at the right time to the right people.24

Two-thirds of U.S. adults reported that their regular doctor helped coordinate their care by assisting them with getting appointments, following up to make sure patients received recommended care, and ensuring other doctors had important information about them.

Gumas_finger_on_the_pulse_primary_care_Exhibit_10

Patient care plans, which are collaboratively designed care processes tailored to the specific health priorities and social context of a patient, have been found to improve health outcomes.25 Coordinating and communicating about patient care plans is critical for ensuring all physicians are aware of patient preferences and are providing effective treatment, all while reducing the burden on patients.

In the U.S., the decentralized and fragmented nature of the health system makes care coordination complicated.26 Only four in 10 U.S. physicians reported usually receiving information about changes to their patient’s care or medication plans from specialists or hospitals. In Germany, just one in five physicians report coordinating care. By contrast, in the U.K. and New Zealand, over two-thirds of physicians reported regularly receiving this critical information.

Conclusion

Our analysis reveals primary care systems around the world are facing challenges. Consistent with prior research, we found the U.S. trails its peers, particularly in access to and continuity of care. Patients in the U.S. are among the least likely to have access to primary care outside of regular business hours or a longstanding relationship with their primary care physician.27 Experts point to a few likely causes. Primary care physicians in the U.S. are paid less than specialists, and investment in primary care overall is low and decreasing over time.28 Furthermore, fewer practitioners are entering the field at a time when the health care needs of patients are growing, inequities are widening, and we are asking more of the primary care physicians we do have.29

There are several options for federal and state policymakers seeking to strengthen primary care in the United States:

  • Invest in primary care. The U.S. spent 4.7 percent of its total health care spending on primary care in 2021 compared to an average of 14 percent in other high-income countries.30 Greater financial support for primary care, including physicians and their care teams, would give providers greater resources to expand access through telehealth, home visits, and after-hours appointments, and make care more comprehensive by addressing behavioral health and social needs. More than 20 states have increased investment in primary care in recent years, and there are opportunities for supportive federal policy action, like updating the Medicare physician fee schedule.31
  • Grow the primary care workforce. The U.S. has the largest wage gap between generalist and specialist physicians, as well as the highest medical tuition fees, among the countries included in this analysis.32 Facing lower salaries and large student loans, fewer physicians are going into primary care, and even fewer choose to practice primary care in underserved communities. Policymakers can narrow this wage gap and increase federal funding for workforce development by pushing for more competitive compensation and loan repayment programs, particularly those that encourage physicians to practice in rural and underserved areas, such as Teaching Health Center Graduate Medical Education Program and the National Health Services Corps. Similarly, Australia has a well-established Workforce Incentive Program to financially incentivize physicians to practice in rural or remote areas.33
  • Reform payment for primary care. The U.S. pays for primary care largely through volume-based, fee-for-service payments, which incentivizes physicians to deliver more services while limiting which services they can provide. Moving to population-based payments, which provide upfront, predictable payment, would enable and incentivize physicians to offer a more comprehensive set of services — such as care coordination or addressing social needs — and give them greater flexibility to deliver the right care at the right time.34 Federal and state policymakers can develop new primary care payment reform models, or scale existing ones, to increase flexibility and hold physicians accountable for patient outcomes.
  • Facilitate better coordination between primary care and other physicians. Our findings also show there is a disconnect in the patient–provider relationship when it comes to care coordination. In the U.K., for example, the majority of physicians believe that patient care is being coordinated, but just half of patients feel their care was coordinated. In the U.S., federal and state policymakers can financially incentivize communication between primary care physicians, specialists, and hospitals by, in part, expanding interoperability between electronic health records (EHRs) and ensuring all stakeholders, including patients, feel their care plans are being coordinated and communicated with all providers.35
  • Reduce the administrative burden on primary care physicians. Primary care physicians are facing unprecedented burnout and administrative burden across the globe.36 Policymakers can take steps to reduce the many requirements primary care physicians uniquely face in reporting, prior authorizations, billing, and documentation. This could improve care, reduce burnout, and minimize hurdles to providing care, enabling physicians to spend more time with patients.37 Additional strategies to streamline administrative work, reduce physician workload, and improve care delivery include redesigning health care processing technology — like electronic health records and other electronic administrative tasks — with the input of physicians.38
HOW WE CONDUCTED THIS STUDY

The Commonwealth Fund 2022 International Health Policy Survey of Primary Care Physicians was administered to nationally representative samples of practicing primary care doctors in Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. These samples were drawn at random from government and private lists of primary care doctors in every country except France, where they were selected from publicly available lists of primary care physicians. Within each country, experts defined the physician specialties responsible for primary care, recognizing that roles, training, and scopes of practice vary across countries. In all countries, general practitioners (GPs) and family physicians were included, with internists and pediatricians also sampled in Switzerland and the United States.

The questionnaire was designed with input from country experts and pretested in most countries. Pretest respondents provided feedback about question interpretation via semistructured cognitive interviews. SSRS, a survey research firm, worked with contractors in each country to survey doctors from February through September 2022; the field period ranged from 8 to 31 weeks. Survey modes (mail, online, and telephone) were tailored based on each country’s best practices for reaching physicians and maximizing response rates. Sample sizes ranged from 321 to 2,092, and response rates ranged from 6 percent to 40 percent. For analyses that are limited to primary care physicians who use telehealth, sample sizes ranged from 317 to 2,056. Across all countries, response rates were lower than in 2019. Final data were weighted to align with country benchmarks along key geographic and demographic dimensions.

The Commonwealth Fund 2023 International Health Policy Survey collected data from nationally representative samples of noninstitutionalized adults age 18 and older in Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, the United Kingdom, and the United States. Samples were generated using probability-based overlapping landline and mobile phone sampling designs in Australia, Canada, France, Germany, the Netherlands, New Zealand, and the U.K. In the U.K., additional online interviews were completed via a nationally representative probabilistic panel. In Sweden and Switzerland, respondents were randomly selected from listed or nationwide population registries, and surveys were completed via landline and mobile phones, as well as online. In the U.S., three probability-based sample frames were used. Most of the interviews were conducted from address-based sample (ABS). Additional interviews were completed via a nationally representative probabilistic panel and from a sample of cell phone numbers connected to prepaid cell phones to reach populations who are typically underrepresented in ABS samples, including low-income and non-white adults. Respondents in the U.S. completed surveys via mobile phones as well as online.

International partners cosponsored surveys, and some supported expanded samples to enable within-country analyses. Final country samples ranged from 750 to 4,820 participants. The survey research firm SSRS was contracted to field the survey in the U.S. and six additional countries, as well as collaborate with fieldwork partners and oversee survey administration in the other three countries, from March to August 2023, though the field period for each country varied. SSRS also provided methodological oversight for the study as a whole, including supporting questionnaire development, consultation and design of sampling protocols, and managing the statistical weighting across countries. Response rates varied from 6 percent to 49 percent. Data were weighted using country-specific demographic variables to account for differences in sample design and probability of selection.

Changes to Included Exhibits

There were some notable changes between the 2022 and 2023 International Health Policy Surveys — some questions were no longer asked, wording was changed, or new questions were added. In this edition, we did not report if patients with a regular doctor received information on how to get help meeting their social needs; the percentage of primary care providers who have social workers in their practice; or the percentage of primary care physicians who had mental health providers in their practice. This edition includes new measures on access to telehealth, preparedness to treat behavioral health conditions, and care coordination.

NOTES
  1. Leiyu Shi, “The Impact of Primary Care: A Focused Review,” Scientifica 2012;, published online Dec. 31, 2012; and Tracey L. Henry et al., “Health Equity: The Only Path Forward for Primary Care,” Annals of Family Medicine 20, no. 2 (Mar./Apr. 2022): 175–78.
  2. Celli E. Horstman, Sara Federman, and Reginald D. Williams II, “Integrating Primary Care and Behavioral Health to Address the Behavioral Health Crisis” (explainer), Commonwealth Fund, Sept. 15, 2022.
  3. Geronimo Jimenez et al., “Revisiting the Four Core Functions (4Cs) of Primary Care: Operational Definitions and Complexities,” Primary Health Care Research and Development 22 (Nov. 2021): e68.
  4. Erin E. Sullivan et al., “Primary Care in Peril: How Clinicians View the Problems and Solutions,” NEJM Catalyst: Innovations in Care Delivery 4, no. 6 (June 2023); and Munira Z. Gunja et al., Stressed Out and Burned Out: The Global Primary Care Crisis — Findings from the 2022 International Health Policy Survey of Primary Care Physicians (Commonwealth Fund, Nov. 2022).
  5. Office of Disease Prevention and Health Promotion, “Access to Primary Care,” Healthy People 2030, n.d.
  6. Melissa Kang et al., “The Relationship Between Having a Regular General Practitioner (GP) and the Experience of Healthcare Barriers: A Cross-Sectional Study Among Young People in NSW, Australia, with Oversampling from Marginalised Groups,” BMC Family Practice 21 (Oct. 2020): 220.
  7. Yalda Jabbarpour et al., The Health of U.S. Primary Care: 2024 Scorecard Report — No One Can See You Now (Milbank Memorial Fund and the Physicians Foundation, Feb. 2024).
  8. Sara R. Collins, Lauren A. Haynes, and Relebohile Masitha, The State of U.S. Health Insurance in 2022: Findings from the Commonwealth Fund Biennial Health Insurance Survey (Commonwealth Fund, Sept. 2022).
  9. Wendy Glauser, “Primary Care System Outdated and Inconvenient for Millennials,” Canadian Medical Association Journal 190, no. 48 (Dec. 3, 2018): e1430–e1431; and Sandra Boodman, “Spurred by Convenience, Millennials Often Spurn the ‘Family Doctor’ Model,” KFF Health News, Oct. 9, 2018.
  10. Shreya Kolluri et al., “Telehealth in Response to the Rural Health Disparity,” Health Psychology Research 10, no. 3 (Aug. 2022): 37445.
  11. Leila Beheshti et al., “Telehealth in Primary Health Care: A Scoping Review of the Literature,” Perspectives in Health Information Management 19, no. 1 (Winter 2022): 1n.
  12. W.A. Alashek and S.A. Ali, “Satisfaction with Telemedicine Use During COVID-19 Pandemic in the UK: A Systematic Review,” Libyan Journal of Medicine 19, no. 1 (Jan. 2024).
  13. Mary Caitlin St. Clair et al., “Incorporating Home Visits in a Primary Care Residency Clinic: The Patient and Physician Experience,” Journal of Patient-Centered Research and Reviews 6, no. 3 (Summer 2019): 203–9.
  14. Thomas Cornwell, “House Calls Are Reaching the Tipping Point – Now We Need the Workforce,” Journal of Patient-Centered Research and Reviews 6, no. 3 (Summer 2019): 188–91; and Jing Yan Seah, “Barriers to Making House Calls by Primary Care Physicians and Solutions: A Literature Review,” Malaysian Family Physician 15, no. 3, published online Nov. 10, 2020.
  15. Gudrun Theile et al., “Home Visits — Central to Primary Care, Tradition or an Obligation? A Qualitative Study,” BMC Family Practice 12 (Apr. 2011): 24.
  16. Jennifer Arnold, “Fostering Long-Term Doctor-Patient Relationships to Improve Outcomes,” Duke Health, Jan. 17, 2017.
  17. Michael Hong et al., “The Impact of Improved Access to After-Hours Primary Care on Emergency Department and Primary Care Utilization: A Systematic Review,” Health Policy 124, no. 8 (Aug. 2020): 812–18.
  18. Connor Drake et al., “Implementation of Social Needs Screening in Primary Care: A Qualitative Study Using the Health Equity Implementation Framework,” BMC Health Services Research 21 (Sept. 2021): 975.
  19. Melinda K. Abrams et al., “Let’s Get It Right: Consistent Measurement of the Drivers of Health,” To the Point (blog), Commonwealth Fund, Dec. 15, 2023.
  20. Sarina Schrager, “Integrating Behavioral Health into Primary Care,” Family Practice Management 28, no. 3 (May/June 2021): 3–4; and Jack M. Westfall et al., The State of Integrated Primary Care and Behavioral Health in the United States (Robert Graham Center and HealthLandscape, 2022).
  21. Coverage and Payment of Interprofessional Consultation in Medicaid and the Children’s Health Insurance Program (CHIP),” letter from Daniel Tsai, Deputy Administrator and Director, Center for Medicaid and CHIP Services, to state health officials, Jan. 5, 2023.
  22. Centers for Medicare and Medicaid Services, “CMS Announces Multi-State Initiative to Strengthen Primary Care, press release, June 8, 2023.
  23. The Academy, “Health Equity and Behavioral Health Integration,” Agency for Healthcare Research and Quality, n.d.; Bijal A. Balasubramanian et al., “Outcomes of Integrated Behavioral Health with Primary Care,” Journal of the American Board of Family Medicine 30, no. 2 (Mar. 2017): 130–39; and David J. Kolko et al., “Collaborative Care Outcomes for Pediatric Behavioral Health Problems: A Cluster Randomized Trial,” Pediatrics 133, no. 4 (Apr. 2014): e918–e992.
  24. Centers for Medicare and Medicaid Services, “Care Coordination,” CMS.gov, n.d.
  25. Rendelle E. Bolton et al., “Integrating Personalized Care Planning into Primary Care: A Multiple-Case Study of Early Adopting Patient-Centered Medical Homes,” Journal of General Internal Medicine 35, no. 2 (Feb. 2020): 428–36.
  26. K.M. McDonald et al., Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies — Vol. 7: Care Coordination (Agency for Healthcare Research and Quality, June 2007).
  27. Jabbarpour et al., Health of U.S. Primary Care, 2024.
  28. National Academies, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (2021).
  29. Yalda Jabbarpour et al., Relationships Matter (Primary Care Collaborative and Robert Graham Center, Nov. 2022).
  30. Jabbarpour et al., Health of U.S. Primary Care, 2024; and Organisation for Economic Co-operation and Development, “Primary Care,” n.d.
  31. Yalda Jabbarpour, The Health of U.S. Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care (Milbank Memorial Fund and the Physicians Foundation, Feb. 2023).
  32. Irene Papanicolas, Liana R. Woskie, and Ashish K. Jha, “Health Care Spending in the United States and Other High-Income Countries,” JAMA 319, no. 10 (Mar. 13, 2018): 1024–39; and Commonwealth Fund, “Country Profiles: International Health System Profiles,” 2020.
  33. Department of Health and Aged Care, “Workforce Incentive Program,” Australian Government, last updated Dec. 18, 2023.
  34. Celli Horstman, Corinne Lewis, and Melinda K. Abrams, “Strengthening Primary Health Care: The Importance of Payment Reform,” To the Point (blog), Commonwealth Fund, Dec. 10, 2021.
  35. Edmond Li et al., “The Impact of Electronic Health Record Interoperability on Safety and Quality of Care in High-Income Countries: A Systematic Review,” Journal of Medical Internet Research 24, no. 9 (Sept. 2022): e38144.
  36. Gunja et al., Stressed Out and Burned Out, 2022.
  37. Evan D. Gumas et al., Overworked and Undervalued: Unmasking Primary Care Physicians’ Dissatisfaction in 10 High-Income Countries — Findings from the 2022 International Health Policy Survey (Commonwealth Fund, Aug. 2023).
  38. Shari M. Erickson et al., “Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians,” Annals of Internal Medicine 166, no. 9 (May 2, 2017): 659–61.

Publication Details

Date

Contact

Evan D. Gumas, Research Associate, International Health Policy and Practice Innovations, The Commonwealth Fund

[email protected]

Citation

Evan D. Gumas et al., Finger on the Pulse: The State of Primary Care in the U.S. and Nine Other Countries (Commonwealth Fund, Mar. 2024). https://doi.org/10.26099/p3y4-5g38