THE
COMMONWEALTH
FUND
The Commonwealth Fund
2009 International Health Policy Survey of
Primary Care Physicians in Eleven Countries
Cathy Schoen and Robin Osborn
The Commonwealth Fund
November 2009
2
2009 International Health Policy Survey
• Mail, phone, and e-mail survey of primary care physicians from
February to July 2009 in Australia, Canada, France, Germany, Italy,
Netherlands, New Zealand, Norway, Sweden, United Kingdom, and
United States
• Samples: 1,016 Australia, 1,401 Canada, 502 France, 715 Germany,
844 Italy, 614 Netherlands, 500 New Zealand, 774 Norway,
1,450 Sweden, 1,062 United Kingdom, and 1,442 United States
• Conducted by Harris Interactive subcontractors, and Dutch
Scientific Institute for Quality of Healthcare, Swedish Ministry
of Health, Norwegian Knowledge for the Health Services, and
Italian Primary Care Physicians Association
• Core Topics: System views and satisfaction, access to care,
managing chronic illness, teams, information technology,
measuring practice performance, and financial incentives
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
3
Health Information Practice Capacity
THE
COMMONWEALTH
FUND
Doctors Use Electronic Patient Medical Records*
4
Percent
100
99
97
97
96
95
94
94
72
75
68
46
50
37
25
0
NET
NZ
NOR
UK
AUS
ITA
SWE
GER
* Not including billing systems.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
FR
US
CAN
THE
COMMONWEALTH
FUND
Doctors Use Electronic Patient Medical Records
in Their Practice, 2006 and 2009*
5
Percent
100
98 99
2006
92
97
96
2009
95
89
79
72
75
50
46
42
37
28
25
23
0
NET
NZ
UK
AUS
GER
US
* 2006: “Do you currently use electronic patient medical records in your practice?”
* 2009: “Do you use electronic patient medical records in your practice (not including billing systems)?”
Source: 2006 and 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
CAN
THE
COMMONWEALTH
FUND
6
Practice Use of IT on a Routine Basis for Core Tasks
Percent reporting
ROUTINE:
AUS
CAN
FR
GER
ITA
NET
NZ
NOR
SWE
UK
US
Electronic ordering of
laboratory tests
86
18
40
62
91
6
64
45
81
35
38
Electronic access to
patients’ test results
93
41
36
80
50
76
92
94
91
89
59
Electronic prescribing
of medication
93
27
57
60
90
98
94
41
93
89
40
Electronic alerts/
prompts about a
potential problem with
drug dose/interaction
92
20
43
24
74
95
90
10
58
93
37
Electronic entry of
clinical notes
92
30
60
59
82
96
96
81
89
97
42
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
7
Computerized Capacity to Generate
Patient Information
Percent report the
COMPUTERIZED
capacity to generate:
AUS
CAN
FR
GER
ITA
NET
NZ
NOR
SWE
UK
US
List of patients by
diagnosis
93
37
20
82
86
73
97
57
74
90
42
List of patients by
lab result
88
23
15
56
76
62
84
49
67
85
29
List of patients who
are due or overdue for
tests/preventive care
95
22
19
65
76
69
96
32
41
89
29
List of all medications
taken by an individual
patient*
94
25
24
65
78
61
96
45
49
86
30
* Including those that may be prescribed by other doctors.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
THE
COMMONWEALTH
FUND
Doctor Routinely Receives Reminders for
Guideline-Based Interventions or Screening Tests
8
Percent
100
Yes, using a manual system
75
73
6
Yes, using a computerized system
72
10
54
50
49
4
27
67
47
16
62
39
19
25
45
31
27
17
20
0
AUS
UK
FR
NZ
ITA
27
US
9
CAN
21
16
16
12
7
9
9
7
GER
NET
NOR
10
Percentages may not sum to totals because of rounding.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
10
6
4
SWE
THE
COMMONWEALTH
FUND
Practice Routinely Sends Patients Reminders
for Preventive or Follow-Up Care
9
Percent
100
97
97
Yes, using a manual system
89
4
21
7
Yes, using a computerized system
80
75
31
60
51
50
92
76
35
82
47
33
25
29
25
48
24
24
26
18
32
15
9
17
ITA
GER
0
NZ
UK
AUS
NET
FR
SWE
US
Percentages may not sum to totals because of rounding.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
31
21
15
10
12
3
CAN
NOR
THE
COMMONWEALTH
FUND
10
Practices with Advanced Electronic
Health Information Capacity
Percent reporting at least 9 of 14 clinical IT functions*
100
92
91
89
75
66
54
50
49
36
26
19
25
15
14
FR
CAN
0
NZ
AUS
UK
ITA
NET
SWE
GER
US
NOR
* Count of 14 functions includes: electronic medical record; electronic prescribing and ordering of tests; electronic
access test results, Rx alerts, clinical notes; computerized system for tracking lab tests, guidelines, alerts to provide
patients with test results, preventive/follow-up care reminders; and computerized list of patients by diagnosis,
medications, due for tests or preventive care.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
THE
COMMONWEALTH
FUND
11
Access and Barriers to Care
THE
COMMONWEALTH
FUND
Doctors’ Perception of Patient Access Barriers
Percent reporting
patients OFTEN:
12
AUS
CAN
FR
GER
ITA
NET
NZ
NOR
SWE
UK
US
Have difficulty
paying for
medications or
other care
23
27
17
28
37
33
25
5
6
14
58
Have difficulty
getting specialized
diagnostic tests
21
47
42
26
52
15
60
11
22
16
24
Experience long
waiting times to
see a specialist
34
75
53
66
75
36
45
55
63
22
28
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
13
Insurance Restrictions on Medication or Treatment
for Patients Pose Major Time Concerns for Doctors
Percent saying amount of time physician or staff spend getting patients needed
medications or treatment due to coverage restrictions is a MAJOR PROBLEM
48
50
42
34
25
10
10
NET
SWE
13
16
16
17
FR
NZ
NOR
19
6
0
UK
AUS
CAN
GER
ITA
US
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
14
Practice Has Arrangement for Patients’
After-Hours Care to See Doctor/Nurse
Percent
100
97
89
89
78
77
75
54
54
50
43
50
38
29
25
0
NET
NZ
UK
FR
ITA
GER
SWE
AUS
CAN
NOR
US
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
15
Managing Patient Care
THE
COMMONWEALTH
FUND
16
Practice Routinely Uses Written
Treatment Guidelines, by Condition
Diabetes
Percent
100
Depression
Percent
98 96
94 94 93
100
87 86
82 82
80
77
71
75
75
65 63
62
50
49 49
50
45
39
26
GE
R
FR
NE
T
ITA
CA
N
US
NO
R
SW
E
NZ
AU
S
FR
GE
R
US
CA
N
NO
R
AU
S
NZ
SW
E
0
ITA
0
UK
25
NE
T
25
UK
31 30
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Doctor Routinely Gives Chronically Ill Patients
Written Instructions on Managing Care at Home
17
Percent saying yes, ROUTINELY gives written instructions
100
75
63
50
33
30
25
24
23
22
16
15
11
9
9
SWE
FR
NOR
0
ITA
UK
US
AUS
GER
NET
CAN
NZ
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Practice Routinely Gives Patients Written List
of All Medications
18
Percent saying yes, ROUTINELY gives list of all medications
100
83
75
66
59
43
50
30
29
20
25
16
12
5
4
NZ
NET
0
UK
GER
ITA
FR
US
SWE
NOR
CAN
AUS
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
19
Practices Use Nonphysician Clinical Staff
for Patient Care
Percent reporting practice shares responsibility for managing care,
including nurses, medical assistants
100
98
98
91
88
88
73
75
73
59
54
52
50
25
11
0
SWE
UK
NET
AUS
NZ
GER
NOR
US
ITA
CAN
FR
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
20
Patient Safety
THE
COMMONWEALTH
FUND
Does Your Practice Have a Process for Identifying
Adverse Events and Taking Follow-Up Action?
Yes, works well
100%
5
12
15
Yes, needs improvement
38
58
44
53
No process
15
31
75%
21
48
48
37
55
68
52
50%
45
25%
23
56
41
32
32
30
37
47
31
25
20
18
18
13
12
10
5
ITA
NOR
CAN
NET
0%
UK
SWE
AUS
NZ
US
FR
GER
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
22
Performance Reviews, Benchmarks,
and Reporting
THE
COMMONWEALTH
FUND
23
Practice Routinely Receives and Reviews
Data on Patient Clinical Outcomes
Percent
100
89
71
75
68
65
50
43
41
40
25
24
25
17
12
0
UK
SWE
NZ
NET
US
GER
ITA
NOR
AUS
CAN
FR
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
24
Practice Routinely Receives and Reviews
Data on Patient Satisfaction and Experience
Percent
100
96
78
75
65
55
52
50
24
25
23
15
12
5
2
NOR
FR
0
UK
SWE
NZ
US
AUS
GER
NET
CAN
ITA
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Practice Routinely Receives Data Comparing
Clinical Performance to Other Practices
25
Percent
100
75
65
50
39
38
28
26
25
25
23
14
11
3
0
UK
SWE
FR
US
NZ
NET
GER
AUS
* Question asked differently in Italy.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
CAN
NOR
ITA*
THE
COMMONWEALTH
FUND
Time Spent Reporting or Meeting Regulations
Is a Major Problem
26
Percent said amount of time spent reporting clinical information
or meeting regulatory requirements is a MAJOR PROBLEM
100
75
67
50
25
15
19
20
NET
NOR
26
27
29
32
AUS
US
NZ
UK
49
50
SWE
ITA
38
0
CAN
FR
GER
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
27
Use of Financial Incentives
for Quality Improvement
THE
COMMONWEALTH
FUND
28
Financial Incentives and Targeted Support
Percent can receive
financial incentives* for:
AUS
CAN
FR
GER
ITA
NET
NZ
NOR
SWE
UK
US
High patient
satisfaction ratings
29
1
2
4
19
4
2
1
4
49
19
Achieving clinical
care targets
25
21
6
6
51
23
74
1
5
84
28
Managing patients
w/ chronic disease
or complex needs
53
54
42
48
56
61
55
9
2
82
17
Enhanced preventive
care activities**
28
26
14
23
28
17
38
12
2
37
10
Adding nonphysician clinicians
to practice
38
21
3
17
44
60
19
7
2
26
6
Non-face-to-face
interactions with
patients
10
16
3
7
***
35
5
30
4
17
7
* Including bonuses, special payments, higher fees, or reimbursements.
** Including patient counseling or group visits.
*** Question not asked in Italy survey.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
THE
COMMONWEALTH
FUND
Doctors Can Receive Any Financial Incentives
29
Percent who can receive any financial incentives for targeted care or meeting goals*
100
89
81
80
70
75
65
62
58
50
50
36
35
25
10
0
UK
NET
NZ
ITA**
AUS
CAN
GER
FRA
US
NOR
* Can receive financial incentives for any of six: high patient satisfaction ratings, achieve clinical care targets, managing
patients with chronic disease/complex needs, enhanced preventive care (includes counseling or group visits), adding
nonphysician clinicians to practice and non-face-to-face interactions with patients. Italy not asked non-face-to-face.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
SWE
THE
COMMONWEALTH
FUND
30
System Views
THE
COMMONWEALTH
FUND
31
Physician Views of Health System
Percent saying*
AUS
CAN
FR
GER
ITA
NET
NZ
NOR
SWE
UK
US
Only minor
changes are
needed
23
33
41
18
38
60
42
56
37
47
17
Fundamental
changes are
needed
71
62
53
51
58
37
57
40
54
50
67
6
4
6
31
4
1
1
2
7
3
15
System needs to be
completely rebuilt
* Respondents asked which statement expresses their overall view of their country’s health system:
only minor changes are needed; fundamental changes are needed; system needs to be completely rebuilt.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
THE
COMMONWEALTH
FUND
Physician Satisfaction with Practicing Medicine
Percent*
Satisfied
100
Very satisfied
32
75
54
54
66
50
54
49
59
54
68
49
36
25
35
34
35
22
27
30
18
21
8
0
NZ
NOR
NET
UK
SWE
ITA
CAN
FR
* The other responses were somewhat dissatisfied or very dissatisfied.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
15
12
US
AUS
5
GER
THE
COMMONWEALTH
FUND
Physician Views of the Quality of Care Their
Patients Get Throughout the Health Care System
% saying quality
of care in past three AUS CAN
years has
33
FR
GER
ITA
NET
NZ
NOR
SWE
UK
US
Improved
13
17
19
1
32
36
32
29
28
51
19
Stayed the same
65
50
39
24
40
42
56
61
42
37
54
Become worse
22
31
41
73
27
19
12
9
28
12
26
THE
COMMONWEALTH
FUND
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
34
Summary and Implications
• Wide differences across countries in access, information
systems, teams, and incentives to improve
– Arrangements for after-hours care vary significantly
• Leading countries on Health Information Technology have broad
functional capacity but different emphases
• Chronic care and teams: new roles and emerging care models
• Patient safety lags behind in primary care
• Primary care doctors often lack feedback on performance
• Payment incentives are increasingly used to encourage quality
• U.S. Concerns: U.S. stands out for reporting cost-related access
problems, lack of after-hours care, and lag in IT adoption
THE
COMMONWEALTH
FUND
35
Opportunities to Learn
• Country patterns reflect strategic policy choices and
extent to which policies are national in scope
–
–
–
–
–
Coverage and benefit design
Payment and information for quality and care management
IT: investing in primary care capacity and connectivity
After-hours access
Chronic disease management and use of teams
• Primary care “redesign” is central to international
initiatives to improve health care system performance
– Shared principles but different approaches
• Rich opportunities to learn as countries seek
to transform primary care and develop patientcentered, integrated care systems
THE
COMMONWEALTH
FUND
36
Acknowledgements and Cofunders
Thanks to coauthors M. M. Doty, D. Squires, J. Peugh, and S. Applebaum,
and to Harris Interactive, Inc., and contractors for conducting the survey.
Published by Health Affairs as, “A Survey of Primary Care Physicians in
Eleven Countries, 2009: Perspectives on Care, Costs, and Experiences,”
Web Exclusive, Nov. 5, 2009, w1171–w1183.
Cofunders
•
Canada: Health Council of Canada, Ontario Quality Council, Quebec
Health Commission
•
France: Haute Authorité de Santé (HAS), Caisse Nationale d'Assurance
Maladie des Travailleurs Salariés (CNAMTS)
•
Germany: Institute for Quality and Efficiency in Health Care (IQWiG)
•
Italy: Italian Primary Care Physicians Association
•
Netherlands: Dutch Ministry of Health, Welfare and Sport and IQ Health,
Radboud University Nijmegen
•
Norway: Norwegian Knowledge Centre for the Health Services
•
Sweden: Swedish Ministry of Health
•
United Kingdom: Health Foundation
THE
COMMONWEALTH
FUND