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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
THE COMMONWEALTH
FUND
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
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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THE COMMONWEALTH
FUND
Health Information Practice Capacity
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THE COMMONWEALTH
FUND
99 97 97 96 95 94 94
72 68
4637
0
25
50
75
100
NET NZ NOR UK AUS ITA SWE GER FR US CAN
Doctors Use Electronic Patient Medical Records*
* Not including billing systems.
Percent
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
5
THE COMMONWEALTH
FUND
9892 89
79
42
2823
99 97 96 95
72
4637
0
25
50
75
100
NET NZ UK AUS GER US CAN
2006 2009
Doctors Use Electronic Patient Medical Recordsin Their Practice, 2006 and 2009*
* 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)?”
Percent
Source: 2006 and 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
6
THE COMMONWEALTH
FUND
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
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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THE COMMONWEALTH
FUND
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.
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THE COMMONWEALTH
FUND
67 62
27
4531
209 9 7 4
6 10
274
16
19
177 9
612
10
0
25
50
75
100
AUS UK FR NZ ITA US CAN GER NET NOR SWE
Yes, using a manual system
Yes, using a computerized system
Doctor Routinely Receives Reminders for Guideline-Based Interventions or Screening Tests
Percent
73 72
5449 47
39
2721
161610
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Percentages may not sum to totals because of rounding.
9
THE COMMONWEALTH
FUND
9276 82
48
24 2618 17
103
421 7
31
35 2529
1521
129
24
0
25
50
75
100
NZ UK AUS NET FR SWE US ITA GER CAN NOR
Yes, using a manual system
Yes, using a computerized system
Practice Routinely Sends Patients Reminders for Preventive or Follow-Up Care
Percent
979789
80
6051
47
33 32 31
15
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Percentages may not sum to totals because of rounding.
10
THE COMMONWEALTH
FUND
92 91 89
66
5449
36
2619 15 14
0
25
50
75
100
NZ AUS UK ITA NET SWE GER US NOR FR CAN
Practices with Advanced Electronic Health Information Capacity
Percent reporting at least 9 of 14 clinical IT functions*
* 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.
11
THE COMMONWEALTH
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Access and Barriers to Care
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THE COMMONWEALTH
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Doctors’ Perception of Patient Access Barriers
Percent reporting patients OFTEN:
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
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
13
THE COMMONWEALTH
FUND
610 10
1316 16 17
19
34
42
48
0
25
50
UK NET SWE AUS FR NZ NOR CAN GER ITA US
Insurance Restrictions on Medication or Treatment for Patients Pose Major Time Concerns for DoctorsPercent saying amount of time physician or staff spend getting patients needed medications or treatment due to coverage restrictions is a MAJOR PROBLEM
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
14
THE COMMONWEALTH
FUND
9789 89
78 77
54 5450
4338
29
0
25
50
75
100
NET NZ UK FR ITA GER SWE AUS CAN NOR US
Practice Has Arrangement for Patients’ After-Hours Care to See Doctor/Nurse
Percent
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
15
THE COMMONWEALTH
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Managing Patient Care
16
THE COMMONWEALTH
FUND
Practice Routinely Uses Written Treatment Guidelines, by Condition
98 96 94 94 9387 86
82 8277
62
0
25
50
75
100
Diabetes
80
7165 63
49 4945
3931 30
26
0
25
50
75
100
DepressionPercent
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
Percent
17
THE COMMONWEALTH
FUND
63
33 3024 23 22
16 1511 9 9
0
25
50
75
100
ITA UK US AUS GER NET CAN NZ SWE FR NOR
Doctor Routinely Gives Chronically Ill Patients Written Instructions on Managing Care at Home
Percent saying yes, ROUTINELY gives written instructions
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
18
THE COMMONWEALTH
FUND
83
6659
43
30 2920
1612
5 4
0
25
50
75
100
UK GER ITA FR US SWE NOR CAN AUS NZ NET
Practice Routinely Gives Patients Written List of All Medications
Percent saying yes, ROUTINELY gives list of all medications
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
19
THE COMMONWEALTH
FUND
98 9891 88 88
73 73
5954 52
11
0
25
50
75
100
SWE UK NET AUS NZ GER NOR US ITA CAN FR
Practices Use Nonphysician Clinical Staff for Patient Care
Percent reporting practice shares responsibility for managing care, including nurses, medical assistants
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
20
THE COMMONWEALTH
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Patient Safety
21
THE COMMONWEALTH
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5641
3220 18 18 13 12 10 5
38
4453 52
45
2330 37
47
3125
5 12 15 1531
5848 48
3755
68
32
0%
25%
50%
75%
100%
UK SWE AUS NZ US FR GER ITA NOR CAN NET
Yes, works well Yes, needs improvement No process
Does Your Practice Have a Process for Identifying Adverse Events and Taking Follow-Up Action?
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
22
THE COMMONWEALTH
FUND
Performance Reviews, Benchmarks, and Reporting
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THE COMMONWEALTH
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89
71 68 65
43 41 40
25 2417
12
0
25
50
75
100
UK SWE NZ NET US GER ITA NOR AUS CAN FR
Percent
Practice Routinely Receives and Reviews Data on Patient Clinical Outcomes
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
24
THE COMMONWEALTH
FUND
96
78
65
55 52
24 2315 12
5 20
25
50
75
100
UK SWE NZ US AUS GER NET CAN ITA NOR FR
Percent
Practice Routinely Receives and Reviews Data on Patient Satisfaction and Experience
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
25
THE COMMONWEALTH
FUND
65
39 38
28 26 25 2314 11
30
25
50
75
100
UK SWE FR US NZ NET GER AUS CAN NOR ITA*
Practice Routinely Receives Data Comparing Clinical Performance to Other Practices
Percent
* Question asked differently in Italy.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
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THE COMMONWEALTH
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1519 20
26 27 29 3238
49 50
67
0
25
50
75
100
CAN NET NOR AUS US NZ UK FR SWE ITA GER
Time Spent Reporting or Meeting Regulations Is a Major Problem
Percent said amount of time spent reporting clinical information or meeting regulatory requirements is a MAJOR PROBLEM
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
27
THE COMMONWEALTH
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Use of Financial Incentives for Quality Improvement
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THE COMMONWEALTH
FUND
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 non-physician 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.
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THE COMMONWEALTH
FUND
Doctors Can Receive Any Financial Incentives
81 80
7065
89
6258
50
36 35
10
0
25
50
75
100
UK NET NZ ITA** AUS CAN GER FRA US NOR SWE
Percent who can receive any financial incentives for targeted care or meeting goals*
* 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.
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THE COMMONWEALTH
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System Views
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THE COMMONWEALTH
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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
System needs to be completely rebuilt 6 4 6 31 4 1 1 2 7 3 15
* 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.
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THE COMMONWEALTH
FUND
35 3522 27 30
18 218 15 12 5
54 5466 54 49
59 5468 49
3634
0
25
50
75
100
NZ NOR NET UK SWE ITA CAN FR US AUS GER
Satisfied
Very satisfied
Percent*
Physician Satisfaction with Practicing Medicine
* The other responses were somewhat dissatisfied or very dissatisfied.
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
33
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 years has
AUS CAN 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
Source: 2009 Commonwealth Fund International Health Policy Survey of Primary Care Physicians.
34
THE COMMONWEALTH
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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
35
THE COMMONWEALTH
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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 patient-centered, integrated care systems
36
THE COMMONWEALTH
FUND
Acknowledgements and Cofunders
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
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.
