US lags in usual source of care, primary care access

April 03, 2024 - Adults in the United States are among the least likely to have a usual source of care compared to other high-income nations, a finding that Commonwealth Fund researchers say may signal the nation’s lapses in primary care access.

The issue brief, based on 2022 and 2023 data from the International Health Policy Survey of Primary Care Physicians and International Health Policy Survey of patients over age 18, indicates that workforce shortages, physician burnout, and limited patient access to care are hampering the primary care system in the US.

But the US isn’t alone in these setbacks, the Commonwealth Fund researchers wrote in their issue brief.

“Many countries struggle to ensure access to care, or first contact; continuity of care; comprehensiveness of care; and coordination of care,” the researchers said. “These four core components of high-quality primary care are essential to better overall health outcomes.”

The leading issue is overall patient access to care, often measured as having a usual source of care. The bulk of patients in all 10 countries included in the report (the US plus Australia, Canada, France, Germany, the Netherlands, New Zealand, Sweden, Switzerland, and the United Kingdom) do indeed have a usual source of care, with at least 86 percent reporting as much.

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But some countries do better at this than others. In the Netherlands, nearly every patient (99 percent) has a usual source of care. The rates are similar in Germany, the UK, and New Zealand. In the US, that proportion is 87 percent, while it’s 86 percent in Canada.

That’s bad news, considering the key role a usual source of care, which is a primary care provider for most adults, plays in overall health and well-being.

“Having a regular doctor or place of care is key to preventive care, the early detection and treatment of disease, and chronic disease management,” the researchers said. “Patients with a usual source of care are more likely to receive immunizations, blood pressure screenings, and cancer screenings.”

Having a usual source of care also makes it easier to gain access to other types of healthcare and improves the patient experience, they added.

Even when adults in the US do have a usual source of care, that patient-provider relationship is not longstanding. Only 43 percent of patients in the US said they have a longstanding relationship with their primary care provider.

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That’s the situation in many high-income countries. In Australia, 45 percent of patients said they have a longstanding relationship with their primary care provider, and in Sweden, that figure was 51 percent. Patients in the Netherlands are the most likely to report a longstanding relationship with their primary care provider, with 76 percent reporting as much.

But it’s not all bad news.

For one thing, primary care providers across the globe are increasingly saying that they are prepared to manage their patients’ behavioral health needs. This was the least common in France, and still, 90 percent of French primary care providers said they were ready to meet behavioral health needs. In the US, that figure was 91 percent.

What’s more, primary care providers in the US were the most likely to say they screen their patients for social determinants of health, with around a third saying they conduct screenings. An equal proportion of primary care providers in Germany do the same.

Still, there are challenges in terms of SDOH work.

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More than half (63 percent) of primary care providers in the US said they have trouble coordinating patient care with social services. Said otherwise, primary care providers often know when a patient experiences one or more SDOH, but their hands are tied in social services referrals.

And it’s more than care coordination for social services that’s falling behind. In half of the surveyed countries, two-thirds of patients said their regular doctor helped coordinate care with a specialist. In the US, this figure was 66 percent, around the middle of the pack. Sweden had the smallest proportion of regular providers leading the care coordination charge, with only 27 percent of patients reporting as much.

But physicians in these nations say care coordination is a challenge. Physicians in less than half of the surveyed nations said they see adequate levels of care coordination with specialists, with 41 percent of physicians in the US saying as much. New Zealand doctors were the most likely to report adequate care coordination, coming in at 72 percent.

In addition to limited longitudinal provider relationships and poor care coordination, the survey found that patients in the US have less access to emerging alternative modalities of primary care, like after-hours care. Patients in the US are also among the least likely to have access to home visits from their primary care provider or primary care via telehealth.

“Primary care physicians in the U.S. are paid less than specialists, and investment in primary care overall is low and decreasing over time,” the researchers offered as one explanation for the lapses in US primary care. “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.”

Right now, investment in US primary care is low, with the nation spending 4.7 percent of its total healthcare spend on primary care in 2021, compared to an average of 14 percent in peer nations. Increasing investment in primary care will be key to advancing the field moving forward, the researchers advised.

Such increased investment should help the US grow its primary care workforce, reform payments for primary care, support better care coordination between primary care and specialist providers, and reduce the administrative burden primary care providers commonly face, the report concluded.