The dwindling number of primary care physicians is a dagger at the heart of health care reform. If nearly all Americans have insurance, how will we find enough doctors to take care of them? Changes to Medicaid alone could bring as many as 15 million new customers searching for primary care. Yet far fewer medical graduates in the United States entered residencies in family medicine and internal medicine in 2009 than did in 1999.

That's not the only way our primary-care system is in trouble. It lags behind other developed countries in myriad ways. The newest evidence of this comes from a foundation called The Commonwealth Fund, which recently sent an army of researchers to survey 10,000 primary care physicians in 11 countries on the way they provide basic services and what it costs to do so.

Some of the findings are not surprising. For example, we're way behind on electronic health records, which most experts believe could bring down the cost and improve the provision of basic health care. More than 97 percent of primary-care docs in the Netherlands, New Zealand and Norway use electronic medical records; only 46 percent of U.S. doctors say they do. The good news is that many states have been working on closing this gap. Now, with the help of federal stimulus money targeted at health information technology, most states should make progress in boosting the e-record capabilities of hospitals and doctors.

But other findings get to the core of why our system is so much more expensive and difficult to access than others. For instance, more than two out of three U.S. physicians report that their practices make no provision for after-hours care. That leaves patients no choice but to go to the emergency room if they are worried about an ailment late at night. The U.S. scores worse than any other country surveyed on this point. Retail health clinics in chain stores are one small answer, but they're appropriate only for simple medical conditions such as a sore throat or earache.

Payment issues also loom large. Some 58 percent of U.S. primary-care physicians say their patients often have trouble paying for their medications and care -- compared with between 5 and 37 percent in the other 10 countries. That helps explain why nearly half of American physicians, many more than in other countries, say they spend too much time dealing with insurance-coverage restrictions for their patients' medications and treatments.

Another key finding has to do with paying primary-care doctors for performance. One-third of U.S. physicians report receiving some kind of financial incentive for the quality-improvement measures tracked in the survey. By contrast, 89 percent of doctors in the United Kingdom and sizable majorities of their counterparts in the Netherlands, New Zealand, Italy and Australia report receiving financial incentives of some kind to implement quality initiatives.

Some of these primary-care gaps might need federal intervention for improvements to be made. Others could be fixed by states or by local medical associations. But they need to be addressed if we're to use primary care to help drive down the high cost of keeping people healthy.