What steps can healthcare stakeholders take to elevate primary care in the United States?
Yalda Jabbarpour, MD is a firm believer that primary care is not only essential to the health and well-being of every patient in the U.S., but it’s the backbone of the entire healthcare system.
“Everyone in their lifetime will see a primary care clinician,” she said.
Indeed, good primary care is essential for population and individual health, said Dr. Jabbarpour, a family physician and director of the Robert Graham Center for Policy Studies.
From a population perspective, studies have shown that good primary care leads to higher life expectancy, lower healthcare costs, and better health equity. “I think that has been proven repeatedly in the literature, and it is the only medical specialty to have those three findings,” she said. “Primary care is absolutely essential to the health of the population.
“On an individual level,” she continued, “if you talk to anyone who has a good relationship with a long-term primary care doctor, they will tell you that it is absolutely invaluable in terms of their health and wellness, just having that person who knows them, knows their history, that they can turn to for questions or they can turn to when it’s a scary diagnosis and they need help navigating that.”
For individuals who don’t have a primary care doctor because they can’t get access to one, it is challenging to navigate the healthcare system and get timely care when they need it. Often their health ends up spiraling. They may frequent the ER or get in to see specialists too late when their diagnoses could have been prevented with treatment from a primary care physician.
Lack of investment
Despite this evidence, the investment in primary care in the U.S. compared to other countries remains low. The U.S. spends about 5 cents on the healthcare dollar on primary care. That lack of financial backing is causing problems for primary care providers, as well as negatively affecting the U.S. patient population, Dr. Jabbarpour said.
First, the lack of financial backing for primary care services means primary care practices are often overworked and under-resourced. There is a likelihood of higher turnover in those practices at the physician, nurse and front desk level – all because of burnout.
Trainees see this burnout. When they go into primary practice environments and observe the heavy workloads of primary care team members, they may think twice about getting into the field. “They’re seeing overworked and under-financed teams, so trainees are not choosing to go into primary care for that reason,” Dr. Jabbarpour said.
Even though there have been calls to increase the primary care physician workforce over the last decade to address the increase in chronic disease, mental health burdens and overall rise in sicker patients in the U.S. healthcare system, the number of physicians has actually gone down, Dr. Jabbarpour said.
The trickle-down effect hurts patient satisfaction. Patients are upset because they often can’t get in to even see a primary care physician. It can lead to poorer outcomes too.
These issues all tie back to a lack of investment, Dr. Jabbarpour said. “If you look at other countries with better health outcomes, they are spending at least double to triple what we’re spending on primary care.”
Creating the scorecard
To better understand the current realities of primary care in the U.S. and map out models for improvement, in 2022, the Milbank Memorial Fund and The Physicians Foundation announced a partnership with the Robert Graham Center to develop an annual “Health of U.S. Primary Care Scorecard” to measure the implementation of high-quality primary care and inform national and state policy. The scorecard is grounded in the recommendations of the 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report, Implementing High Quality Primary Care: Rebuilding the Foundations of Healthcare. Its aim is to provide accountability for the nation’s progress in high-quality primary care implementation across five dimensions: payment reform, access, workforce development, information technology, and accountability.
The inaugural scorecard in 2023 found a systemic underinvestment in primary care, shrinking workforce, increasing gaps in access to care, too few physicians being trained in community settings, and little to no federal funding for primary care research. The results of the 2024 scorecard revealed many of the same issues. The scorecard authors (including Dr. Jabbarpour) identified five reasons why primary care in the United States is inaccessible for so many Americans:
Reason No. 1: The primary care workforce is not growing fast enough to meet population needs.
- The number of primary care physicians (PCPs) per capita has declined over time from a high of 68.4 PCPs per 100,000 people in 2012 to 67.2 PCPs per 100,000 people in 2021.
- While the rate of total clinicians in primary care, inclusive of nurse practitioners (NPs) and physician assistants (PAs), has grown over the past several years, it is still insufficient to meet the demands of overall population growth, a rapidly aging population with higher levels of chronic disease, and workforce losses during the pandemic. Compared to Canada, which boasts a primary care physician-only density of 133 per 100,000 people, the U.S. primary care total clinician (physician, NP, and PA) density was only 105 per 100,000 people in 2021.
Reason No. 2: The number of trainees who enter and stay on the professional pathway to primary care practice is too low, and too few primary care residents have community-based training.
- In 2021, 37% of all physicians in training (residents) began training in primary care, yet only 21% of all physicians were practicing primary care three to five years after residency.
- In 2020, only 15% of primary care residents spent a majority of their time training in community-based settings where a majority of the U.S. population receives their care. Fewer than 5% of primary care residents spent a majority of their training with the most underserved communities in the United States.
- The number of medical residents per person in primary care has risen at a slower pace than all other specialties, increasing by only 21% compared to 26% in other specialties.
Reason No. 3: The U.S. continues to underinvest in primary care.
- The investment in primary care as a share of total health care spending has dropped from 5.4% in 2012 to 4.7% in 2021.
- Medicaid and commercial insurer investment in primary care has decreased since 2012, and Medicare investment remains low. Since 2019, primary care investment has steadily declined for all payers; this decline is most pronounced in the Medicare population.
Reason No. 4: Technology has become a burden to primary care.
- Data limited to family physicians demonstrate that health care technologies do not serve primary care physicians adequately; more than 40% of family physicians report unfavorable scores in electronic heath record (EHR) usability, and over 25% report overall dissatisfaction with their EHR.
Reason No. 5: Primary care research to identify, implement, and track novel care delivery and payment solutions is lacking.
- Since 2017, only around 0.3% of federal research funding (administered through the National Institutes of Health and the Agency for Healthcare Quality and Research, for example) per year has been invested in primary care research, limiting new information on primary care systems, payment and delivery models, and quality.
- Lack of adequate data about the primary care infrastructure hinders this Scorecard’s capacity to fully track progress on the NASEM report objectives: (1) Pay for primary care teams to care for people, not doctors to deliver services; (2) Ensure that high-quality primary care is available to every individual and family in every community; (3) Train primary care teams where people live and work; (4) Design information technology that serves the patient, family, and the interprofessional care team; (5) Ensure that high-quality primary care is implemented in the United States.
How the U.S. compares globally
Another recent study by the Commonwealth Fund looked at how the U.S. health system ranked globally, and had less than flattering news. The study concluded that the U.S. health system ranked last among 10 nations on key health equity, access to care, and outcome measures. Despite spending the most of any nation in the study, the United States has the worst-performing health care system overall.
Key findings from the report include:
- Health Outcomes: People in the U.S. have the shortest lives and the most avoidable deaths. The U.S. ranks last on five of six health outcome measures. Australia, Switzerland, and New Zealand perform the best in this domain.
- Access to Care: Americans face the most barriers to getting and affording health care. The U.S. is the only high-income nation in the study that does not provide universal health coverage, Commonwealth study authors said. Despite major coverage gains made under the Affordable Care Act, 25 million Americans remain uninsured, and nearly a quarter cannot afford care when they need it. In addition, U.S. patients are more likely to report they don’t have a regular doctor or place of care compared to residents of other countries.
- Equity: The U.S. and New Zealand rank lowest on health equity, with many lower-income people reporting they cannot afford the care they need compared to higher-income counterparts and more people reporting unfair treatment and discrimination when seeking care.
- Administrative Efficiency: Physicians and patients in the U.S. experience among the greatest burdens when it comes to payment and billing. The complexity of the U.S. health system, with its mix of public and private insurers and thousands of health plans, forces providers and patients to navigate a labyrinth of cost-sharing requirements, paperwork, and insurance disputes. This complexity causes the U.S. to rank second-to last in this domain, only slightly higher than Switzerland.
New ways of thinking
Building stronger primary care in the United States will take a concerted, collaborative effort among academic institutions, the government, public and private payors, and the vendors and technology companies.
At the payer level, everything starts with Medicare and the physician fee schedule, Dr. Jabbarpour said. If the government can move away from a majority fee-for-service schedule of payment and towards a payment model that values primary care, then commercial payers might be more inclined to follow suit.
“There should be more financial rewards for providing good quality care,” she said. “Hopefully both public and private payers will see the value in increasing the payments going to primary care practices so that there can be innovation in the primary care practice.”
There currently aren’t enough doctors, nurse practitioners and PAs in primary care to meet the need. Replenishing the workforce won’t happen overnight. Until then, healthcare providers must find innovative ways to distribute the work within the team.
“With the advent of technology and AI, you can imagine how if you have upfront payments to practices to support technology, so much of the administrative or busywork that is given to clinicians could be taken away and given to AI so that clinicians could spend their time actually taking care of patients face-to-face,” Dr. Jabbarpour said. “There’s a lot of innovation that can happen. Team-based care is important, but all these things take upfront payments. Right now, primary care practices are too cash-strapped to be able to do any of these innovative things or try new models.”
For its part, the Centers for Medicare & Medicaid Services Innovation has put forth several models that could help foster growth in primary care in the United States.
For instance, in June 2023, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary primary care model – the Making Care Primary (MCP) Model – that will be tested in eight states. The goal of the 10.5-year model is to improve care management and care coordination, equip primary care clinicians with tools to form partnerships with health care specialists, and leverage community-based connections to address patients’ health needs as well as their health-related social needs (HRSNs) such as housing and nutrition. CMS is working with State Medicaid Agencies in eight states – Colorado, North Carolina, New Jersey, New Mexico, New York, Minnesota, Massachusetts and Washington – to engage in full care transformation across payers, with plans to engage private payers in the coming months.
MCP provides primary care clinicians with enhanced model payments, tools, and support to improve the health outcomes of their patients, CMS states on its website. It provides additional resources and data to help primary care clinicians better coordinate care with specialists. It also supports better care integration, meaning that clinicians can more seamlessly address physical and behavioral health needs and tap into community networks to reduce health disparities.
CMS said the MCP care delivery approach communicates its vision for care delivery through three domains:
- Care Management: Participants will build their care management and chronic condition self-management support services, placing an emphasis on managing chronic diseases such as diabetes and hypertension, and reducing unnecessary emergency department (ED) use and total cost of care.
- Care Integration: In alignment with CMS’ Specialty Integration Strategy, participants will strengthen their connections with specialty care clinicians while using evidence-based behavioral health screening and evaluation to improve patient care and coordination.
- Community Connection: Participants will identify and address health-related social needs (HRSNs) and connect patients to community supports and services.
“Primary care clinicians are the first line of defense for prevention, screening, management of chronic conditions, and overall wellness,” CMS said. “Patients are increasingly diagnosed with multiple chronic conditions, which only intensifies the importance of accessible, affordable, high-quality primary care teams that can help anchor their overall health care. However, care coordination is increasingly challenging as patients see a greater number of specialists more frequently. Through MCP, the Center for Medicare and Medicaid Innovation (the Innovation Center) increases the investment in primary care so patients can access more seamless, high-quality, whole-person care.”
Another model, the Primary Care First Model Option, is a voluntary alternative five-year payment model that rewards value and quality by offering an innovative payment structure to support the delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First is based on the principles underlying the existing Comprehensive Primary Care Plus (CPC+) model design: prioritizing the clinician-patient relationship; enhancing care for patients with complex chronic needs and focusing financial incentives on improved health outcomes.
There are approximately 2,100 practices participating in Primary Care First across both cohorts, and 17 payer partners. The Primary Care First model is designed to help primary care practices better support their patients in managing their health – especially patients with complex, chronic health conditions – and enables primary care doctors to offer a broader range of health care services that meet the needs of their patients. For example, practices may offer around-the-clock access to a clinician and support for health-related social needs.
While it remains to be seen whether these models will lead to improvements and long-term changes in the way the U.S. approaches primary care, Dr. Jabbarpour is encouraged that CMS and state agencies recognize the problem and are creating measures to address the issues.
“These programs are examples of what we’ve been asking for,” she said, “and hopefully these will pan out and be a good path forward.”
Taking Action
The Commonwealth study researchers suggested the following policy actions need to take place in order to improve health outcomes and the U.S. healthcare system overall:
- Make health care more affordable and more accessible by extending health care coverage to the remaining uninsured and reforming insurance coverage to meet minimal standards of adequacy, including limits on patients’ out-of-pocket expenses.
- Invest in the long-neglected primary care system by improving compensation and supporting training for primary care providers.
- Improve health equity by eliminating disparities in the health and health care delivery that low-income individuals, Black, Latino, and Indigenous people, women, and people who live in rural areas receive. These populations often face discrimination and receive lower-quality care.
- Address the uncontrolled consolidation of health care systems and resources in local markets, which drives prices higher and makes insurance less affordable.
- To safeguard the well-being of all Americans, invest in interventions outside the health care system to address the social drivers of health, including poverty, homelessness, hunger, gun violence, and substance use.