National Primary Care Scorecard Highlights Needs for Funding, Workforce Development, and Care Access

A newly published national report, The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care, reveals a lack of financing, a shrinking workforce, gaps in care access, and nearly no federal funding for research in the primary care space.¹

The report was created following a call to action in the 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report on the implementation of primary care in the United States. The new report is the first national primary care scorecard and was co-funded by the Milbank Memorial Fund and The Physicians Foundation.

“We cannot underestimate the critical role primary care plays in our health care system, from improving patient outcomes to enhancing access to quality care for everyone,” Ripley Hollister, MD, a board member of The Physicians Foundation and family medicine physician, said in a statement.² “This first benchmark report provides necessary recommendations to help address the mounting challenges that primary care physicians are facing. We look forward to seeing the report published annually to ensure we embrace opportunities to improve primary care and provide a better future for America’s health.”

The authors addressed several key areas where there is room for improvement based on data from the past decade: systemic investment in primary care, the primary care physician (PCP) workforce, access to care, physician training, and federal research funding.

A Lack of Investment Minimizes Progress

“I think this scorecard is extraordinarily important, because we need to have a synthesis and we need the data, and we need to have a baseline in order to track which direction we're headed,” said Jennifer Lee, MD, chief medical officer of the Alliance of Community Health Plans, during a virtual panel discussion following the release. “Unfortunately, the scorecard reveals that we are headed in the wrong direction when it comes to investing in primary care.”

The report found that less than 6.5% of total health spending was dedicated to primary care between 2010 and 2020 in the United States. However, nations in the Organization for Economic Co-operation and Development dedicated 7.8% of health care spending to primary care on average in 2016, per the initial NASEM report.

While primary care spending can be defined differently by different stakeholders, the report considers it “the proportion of total health care expenditures being spent on outpatient and office-based visits to primary care clinicians.” Medicare primary care spending has also decreased consistently since 2014, with a low of 4.2% in 2020, according to the report.

Additionally, payment models for physician reimbursement are often unsupportive of teams rooted in whole-person care. Hybrid models with elements of fee-for-service and capitation reimbursement that reimburse the entire primary care team are ideal, but can be administratively complex, the authors wrote.

As the Workforce Shrinks, Gaps in Care Access Persist

The report highlighted a drop in the proportion of physicians practicing primary care in recent years. In 2010, 1 in 3 physicians practiced primary care, but only 1 in 5 medical residents between 2012 and 2020 were practicing primary care 2 years later. This indicates a need to strengthen the pipeline to primary care practice, the authors wrote.

In 2010, 23% of US adults reported using the emergency department as a source of care and not having a PCP. This proportion climbed to 27% in 2020. The proportion of clinicians who perform primary care also varies by state, and primary care access overall is lacking in underserved communities, the authors noted. In underserved areas, there were approximately 55.8 PCPs per 100,000 people vs 79.7 PCPs per 100,000 in areas that were not considered medically underserved in 2020.

“Although efforts by organizations such as community health centers play a central role in providing access to patients in medically underserved areas, the data demonstrate that much of the country still falls short in meeting these critical access needs,” the authors wrote.

The Need for Training in Community Settings

Most primary care occurs in the community setting, and the NASEM report emphasized a need for training to reflect this. Some states expose all physicians to medically underserved areas or rural settings, but in some states, only 5.9% of physician residents will experience these settings in training, the scorecard report found.

The distribution of physician residents also does not align with the geographic areas where physicians are entering primary care, the authors noted. “The mismatch between training opportunities and PCP supply signals that graduate medical education funding is not set up to support the growth of primary care but instead encourages subspecialty fields,” they wrote. Graduate medical education funding is most often allocated to sponsor institutions, although primary care is more often performed in community settings.

Research Needs for All Stakeholders

Family medicine departments received just above 0.2% of the National Institutes of Health research funding. While there are other primary care specialties, family medicine was chosen as the measurement because it has the most US health care encounters, the authors noted. 

During the panel discussion, Yalda Jabbarpour, MD, lead author of the scorecard and director of the Robert Graham Center, also highlighted a lack of uniform data available for research purposes.

“If we don't have uniform data that's easily accessible to all stakeholders who want to research this either on the state or health system or national level, it's going to be hard to keep the nation accountable to moving towards implementing high-quality primary care,” Jabbarpour said. “As a research team, that was what we noticed right away…and we looked at these data in so many different ways, using so many different data sources. Maybe we didn't get to perfection, but we got to good enough—but it would be nice to not have to spend all those resources to do that.”

Overall, the baseline scorecard emphasizes a need for research and investment into primary care, as well as consistent reporting to improve care access, workforce development, and the PCP pipeline in the United States going forward.

“Our health care system is wildly out of balance and in critical need of reform,” Christopher Koller, president of the Milbank Memorial Fund, said in a statement. “We can do better, and this scorecard can serve as an essential tool for policymakers and other stakeholders to pursue policies that will increase investments in high-quality primary care in every community.”

References

1. Jabbarpour Y, Petterson S, Jetty A, Byun H. The health of US primary care: a baseline scorecard tracking support for high-quality primary care. February 22, 2023. Accessed February 23, 2023. https://www.milbank.org/publications/health-of-us-primary-care-a-baseline-scorecard/v-research-there-are-few-federal-funding-opportunities-for-primary-care-research-with-only-0-2-of-national-institutes-of-health-funding-allocated-to-primary-care/

2. Underinvestment, workforce shortages, and lack of research funding threaten the future of America’s primary care. News release. Milbank Memorial Fund. February 22, 2022. Accessed February 23, 2023. https://www.milbank.org/news/first-national-primary-care-scorecard-reveals-a-health-care-sector-in-peril/