First national primary care scorecard shows the field is 'headed for a crisis'

Due to a combination of chronic underinvestment, diminishing access and more, primary care is in peril, according to results of the first national primary care scorecard.

The findings were announced in a webinar held by The Physicians Foundation and the Milbank Memorial Fund, which co-funded the scorecard.

The scorecard “showed that our primary care system is headed for a crisis,” Ripley Hollister, MD, a board member of The Physicians Foundation, told Healio.

“Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes,” Hollister said. “While primary care plays one of the most important roles in shifting our health care system to one that focuses heavily on disease prevention, this report suggests it is not being adequately supported.”

The scorecard was developed in response to the 2021 National Academies for Sciences, Engineering and Medicine (NASEM) report on primary care, which called for a tool to track improvements in the implementation of high-quality primary care over time, according to a press release.

Overall, the scorecard “measures key primary care indicators over the past decade and reveals the urgent need for policies to improve a primary care infrastructure in crisis,” according to the release.

Yalda Jabbarpour, MD, medical director of the Robert Graham Center for Policy Studies and a coauthor of the scorecard report, told Healio that quality “can be somewhat of a loaded term.”

“Are we talking about patient quality outcomes? Are we talking about whether people can get access? That's a measure of quality. I think this looks at quality in the bigger sense. So, we're not looking in any way at outcomes of patients, but we are looking at intermediaries to high-quality care,” she said.

For the scorecard, that meant looking at factors like where primary care is being provided and for whom, how physicians are trained in the United States and how much the country is investing in both primary care overall and research to advance the field.

Investments in Primary Care

In terms of investment, Jabbarpour said “we're looking at the metrics of primary care spending and how the percent of visits in the United States that are paid under a capitated model as opposed to fee-for-service in terms of access for all patients.”

She said there is “poor investment in primary care overall” and that the total health care expenditures going to primary care were “not very high, which is disappointing given that primary care is kind of the backbone of U.S. health care, but we’re spending about a nickel on the dollar on primary care.”

According to the report, between 2010 and 2020, the U.S. invested less than 6.5% of total health spending on primary care. In contrast, Organization for Economic Co-operation Development nations spent about 7.8% of total health expenditures on primary care in 2016.

The report also showed that spending on primary care in Medicaid has steadily dropped since 2014, from 5.3% to a low of 4.2% in 2020. Additionally, as a percentage of total health spending, Medicare spent the least on primary care.

“We also showed that in terms of payment models, we want to move away from a fee-for-service payment model and towards a hybrid model where you're not just paying the doctors for delivering services, you're actually paying for teams to deliver high quality care,” Jabbarpour said. “We found that those payment models essentially don't exist or it's very limited in primary care in terms of workforce.”

Jabbarpour and colleagues also identified few federal funding opportunities for research in primary care. Only 0.2% of NIH dollars were allocated to family medicine departments from 2017 to 2021.

Access

The report additionally showed that the number of Americans who report not having a usual source of primary care has increased over time, “which is sad,” Jabbarpour said.

About 27% of adults in the U.S. reported not having a usual source of primary care or using the ER as their source of care in 2020, according to the report. In 2010, the rate was 23%.

The workforce shortage is another barrier to access. Between 2012 and 2020, just one in five medical residents entered primary care, compared with one in three physicians in 2010. In that same time frame, the gap in the number of primary care physicians per 100,000 people in medically underserved areas and non-medically underserved areas increased by 5%.

In other words, the PCP workforce is shrinking while gaps in care access seem to be growing, according to Jabbarpour and colleagues.

“We also found that that gap is widening between medically underserved areas and non-medically underserved areas,” Jabbarpour said, “except for some states, which actually have the reverse; they tend to have more physicians in the medically underserved areas, which is what you want to see.”

Reactions

Overall, Jabbarpour said that the report “showed that we are not doing well as a nation,” but she was not surprised by the findings.

“Part of it is we've been researching this stuff for a while, but the other part is as a physician myself working in practice, I see how under-resourced primary care is, how we don't have the same sorts of financial and human resources as our subspecialty colleagues. Patients are always calling to ask ‘why can I not get in to see you?’ It's because there's not enough of us. I see that on a day-to-day basis and the data just played that out,” she said.

Hollister said the fact that primary care is “a common good” indicates that the quality and strength of primary care services are national public concerns.

“We cannot underestimate the critical role primary care plays in our health care system,” he said. “This report provides insights into the current challenges primary care physicians are facing and tangible solutions for how we can address them. It is important that we continue developing this data and encourage further research on primary care. The recommendations included in this report are necessary to not only support physicians but also to improve patient outcomes and access to quality care for everyone.”

However, he, too, said that he has seen these trends as a practicing PCP.

“The comprehensiveness of this report and the baseline data it provides is unprecedented, and it demonstrates how important it is to collect data and conduct research on primary care, because we need to understand the problems to create solutions,” he said.

Next steps

The report laid out several recommendations for both public and private stakeholders from the 2021 NASEM report on primary care, Hollister said, including increasing the portion of the CMS spending dedicated to primary care to address the lack of financial resources.

Jabbarpour and colleagues wrote in the report that “it is time to accelerate adoption of policies that will demonstrably increase investment in high-quality primary care, create a robust primary care workforce, and enable analysis and learning around the impact of primary care.”

Jabbarpour said that the next steps in this work are accountability and learning from the report’s “bright spots.”

“I really think it's sharing examples and holding the nation accountable,” she said. “We need accountability. We need to be able to trace year by year: are we improving in these metrics or not? I think that's one next step. The report also lays out some bright spots ... so, learning from those states or those clinics or those specialties that are doing things right would be a next step.”

References:

• First national primary care scorecard reveals a health care sector in peril. https://www.milbank.org/news/first-national-primary-care-scorecard-reveals-a-health-care-sector-in-peril/. Published Feb. 22, 2023. Accessed Feb. 21, 2023.
• The health of US primary care: A baseline scorecard tracking support for high-quality primary care. https://www.milbank.org/publications/health-of-us-primary-care-a-baseline-scorecard/. Published Feb. 22, 2023. Accessed Feb. 21, 2023.
• First national primary care scorecard — what it reveals and what comes next. Webinar; Presented: Feb. 22, 2023.