'You're not going crazy': Second annual primary care scorecard highlights critical issues

Key takeaways:

• Some of the biggest reasons for primary care’s troubles include inadequate funding and a workforce shortage.
• Experts say primary care is at a tipping point, but there is still hope.

The results of the second annual national primary care scorecard suggest the field is facing major problems — poor funding and a diminishing workforce, among them — but increased attention on the issues may offer hope, according to experts.

Primary care is “critically important to the health of our nation’s health care system and our ability to deliver high-quality care” efficiently, Gary Price, MD, president of The Physicians Foundation, told Healio.

“There are numerous studies that have shown that primary care is really the portal through which we minimize waste in our health care dollars, but also where we optimize patients’ health with the least time and the most efficient use of our health care dollars,” Price said. “So, there’s really no debate at all as to how critical it is. Our primary care system’s really just the portal to high-quality, cost-efficient care for the entire country.”

And yet, last year’s scorecard — the first of its kind — revealed a field headed for a crisis. The report noted a perilous combination of reduced access to care and chronic underinvestment as contributors to the field’s struggles.

This year’s report was titled “No One Can See You Now” — a play on the common phrase, “Your doctor will see you now” — highlighting the current barriers to primary care access in the United States. Yalda Jabbarpour, MD, medical director of the Robert Graham Center for Policy Studies and a co-author of the scorecard report, said the prolonged wait times patients have seen recently was a major focus for this year’s report.

“When you go to call for a primary care visit, it’s 3 months to see an already established doctor, sometimes 6 months to establish with a new doctor,” Jabbarpour told Healio. “So, we wanted to find out what’s going on. Why can no one see you now?”

‘We have a real problem’

The report identified five main reasons why access to primary care is diminishing across the country: primary care is facing a workforce exodus, the existing workforce is struggling to meet population demands, administrative burden, federal underinvestment and insufficient research funding.

Thirty-seven percent of all physicians in training specialized in primary care in 2021, according to the report. But 3 to 5 years after residency, many leave the field; just 15% were practicing in primary care after that time. Meanwhile, the number of primary care providers per person has decreased despite “a rapidly aging population with higher levels of chronic disease,” according to the report.

From 2012 to 2021, the number of PCPs per 100,000 people declined from 68.4 to 67.2, and from 2016 to 2021, the proportion of all clinicians in primary care stayed stagnant, at about 28%, according to the report. During the past decade, there has also been a 21% increase in the share of adults in the U.S. without a usual source of care and a 36% increase for children.

“You’re not going crazy. When you’re like, ‘Why is my workload getting harder?’ These are the reasons why,” Jabbarpour said. “The data are there to support it. There’s not enough for you to go around, and that’s why you’re feeling stressed.”

The NIH has estimated that the number of people aged at least 50 years who have one or more chronic diseases will rise 99.5% by 2050 — from 72 million to 143 million.

“We have an increased demand and ... a decreasing supply,” Jabbarpour said.

The report additionally stated that just 15% of primary care residents in 2020 spent most their time training in community settings — the rest trained in academic health centers and hospitals. This indicates that “many residents may lack adequate experience practicing in real-world clinical environments,” according to the report.

Another major challenge facing the field is administrative burden. According to the report, PCPs are burdened by “cumbersome electronic health records.” In fact, in 2022, more than 40% of family physicians rated their EHR systems’ usability as unfavorable, and 25% said they were dissatisfied with the overall system.

Notably, the American Board of Family Medicine has reported that 16% of family physicians spend at least 4 hours each day on EHRs. Price said that technology have actually “made it more difficult to practice.”

“We have lots of statistics on dissatisfaction that all physicians, but PCPs in particular, have with the technology, particularly the electronic medical record, actually making them less time-efficient than they were before,” Price said. “The good news there is that once we admit we have a problem with that, I’m confident that the technology can be used to turn things around, and hopefully artificial intelligence will make that easier. But overall, we really have a tragedy in the technological implementation of the electronic record in our country that hasn’t gotten enough attention and needs to be addressed.”

Funding also has a lot to do with the state of primary care, according to the report. For example, from 2012 to 2021, the proportion of total U.S. health care spending given to primary care stayed under 6%. Additionally, investment in primary care has steadily declined across all major health care payers since 2019.

“What you’re seeing, what you’re feeling and the stress that you’re under, is backed up by the data and the lack of investment by the United States into primary care. And you’re feeling it in the clinic,” Jabbarpour said. “We spend about 4 cents on the dollar on primary care, but that’s the backbone of our health care system.”

Additionally, 0.3% of federal research funding — which is administered through the Agency for Healthcare Research and Quality, the CDC, the FDA and the NIH — has gone toward primary care research.

This, according to the report, limits the amount of new data on primary care quality, delivery models and systems. That lack of evidence in areas like payment models and the training of physician assistants or nurse practitioners then makes tracking high-quality primary care even more difficult.

“The overall spending by the NIH on primary care research is a fraction of a percent of their total spending, yet we have this critical area of health care delivery that’s responsible for a lot of our failure to address chronic disease, and that results in expensive treatments later on that perhaps could have been avoided,” Price said. “We have a real problem. We have a sick patient.”

However, Price said, through what studies are available, researchers have identified “a number of areas where we need to change to improve the situation.”

“Now, all we need is the will and the determination to address them,” he said.

Jabbarpour said “nothing has gotten better, unfortunately,” since last year’s report.

“Nothing much has changed in the year, and I guess we wouldn’t have expected it to, given that policies don’t change that quickly,” she said. “I guess we were hoping, though, that using post-pandemic data, we’d see that more people were seeking out primary care, there’d be more investment in primary care because of what we learned from the pandemic and, unfortunately, we just didn’t see that. The trend has continued to get worse or stay stagnant.”

Price also stressed that the report card “reveals some real problems,” but that they were unsurprising given that “there really haven’t been any significant interventions” since last year’s report.

“This year’s report card underscores the fact that we haven’t paid attention to the things we need to do to make sure that people do have access to a PCP, and that they’re really getting everything they deserve from our health care system in maintaining their well-being and keeping them well in the long run,” Price said.

Optimism at ‘a critical juncture’

Price said primary care’s future “doesn’t need to be as bleak as the report suggests,” mostly because of the increased attention focused on its problems.

“There’s enough concern now that we are looking at it very critically, and we’ve identified where our weak spots are,” he said. “I think we’re at an inflection point in our health care system where we’re beginning to address some of the root causes of not maintaining wellness. As we pay attention to that and make investments in it, I think that there’s real hope that we can make the overall health of our population much better, and I also think that offers the promise of accomplishing them more cost efficiently, so I’m very hopeful.”

Price pointed to the fact that the report itself represents a step forward in improving the field.

The scorecard was initially developed in response to the 2021 National Academies of 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. The report is a collaborative effort between The Physicians Foundation, the Milbank Memorial Fund and the Robert Graham Center.

That alone “reflects the fact that a lot of people recognize what a problem this is,” he said.

“We have a prestigious national organization that’s recognized the problem. We have a very credible research organization and professional associations that have cooperated to begin to gather these data, and we’re now doing it for the second year in a row, so we’re having some longitudinal results start to come in,” Price said.

Price also said he is hopeful that primary care will start to see results from innovative solutions.

“I don’t think we’re delivering a terminal diagnosis to this patient,” he said, referring to primary care.

Jabbarpour had a similarly optimistic outlook.

“I could say that [the future of primary care] depresses me, but I think another way to spin it actually is that it excites me that we’re at such a critical juncture,” she said. “And maybe that sounds weird, but ... it’s almost like when you need something to just get so bad that someone will make a change. And that feeling of, I don’t know, anticipation, excitement that a change is coming hopefully — I think that’s where we’re at.”

In the face of such major obstacles in primary care, it can be difficult to find optimism. But Jabbarpour said the NASEM report that the scorecard was built on “actually has the policy solutions that we know will work — they just need to be implemented.” She said the report “really calls out specific players” and lays out some of the paths for change, but not much progress has been made.

Jabbarpour additionally emphasized that there is strength in numbers for PCPs looking to make changes.

“If you’re a family physician, join [American Academy of Family Physicians]. If you’re an internist, join ACP. If you’re a pediatrician, join [American Academy of Pediatrics],” she said. “Those people’s day jobs are to advocate for their physicians and their patients. As an individual PCP, it’s really hard to take time away from your patients to go advocate for these things, even at your own health system level.”

But even on an individual level, Jabbarpour said providers can use the findings from the report to advocate for themselves and show what is happening on a national scale to explain why they may be having a hard time seeing patients.

The report also has a dashboard that allows providers to discover primary care spending as a share of total health care spending by all payers across the country, which allows them to explain to their health systems, “I’m not crazy when I say I have too much work. Look at all this stuff that’s going on at the state level,” Jabbarpour said. “But I think the most effective way, really, is to join these coalitions that are already there to fight for them.”

References:

• Primary care in crisis: New scorecard reveals sector struggling to meet demand, retain physicians and secure adequate funding. https://physiciansfoundation.org/primary-care-in-crisis-new-scorecard-reveals-sector-struggling-to-meet-demand-retain-physicians-and-secure-adequate-funding/. Published Feb. 28, 2024. Accessed Feb. 28, 2024.
• Scorecard data dashboard. https://www.milbank.org/primary-care-scorecard/. Published Feb. 28, 2024. Accessed Feb. 28, 2024.
• The health of U.S. primary care: 2024 scorecard report — no one can see you now. https://www.milbank.org/publications/the-health-of-us-primary-care-2024-scorecard-report-no-one-can-see-you-now/. Published Feb. 28, 2024. Accessed Feb. 28, 2024.