'This hurts': Third annual primary care scorecard details field's systemic underinvestment

Key takeaways:

• The latest national primary care scorecard revealed the impact chronic underinvestment has had on the field.
• Experts highlighted reduced access and a diminishing workforce as major consequences.

The third annual national primary care scorecard spotlighted underinvestment in the field and the detrimental, worsening impact it has on primary care providers.

The findings were announced during a webinar held by The Physicians Foundation and the Milbank Memorial Fund, which cofunded the scorecard.

Ripley Hollister, MD, a board member of The Physicians Foundation, told Healio that in his 35 years as a PCP, he has witnessed the landscape of primary care shift dramatically.

He has gone from being a young physician in the 1980s, joyfully opening a full-spectrum practice in an underserved community with significant social challenges, to today, running a practice “beleaguered by a number of issues,” like declining Medicare reimbursements, inflation, staff shortages, “the burden of caring for an increasing number of patients with multiple chronic diseases,” administrative struggles and unsatisfying electronic health record products, he said.

“This happens in a health care system [that] seems to value high-cost care by hospital systems and corporations and emergency rooms and disconnected urgent care centers at the expense of access to good, low-cost primary care teams,” he added. “Primary care is the spine [of health care]. It supports the whole skeleton and all the organ systems within our health care system.”

And yet, the scorecards from the past 2 years — the first of their kind — highlighted critical issues in a field headed for a crisis. The reports also noted perilous combinations of reduced access to care and chronic underinvestment as major contributors to the specialty’s struggles.

“Our bone density is rapidly declining, and our health care system is developing osteoporosis,” Hollister said. “A vertebral body fracture is eminent, which could lead to devastating and expensive results. Primary care needs an urgent infusion of nutrients and attention to prevent this needless occurrence.”

A paradoxical relationship

This year’s report, titled “The Cost of Neglect,” focused on how chronic underinvestment is failing primary care and its providers.

Yalda Jabbarpour, MD, medical director of the Robert Graham Center for Policy Studies and a co-author of the scorecard report, said in the webinar that most of the money spent on health in the United States focuses on reactive rather than preventive care.

“Basically, the focus of this year’s report is all about the money,” Jabbarpour said. “How it impacts the workforce, the training pipeline, technologies in primary care and recent research in primary care, ultimately leading to a system that is just not meeting the health care needs of the patients in the U.S.”

In 2022, spending on primary care was less than 5% of total health care expenditures, according to the report. The decline continued across all payers, but since the last scorecard, primary care spending in Medicare and Medicaid has decreased the most — down to 3.2% and 4.3%, respectively.

“We know that the U.S. far outpaces every other country when it comes to health care spending, and we would like to think that this investment translates to health for the population, but unfortunately, that's just not the case,” Jabbarpour said.

For example, in 2020, the U.S. spent 17.8% of its gross domestic product on health care, according to recent data from the Commonwealth Fund. In comparison, Germany — the next highest on the list — spent 12.8%, Canada spent 11.7%, Australia spent 10.6% and Korea spent 8.8%.

Additionally, life expectancy in the U.S. is significantly lower than that of comparable nations. In 2020, life expectancy in the U.S. was 77 years. In the other aforementioned countries, life expectancy was:

• 80.9 years in Germany;
• 81.7 years in Canada;
• 83.2 years in Austrailia; and
• 83.5 years in Korea.

In other words, “we spend the most, but we have the lowest life expectancy,” Jabbarpour said.

“So why is there such a mismatch between health spending and health in the United States? We argue in this year's report that one of the reasons is that spending is actually not invested in the right way,” she said.

The primary care field is being neglected under a “systemic underinvestment and disinvestment,” Hollister said. Many policymakers who make critical funding decisions do not understand the importance of primary care, so the underinvestment actually leads to higher health care costs, he added.

According to the report, federal funding for research in primary care was 0.34% of the 2023 total health care research budget.

“The paradox is that if you want to reduce total health care spending, you need to increase primary care spending,” Hollister said. “Primary care leads to a — and this is shown in the studies — healthier and longer life. And with this rise of chronic disease, our investment in primary care remains insufficient.”

The underinvestment directly affects patients’ access to primary care, according to the report. In 2022, more than 30% of adults in the U.S. lacked a usual source of care, marking “the highest level in a decade, despite historically high rates of insurance coverage,” the report noted.

“That's huge,” Hollister said. “Effectively, a third of American adults don’t have access to primary care.”

The scorecard “challenges us more than ever to find solutions to address this big deficit,” he continued. “We've got to prioritize primary care,” Hollister said. “We have complex health issues, and primary care deals with them more effectively and at a lower cost than large health care systems. It reduces hospitalizations and improves patient outcomes.”

This is particularly relevant within the current political climate — “in the time of DOGE and minimizing governmental expenditures,” he said.

“There has to be a realization among policymakers that primary care is just essential,” Hollister said. “Policymakers ... need to understand that paradox of primary care. If we increase our spending in primary care, health care costs are going to go down.”

Workforce woes

Unfortunately, the outlook is somewhat bleak, particularly considering that another consequence of the underinvestment in primary care is a dwindling workforce.

Between 2021 and 2022, the number of primary care clinicians dropped from 105.7 per 100,000 to 103.8 per 100,000 — a finding Hollister called “extremely disturbing.”

“This hurts me, to look at this report,” he said.

Physician’s assistants (PAs) and nurse practitioners (NPs) have previously offered a ray of hope for overworked physicians, but the percentage of these providers in primary care hit new lows in 2022. About 30% of NPs were in primary care compared with 34% in 2021. Similarly, 24.3% of PAs specialized in primary care in 2022, but that number was 29.7% in 2021.

“One of the areas that we look at to help us with primary care is what we would call mid-level providers — NPs and PAs — and the drop in that group of people is even worse,” Hollister said. “That’s kind of astonishing.”

Reimbursement rates for PCPs are likely to blame, according to the report. In 2022, PCPs were reimbursed an average of $259 per visit, but in gastroenterology — a specialty that is very high in procedures — physicians received an average of $1,092 per visit.

This not only reflects how “the U.S. payment system rewards procedures over the comprehensive care of patients,” according to the report, but it also hinders the attraction of new clinicians into the field.

“Within the specialists, they have more money to expend within their practice, so, naturally, they're going to offer more money to mid-level providers,” Hollister said. “I think for mid-level providers, not only do they see that as being attractive, but the amount of information flow that you need within a defined specialty is much narrower than it is in a broad primary care specialty.”

Jabbarpour emphasized that “the beauty and power of primary care” is more than a collection of services.

“A fee-for-service model just does not capture the continuity of the relationships that allow us to know with a great deal of confidence when a long-term patient is really sick or simply needs reassurance,” she said. “That same continuity that makes us the most trusted person when a patient has a question about a new vaccine or a new treatment, that comprehensiveness we provide that makes it so we can provide a holistic approach to health care ... that extra stuff we do ... is not adequately reimbursed in a fee-for-service system that tends to value discrete services, particularly procedural ones, over whole-person care.”

References:

• The health of US primary care: 2025 scorecard report — the cost of neglect. Available at: https://www.milbank.org/publications/the-health-of-us-primary-care-2025-scorecard-report-the-cost-of-neglect/. Published Feb. 18, 2025. Accessed Feb. 20, 2025.

• The cost of neglect. Webinar; Presented: Feb. 18, 2025.

• 2025 primary care scorecard data dashboard. Available at: https://www.milbank.org/primary-care-scorecard/. Published Feb. 18, 2025. Accessed Feb. 20, 2025.