Scorecard Finds ‘Chronic Lack of Support’ for Primary Care

Feb. 22, 2023
"Our healthcare system is wildly out of balance and in critical need of reform," said Christopher Koller, president of the Milbank Memorial Fund

The first national primary care scorecard, co-funded by the Milbank Memorial Fund and the Physicians Foundation, finds a chronic lack of adequate support for the implementation of high-quality primary care across the United States. For instance, from 2017 to 2021, the percentage of National Institutes of Health dollars allocated to family medicine departments remained stagnant at just above 0.2 percent per year.

“The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care” offers baseline trend data for the nation and, when available, for states across four key dimensions: financing, access, workforce development, and research. Developed in collaboration with researchers at the American Academy of Family Physicians’ Robert Graham Center, the scorecard’s developers say it provides a long overdue measurement tool, and critical starting point, to track the health of primary care nationwide to inform federal and state policies.

“Our healthcare system is wildly out of balance and in critical need of reform,” said Christopher Koller, president of the Milbank Memorial Fund, 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.”

This inaugural scorecard was developed in response to the challenge issued in the National Academies of Sciences, Engineering, and Medicine (NASEM) 2021 report calling for an annual tracking tool to measure improvements in the implementation of high-quality primary care over time. Informed by the NASEM recommendations and an advisory committee of key stakeholders, 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.

Among other things, the scorecard findings reveal:

Financing: Systemic Underinvestment in Primary Care

• The US invested less than 6.5 percent of total health spending on primary care between 2010 and 2020. By comparison, Organization for Economic Co-operation Development (OECD) nations spent an average of 7.8 percent of total health care expenditures on primary care in 2016, according to the NASEM report.

• Medicare spent the least on primary care as a percentage of total health spending, and spending in Medicaid has fallen nearly continuously since 2014, from a high of 5.3 percent to a low of 4.2 percent in 2020.

• Oregon had the highest primary care spending, at 9.6 percent of total spending, of the 29 states with data in 2020.

Access: Primary Care Physician Workforce Shrinking and Gaps in Access to Care Appear to Be Growing

• One in three physicians practiced primary care in 2010, yet only one in five medical residents (20 percent to 21 percent) entered primary care between 2012 and 2020.

• Between 2012 and 2020, the gap in the number of primary care physicians per 100,000 people in medically underserved areas (MUAs) and non-medically underserved areas increased by 5 percent.

• More than a quarter (27 percent) of U.S. adults reported that they didn’t have a usual source of primary care or used the ER as their source of care in 2020, compared with 23 percent in 2010.

Workforce Development: Too Few Physicians Being Trained in Community Settings

• There are significant discrepancies between where physicians are trained and where people live and work.

• In some states, only 7.5 percent of resident physicians are trained in MUAs or rural counties, where most community-based training occurs.

Research: In addition to the lack of NIH funding for primary care, the report authors also find that a lack of timely, disaggregated data hinders the accurate measurement and implementation of high-quality primary care at the national and state levels. For example, current data cannot provide a complete and accurate picture of the supply and training of all members of the primary care workforce (not just physicians), the percentage of primary care payment that is hybrid, or the impact of information technology on the patient and the provider.

“We cannot underestimate the critical role primary care plays in our healthcare system, from improving patient outcomes to enhancing access to quality care for everyone,” said Ripley Hollister, M.D., a board member of The Physicians Foundation and family medicine physician, in a statement. “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 NASEM report identified recommendations for public and private stakeholders related to each of the key primary care indicators highlighted in the scorecard to strengthen support for primary care. To reform payment, for example, NASEM suggests the Centers for Medicare & Medicaid Services and states increase the overall portion of spending going to primary care. Additionally, to improve access, the U.S. Department of Health and Human Services should target sustained investment in creating new health centers in areas with a shortage of primary care.

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