Scorecard Highlights State-Level Primary Care Performance & Lack of Physician Training in Underserved Communities

February 28, 2024 – The second national Primary Care Scorecard released today reveals an intensifying primary care crisis and identifies five reasons why access to affordable, quality primary care services is expected to get worse.

Developed by researchers at the American Academy of Family Physicians’ Robert Graham Center and co-funded by the Milbank Memorial Fund and The Physicians Foundation, The Health of US Primary Care: 2024 Scorecard report and data dashboard examine critical measures of primary care performance nationally and across all states. Key findings include:

1. The primary care workforce is struggling to meet population demands.

• Despite a rapidly aging population with higher levels of chronic disease, the number of primary care physicians (PCPs) per person has decreased.
  • The share of all clinicians practicing primary care (including nurse practitioners and physician assistants) stagnated around 28% between 2016 and 2021.
  • PCPs declined from 68.4 to 67.2 per 100,000 people between 2012 and 2021.

• There has been a 36% jump in the share of U.S. children without a usual source of care over the last decade and a 21% increase among adults.
  • Demand for PCPs will only increase with time. The National Institute of Health estimates that the number of people 50 or older with at least one chronic disease will increase by 99.5%, from 72 million in 2020 to 143 million by 2050.

2. The primary care sector is experiencing a workforce exodus and lacks real-world community training opportunities.

• Primary care residency does not mean primary care practice. In 2021, 37% of all physicians in training specialized in primary care, yet only 15% of all physicians were practicing primary care three to five years after residency. The remainder subspecialized or became hospitalists who do not work in community settings.

• In 2020, only 15% of primary care residents spent a majority of their time training in community settings (outside of hospitals and academic health centers) — signaling that many residents may lack adequate experience practicing in real-world clinical environments.

• In 2020, fewer than 5% of primary care residents spent the majority of their training in Teaching Health Centers or rural training tracks, two programs that historically serve disinvested communities. Research indicates physicians who train in Teaching Health Centers are more likely to practice in underserved communities.

3. The US continues to underinvest in primary care, despite diminishing supply and growing demand.

• The share of total US health care spending devoted to primary care stayed under 6% from 2012 to 2021.

• Since 2019, investment in primary care has steadily declined across all major health care payers; this decline has been most pronounced for Medicare reimbursements for primary care services and providers, which have dropped by 15%.
  • The compensation gap between primary care physicians and specialists discourages residents from choosing primary care.

4. Cumbersome electronic health records burden primary care physicians.

• In 2022, more than 40% of family physicians rated the usability of their electronic health record (EHR) systems as unfavorable. Over 25% reported overall dissatisfaction with their current EHR system.
  • According to the American Board of Family Medicine, 16% of family physicians reported spending four or more hours per day on EHRs, taking time away from patient care.

5. Inadequate research funding impacts primary care access and quality.

• Since 2017, only 0.3% of federal research funding (administered through the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the U.S. Food and Drug Administration) per year has been invested in primary care research, limiting new information on primary care systems, delivery models, and quality.

• A lack of adequate data on the prevalence of hybrid primary care payment (a combination of fee-for-service and per-person payments) and the training of nurse practitioners and physician assistants), for example, makes it difficult to track progress on the implementation of high-quality primary care.

“As more and more patients struggle to get appointments with primary care practices, policymakers must come together to address the primary care crisis,” said Milbank Memorial Fund President Christopher F. Koller. “By prioritizing investments in primary care and expanding our physician workforce today, we can ensure that everyone in every community has access to high-quality primary care in the future.”

Key State Scorecard Findings:

• Workforce: Alaska ranks second among all states, following Idaho (38.2%), for having 36.2% of its clinician workforce in primary care overall (compared to 28.6% nationally) and first for primary care clinician density in the most disadvantaged areas, with 269 clinicians per 100,000 people (compared to 111.7 clinicians per 100,000 people nationally).
• Training: North Dakota is the highest-ranked state for physician training measures, with a larger share of new doctors entering primary care (36.4%) each year than the national average (21.6%) and a high rate of physicians, physician assistants, and nurse practitioners working in primary care at 26.6%, 44.2%, and 39.4%, respectively.
• Investment: Oregon has the highest overall investment in primary care, with 7.7% of all health care spending going to primary care, compared to the national average (4.7%). The state also has the highest primary care spending for commercial payers (9.1%) and Medicaid (9.2%), compared to the national averages of 5.6% and 4.7% respectively.

The Scorecard was developed in response to a call for an annual tracking tool to inform primary care policy issued by the National Academies of Sciences, Engineering, and Medicine in their 2021 report, Implementing High-Quality Primary Care Rebuilding the Foundation of Health Care. This seminal report provides policy recommendations for federal and state governments, health care organizations, and payers to strengthen primary care.

“Primary care is the cornerstone of our health care system, playing a pivotal role in improving our nation’s health by delivering accessible and timely care to those in need,” said Ripley Hollister, MD, a board member of The Physicians Foundation and a practicing family physician. “The findings and recommendations from the second national Primary Care Scorecard highlight that investment in primary care is vital for the future of health care. The report implores us to embrace and advance solutions that support primary care and allow everyone to live longer, healthier lives.”

About The Physicians Foundation

The Physicians Foundation is a nonprofit seeking to advance the work of practicing physicians and help them facilitate the delivery of high-quality health care to patients. As the U.S. health care system continues to evolve, The Physicians Foundation is steadfast in strengthening the physician-patient relationship, supporting medical practices’ sustainability and helping physicians navigate the changing health care system. The Physicians Foundation pursues its mission through research, education and innovative grant making that improves physician wellbeing, strengthens physician leadership, addresses drivers of health and lifts physician perspectives. For more information, visit www.physiciansfoundation.org.

About the Milbank Memorial Fund

The Milbank Memorial Fund works to improve population health and health equity by collaborating with leaders and decision makers and connecting them with experience and sound evidence. Founded in 1905, the Milbank Memorial Fund advances its mission by identifying, informing, and inspiring current and future state health policy leaders to enhance their effectiveness; convening and supporting state health policy decision makers to advance strong primary care and sustainable health care costs; publishing high-quality, evidence-based publications and The Milbank Quarterly, a peer-reviewed journal of population health and health policy. For more information, visit www.milbank.org.