Underinvestment, Workforce Shortages, and Lack of Research Funding Threaten the Future of America’s Primary Care

February 22, 2023 — 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.

The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care offers unprecedented 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 provides a long overdue measurement tool, and critical starting point, to track the health of primary care nationwide to inform federal and state policies.

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.

Scorecard findings — available in the report and a companion online dashboard — reveal:

Financing: Systemic Underinvestment in Primary Care

• The US invested less than 6.5% 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% 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% to a low of 4.2% in 2020.
• Oregon had the highest primary care spending, at 9.6% 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% to 21%) 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%.
• More than a quarter (27%) 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% 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 5.9% of resident physicians are trained in MUAs or rural counties, where most community-based training occurs.

Research: Almost No Federal Funding for Primary Care Research

• From 2017 to 2021, the percentage of National Institutes of Health dollars allocated to family medicine departments remained stagnant at just above 0.2% a year.

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.

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

“We cannot underestimate the critical role primary care plays in our health care system, from improving patient outcomes to enhancing access to quality care for everyone,” said Ripley Hollister, MD, a board member of The Physicians Foundation and family medicine physician. “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. See the report for a more complete list.

###

METHODOLOGY

The scorecard report and dashboard draw from 20 measures of high-quality primary care implementation. Findings are based on researchers’ analysis of national data from last decade (years varied by measure) through the most recent available, generally 2020. Primary care investment and payment data were calculated for the 29 most populous states and the nation overall using the Medical Expenditure Panel Survey. Primary care investment overall and by payer (Medicare, Medicaid, commercial) were reported. Workforce and training measures were calculated for all 50 states using a combination of data sources including the American Medical Association Masterfile and the Accreditation Council for Graduate Medical Education data file. For the workforce and training measures, results were calculated for physician members of the health care team and non-physician members when data was available. Finally, research funding towards primary care was calculated on the national level using the NIH RePORTER database. For more detail, see Appendix B in the report.

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, healthy aging, 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.

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.