‘Primary care is in crisis’ – 2024 scorecard outlines just how bad it is, and solutions needed

_{© Milbank Memorial Fund}

Workforce, technology and general lack of training, investment and research all are contributing to a primary care crisis in the United States.

“The Health of US Primary Care: 2024 Scorecard Report – No One Can See You Now,” the second such summary of the state of American primary care, was published by The Milbank Memorial Fund, The Physicians Foundation, and the The Robert Graham Center of the American Academy of Family Physicians.

Last year, the inaugural report highlighted “the systemic lack of support for primary care in the United States.” A year later, it’s not a surprise that physicians and patients see anecdotal evidence cropping up in headlines describing fewer doctors and long wait times.

The 2024 report summarizes five reasons why “primary care is in crisis.” Lead author Yalda Jabbarpour, MD, director of The Robert Graham Center, outlined the study and results in an online meeting Feb. 28.

Since 2018, more than 25% of American adults do not have a usual source of care; that figure is rising over time. In 2021, 28.7% of adults and 13.6% of children did not have a usual source of care, Jabbarpour said.

“And given how important a usual source of care or primary care is to managing chronic disease, identifying mental health issues, or providing preventive services like vaccinations, it is alarming that so much of our population is without this care,” she said.

Physicians Foundation President Gary Price, MD, MBA, offered his own example of waiting a year and a half for a primary care appointment when his own physician retired.

“This report continues to demonstrate an urgent need for investment in primary care, which has continued to decline despite undeniable evidence that access to primary care improves our nation's health while reducing health disparities, and ultimately lowering the cost of health care,” he said.

The report cited “Implementing High-Quality Primary Care,” the 2021 plan by the National Academies of Science, Engineering and Medicine, which made 16 policy recommendations under five objectives to address payment, access, workforce, digital health and accountability.

Doctors needed

The first reason: Primary care needs more physicians. The number of doctors have dipped from a high of 68.4 per 100,000 people in 2012 to 67.2 per 100,000 people in 2021.

Numbers of nurse practitioners (NPs) and physician assistants (PAs) are growing, but not enough to serve a growing, aging population or to make up for workforce losses caused by the COVID-19 pandemic. For comparison, Canada has 133 primary care physicians per 100,000; adding NPs and PAs to the U.S. primary care clinician workforce, there are 105 providers per 100,000 people as of 2021.

Training needed

In 2021, 37% of residents began training in primary care, but 15% were practicing in primary care three to five years after residency. More than half of residents with potential to enter primary care subspecialized or became hospitalists instead. As of 2020, 15% of primary care residents spent most of their training time in outpatient settings and less than 5% spent most of their training in underserved communities.

The scorecard noted in 2022, Congress authorized $174 million for primary care training through the Teaching Health Center program. That is far less than $16 billion that Medicare spends each year on hospital-based Medicare GME programs.

Money needed

Primary care spending, as a percentage of total health care spending, has dropped from 5.4% in 2012 to 4.7% in 2021. Medicaid and commercial insurer investment in primary care has decreased since 2012 and Medicare investment has declined since 2019.

For physician payment, the scorecard called Medicare’s Physician Fee Schedule “the chief culprit” that undervalues primary care. It discourages nonvisit services such as emails and phone calls, and care from other members of a primary care team. Changing that will require action by Congress.

The scorecard noted the U.S. Center for Medicare and Medicaid Innovation has introduced new payment models that could promote team-based care and less reliance on in-person visits. Community health centers that now serve almost 10% of the population, and adding more likely would improve the primary care workforce and investment. Improving Medicaid payments also would help.

Technology solutions needed

Primary care technology has abysmal approval ratings. More than 40% of family physicians dislike their electronic health record usability, and 25% report overall dissatisfaction with EHRs.

Medicare and the Office of the National Coordinator for Health Information Technology should implement digital health certification standards supporting relationship-based, continuous, person-centered care. The user experience must be simplified and vendors must be accountable.

Research needed

Since 2017, about 0.3% of federal research funding per year goes to primary care research. That limits new information on primary care systems, payment and delivery models, and quality, the report said. The scorecard recommended high-level primary care advisers and coordinators for Congress and relevant agencies within the U.S. Department of Health and Human Services.

The meeting included a panel discussion with Jabbarpour; Margaret Flinter, APRN, PhD, vice president and clinical director of Community Health Center Inc./Moses Weitzman Health System; Kyu Rhee, MD, president and CEO of the National Association of Community Health Centers; and Frances Stead Sellers of The Washington Post.

The report and accompanying data dashboard with state-level figures are available online.