New “scorecard” finds primary care funding and physician workforce are shrinking

Primary care has been shown to improve population health,^1-3 yet its share of overall U.S. health care spending is falling, and fewer physicians are going into primary care, according to study results released Feb. 22.

The study, called the nation’s first primary care “scorecard,” was funded by the Milbank Memorial Fund and The Physicians Foundation, and developed in partnership with AAFP’s Robert Graham Center.

“We learned that (primary care) is suffering and deserves more support and more resources,” said Yalda Jabbarpour, MD, a family physician and director of the Robert Graham Center who was one of the study’s coauthors.

Decreased funding

According to the scorecard data, primary care’s share of the overall U.S. health care spend decreased from 6.2% in 2013 to 4.6% in 2020. By contrast, the average investment in primary care is almost 8% among all 38 developed nations in the Organization for Economic Co-operation and Development (OECD).

Jennifer Lee, MD, chief medical officer for the Alliance of Community Health Plans, called the results “sobering, but not surprising.”

“What we’re doing is not working, as a nation,” Lee said during a panel discussion on the results hosted by the Milbank Memorial Fund. “We are spending more and more as a nation on health care, and we’re not seeing a return. … We definitely need to redistribute how we are spending our health care dollars.”

The share of health spending going to primary care has dropped across all types of payers — Medicare, Medicaid, and commercial. It is highest among commercial payers (5.6% in 2020) and lowest in Medicare (4.2%).

Lee, whose organization represents non-profit commercial health plans, said primary care provides a proven return on investment and the U.S. should strive to double its investment by 2030. She also advocated a higher percentage of value-based payments — which the scorecard found had not increased between 2010 and 2020 — rather than fee-for-service.

Other findings

Other key scorecard findings included the following:

• The primary care physician workforce is shrinking. While about 1 in 3 U.S. practicing physicians are primary care physicians, only 1 in 5 physicians who completed their residency from 2012 to 2020 were practicing primary care two years later.
• Although there are wide variations in primary care access from state to state, the access gap between medically underserved areas (MUAs) and non-medically underserved areas increased by 5% nationwide from 2012 to 2020. MUAs have an average of 55.8 primary care physicians per 100,000 people; non-MUAs have an average of 79.7.
• While the northeast had the highest concentration of physicians-in-training (residents), the states with the highest percentages of physicians entering primary care tended to be in the northwest.
• More than a quarter (27%) of U.S. adults reported having no usual source of primary care in 2020, up from 23.6% in 2011.
• Less than 0.4% of all National Institutes of Health funding goes to primary care.

Recommendations

The study’s authors released a number of recommendations, including payment reforms that shift a higher percentage of the country’s overall health care spending to primary care and shift primary care payment toward hybrid models (part fee-for-service, part capitation). The authors also recommended access reforms, such as having payers ask all covered individuals to declare a usual source of primary care annually and assign nonresponding enrollees to a source of care.

Jabbarpour said the scorecard will serve as a baseline for measuring future progress and ultimately building a stronger foundation of high-quality primary care. She and other panelists cautioned, however, that the scorecard (which was based largely on 2020 data) may present a more favorable view than the current reality, because the primary care workforce is aging and burnout has only increased in the last few years.

1. Basu S, Berkowitz SA, Phillips RL, Bitton A, Landon BE, Phillips RS. Association of primary care physician supply with population mortality in the United States, 2005-2015. JAMA Intern Med. 2019;179(4):506-514.

2. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502.

3. Shi L. The impact of primary care: a focused review. Scientifica. 2012;2012:432892.

Posted on Feb. 24, 2023 by FPM Editors