July 09, 2020, 03:18 pm News Staff – On the list of truths that are both obvious and difficult to prove conclusively, the link between insufficient primary care spending and lagging U.S. health must be near the top. One reason why: how primary care is defined.
"Variations in definitions of primary care make comparisons of spending difficult, both in the U.S. and other countries," say the authors of a concise recent report that nevertheless goes on to verify the problem through a new statistical lens.
"Primary Care Spending in the United States, 2002-2016," published May 18 in JAMA Internal Medicine, examines Medical Expenditure Panel Survey data to "assess primary care expenditures relative to other sources of health care spending."
"This study builds on our ongoing efforts to quantify spending on primary care so that policymakers and payers are better able to address its deficiency and set targets for greater investment in primary care going forward," corresponding author Andrew Bazemore, M.D., M.P.H., senior VP of research and policy for the American Board of Family Medicine, told AAFP News. "This study is built on a unique, nationally representative, multipayer, survey-based source of information on primary care spend, unlike the commercial and Medicare claims that we and others have previously used for these assessments. It reveals that, amid a decade of increasing proportional spending on pharmaceutical, specialty and inpatient care, the previously existing problem of underinvestment in primary care has remained unchanged, at best."
Bazemore is a former director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care and remains on its advisory board.
The study looked at MEPS spending data from an aggregate of 10 health care subcategories: inpatient, outpatient, office based, prescriptions, dental services, vision services, mental health, home health, emergency department, and other medical. "We further divided outpatient and inpatient spending using clinician type and physician specialty," the authors note. "Primary care physicians were defined as physicians coded as practicing family medicine, general practice, geriatrics, general internal medicine, and general pediatrics."
The 2016 data were the most recent available, while the 2002 set "was the furthest back we could go before hitting survey changes that made comparison more difficult," Bazemore said.
That decade and a half allowed the lens a long exposure, and the picture it captured confirms what Bazemore called a "concerning" discrepancy between increased overall outlay and a decreased proportion of that sum devoted to primary care. The total primary care expenditure dropped from 6.5% in 2002 to 5.4% in 2016, accounting for 4.2% of the total increase in health care expenditures over the period examined while declining as a proportion of all expenditures.
Meanwhile, total U.S. annual health care expenditures, as reported in MEPS data, increased from $810 billion in 2002 to $1.617 trillion in 2016.
Inpatient expenses, the largest spending category, went up but became a smaller percentage of total expenses over the study period, which the authors attribute to faster increases in other categories. Prescription spending, for example -- the second-largest category -- jumped from 18.6% to 23.6% of total expenditures while accounting for 28.6% of the increased spending.
"Using MEPS data, we found that spending on inpatient services, specialty care, and prescriptions combined accounted for about two-thirds of the increase in total U.S. health care expenditures from 2002 to 2016," the study says.
"In contrast, primary care accounted for 4.2% of the total increase in health care expenditures, while declining as a proportion of all expenditures."
In a handful of states, such efforts are already paying dividends. The study points out that, where legislatures have mandated the measurement of primary care spending, access to primary care and a more robust array of primary care services have delivered better outcomes and lower costs.
"Health care spending continues to rise year over year, and has for decades, but primary care spend is shrinking as a proportion of that rise," Bazemore told AAFP News. "Drugs, hospital care, post-acute care, specialty care -- these all are consuming increasing proportions, but not primary care.
"That's bad for public and population health, though it motivates the AAFP and its constituency to continue advocating for increased primary care spend, for the sake of all of primary care's benefits."