Making Primary Care the Primary Focus of Our Health Care System

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Greater use of primary care services has long been associated with better health, better care, and lower costs. But policies in support of primary care are not commensurate with their potential benefit—that must change.

Last week’s unveiling of what is being called the first “scorecard” to track the nation’s commitment and investment in high-quality primary care revealed unsurprising but sobering results. Greater use of primary care services has long been associated with better health, better care, and lower costs. But policies in support of primary care are not commensurate with their potential benefit—that must change.

Inspired by a seminal 2021 National Academies of Sciences, Engineering, and Medicine report on primary care, the new scorecard was developed by the Robert Graham Center and supported by the Milbank Memorial Fund and The Physician’s Foundation. The findings demonstrate continued low U.S. investment in primary care, a shrinking primary care physician workforce with too few being trained in community settings, an increasing percentage of adults reporting they do not have a usual source of care, and limited federal funding opportunities for primary care research.

From my perspective, three significant findings are cause for concern. First, primary care physician spending across all insurance types dropped, or at best did not increase, over the last decade. While spending for nurse practitioners and physician assistant outpatient visits increased, there was no net total increase in spending among this grouping of primary care providers.

Particularly striking is that spending was less among public payers such as Medicare and Medicaid compared to commercial insurance. Given the need to manage multiple chronic conditions and address social needs amongst these vulnerable populations, one might have hypothesized that greater primary care resources to ensure comprehensive, coordinated and patient-centered care would be utilized. That doesn’t seem to be the case.

Second, policymakers on both sides of the aisle have long touted value-based health care transformation as the pathway to unshackle the health care system from the inefficiencies of fee-for-service payments. In tracking the movement to fully capitated physician payments (the most ambitious of value-based models), researchers found no change for either primary care visits or non-primary care visits over the last decade; fully capitated visits represented only 7-9% of total visits.

While tracking hybrid payment models (a mix of fee-for-service and capitation) would have likely demonstrated greater progress, this finding raises questions about the pace of moving toward more efficient payment models.

Third, and perhaps most concerning is that 27.1 percent of adults in 2020 reported that they did not have a usual source of care. This number has increased over the last decade, in spite of the Affordable Care Act leading to a nearly 50% reduction in uninsured Americans during this time. A separate report issued this week by the National Association of Community Health Centers estimated that over 100 million Americans do not have access to a usual source of primary care.

A critical benefit of health insurance is the ability to establish a trusted source of care to address acute, chronic, and preventive health issues, which studies show improve outcomes and reduce unnecessary utilization of higher-intensity care. All payers must do a better job in helping to establish and maintain primary care-patient relationships.

The findings of this report should open policymakers’ eyes. Governors and state officials can use the data to assess their state Medicaid programs’ support of primary care. The Biden administration should release its long-anticipated HHS Action Plan on federal actions to further support high quality primary care. It’s noteworthy that the Centers for Medicare and Medicaid Innovation (CMMI) has signaled its interest in testing new advanced primary care payment models this year.

Congress can also support primary care in a multitude of ways. The Senate HELP Committee has indicated interest in augmenting the health care workforce, and in doing so, the primary care workforce needs to be a focus. In addition, on Thursday, the committee will hold a hearing on the state of the nation’s network of federally qualified health centers, which provide comprehensive primary care to over 30 million Americans; mandatory funding expires for these centers this year and will require reauthorization. Further, a bipartisan group of House members is also seeking input on enhancing value-based incentives for Medicare beneficiaries, which has significant implications for primary care.

Primary care public policy has been a backburner issue for far too long. The new scorecard should provide a sense of urgency to strengthen the primary care infrastructure so that we can achieve affordable high-quality care leading to better health outcomes for all Americans.

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