The Health of US Primary Care: A Baseline Scorecard Tracking Support for High-Quality Primary Care

Supported by the Milbank Memorial Fund and The Physicians Foundation. Prepared by the Robert Graham Center.

Abstract

The 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care proposed the development of a scorecard to better monitor and ensure accountability for progress toward high-quality primary care in the United States. This first national primary care scorecard finds a chronic lack of adequate support for the implementation of high-quality primary care in the United States across all measures, although performance varies across states. The scorecard finds:

1. Financing: The United States is systemically underinvesting in primary care.
2. Workforce: The primary care physician workforce is shrinking and gaps in access to care appear to be growing.
3. Access: The percentage of adults reporting they do not have a usual source of care is increasing.
4. Training: Too few physicians are being trained in community settings, where most primary care takes place.
5. Research: There is almost no federal funding available for primary care research.

Given declining life expectancy, racial and ethnic health disparities, the current epidemic of mental health needs, the ongoing COVID-19 pandemic, and other nationwide issues that primary care can help address, these findings represent an urgent call to policymakers and other stakeholders. It is time to accelerate adoption of policies that will demonstrably increase investment in high-quality primary care, create a robust primary care workforce, and enable analysis and learning around the impact of primary care.

Introduction

Why This Scorecard?

Primary care has long been shown to improve population health and decrease health disparities.^1–3 Yet historic underinvestment and projected workforce shortages threaten the positive impact that primary care can have on the health of the nation.^4,5 The 2021 National Academies of Sciences, Engineering, and Medicine (NASEM) report Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care defined high-quality primary care as “the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.”⁶

The NASEM report offered five major recommendations for the advancement of high-quality primary care in the United States:

1. Pay for primary care teams to care for people, not doctors to deliver services.
2. Ensure that high-quality primary care is available to every individual and family in every community.
3. Train primary care teams where people live and work.
4. Design information technology that serves the patient, family, and interprofessional care team.
5. Ensure that high-quality primary care is implemented in the United States.

The NASEM report called for a scorecard to provide regular updates on the nation’s progress toward these objectives. This initial report provides retrospective trend data for the nation and states, where available, and is intended to serve as a baseline to assess changes over time. The NASEM report did not provide any proposed measures to track information technology; this objective will be tracked in future reports. All data are available in the companion online dashboard organized by the NASEM recommendations. In subsequent scorecards, refinement and updates of these measures will allow for assessment of noteworthy trends nationally and, for some measures, across states.

Measurement Strategy

The NASEM report proposed measures according to the following set of principles:

1. The measures should be previously developed – as opposed to proposed new measures – and each should track the committee’s objectives, either directly or indirectly.
2. The measures should be few, easily understood by the public, and consistent over time.
3. Data for the measures must be collected regularly, comprehensively, and reliably for producing assessment at relevant scope or geography; preferably, data will be publicly available and nonproprietary.
4. Accountable unit – the measure should be available at the national and state levels, so as to engage advocates and policymakers.

To identify the metrics ultimately constructed for this scorecard, the authors began with an environmental scan and meetings with key stakeholders. (See Appendix A for a summary of the meetings.) To validate findings and measurement strategies, scorecard authors engaged with members of the scorecard advisory committee, NASEM committee members, and experts in the data sets being used. Where appropriate, measures were calculated using publicly available data to allow for easier reproducibility by stakeholders in the future. In some instances, particularly when workforce data were needed, the publicly available data did not produce an accurate measure and proprietary data sets were used.

Despite the robust set of measures presented in this scorecard and the accompanying dashboard, there are many gaps in existing data sets that limit the ability to provide an exact evaluation of the health of US primary care. Data limitations notwithstanding, this report can serve as a guide for state and federal agencies, private payers, and other stakeholders invested in strengthening primary care and measuring progress. The detailed methodology section in Appendix B explains the measures, data sources, and limitations, to facilitate replication of these metrics year after year.

Notes

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. doi:10.1001/jamainternmed.2018.7624
2. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x
3. Shi L. The impact of primary care: a focused review. Scientifica. 2012;2012:432892. doi:10.6064/2012/432892
4. Jabbarpour Y, Jetty A, Greiner A. Investing in Primary Care: A State-Level Analysis. Primary Care Collaborative; 2019. Accessed August 16, 2022. https://www.pcpcc.org/sites/default/files/resources/pcmh_evidence_report_2019_0.pdf
5. Petterson SM, Liaw WR, Phillips RL, Rabin DL, Meyers DS, Bazemore AW. Projecting US primary care physician workforce needs: 2010-2025. Ann Fam Med. 2012;10(6):503-509. doi:10.1370/afm.1431
6. National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. The National Academies Press; 2021. doi:10.17226/25983