The Health of US Primary Care: Conclusion

Achieving high-quality primary care for all will require purposeful steps guided by evidence and data. The results from this first national scorecard suggest the need for dramatic improvements in all categories covered in the NASEM report. While performance on the metrics in this first report are not likely to change dramatically in a year or two, they point to the need to enact policies that support high-quality primary care now and sustain them to see improvements over time.

The goal of this scorecard is to give the nation a starting point both for policy advocacy and accountability measures to help ensure that the United States builds a strong foundation of primary care. Today’s primary care clinicians struggle with insufficient payment, not enough trainees entering the workforce, and inadequate funding for community-based training and research needed to sustain and advance the field. Examining performance on each of the measures can inform federal and state official decisions about relative weaknesses and strengths – and help identify policy priorities. (See Strategies for Implementing High-Quality Primary Care below.)

The ideal number or percentage for any of these measures – the percentage of health care dollars going to primary care spending, the percentage of primary care payment based on capitation, the supply of primary care clinicians, and the percentage of research funding going to primary care – is not fully understood. However, it’s abundantly clear that, in each circumstance, there is a need for improvement and reduced variation in performance across regions and populations, as well as more research.

In addition, the report highlights the need for improved data collection and analytics to better assess support for high-quality primary care at the national and state levels. As outlined in detail in Appendix B, additional data are needed to provide a complete and accurate picture of the supply and training of all members of the primary care workforce (not just physicians); the percentage of primary care payment that combines fee-for-service and capitation in ways that support high-quality, whole-patient care; or the impact of information technology on the patient and the provider. Given data gaps and limitations, more progress in measurement will need to be made to fully track progress toward the NASEM report’s objectives. Over time, as the measures included in the scorecard are refined, subsequent scorecards will be able to assess noteworthy trends and score performance nationally and, for some measures, across states.

The United States spends more per capita on health care than any other developed nation yet has the worst health outcomes.³⁵ To move from an inefficient health care system to one that meets everyone’s needs, we need to build a stronger foundation of high-quality primary care. Monitoring and reporting on national and state progress toward achieving high-quality primary care is an essential step toward accountability and positive change. 

Strategies for Implementing High-Quality Primary Care

Along with recommending a primary care scorecard to ensure accountability for the implementation of high-quality primary care, the NASEM report offered recommendations to help strengthen support for primary care. Some of these recommendations are listed below.

Reform Payment

• The Centers for Medicare and Medicaid Services (CMS) and states should increase the overall portion of spending going to primary care.

• Payers should use payment models that promote the delivery of high-quality primary care, rather than focusing on short-term cost savings.

• Payers using a fee-for-service (FFS) model should shift primary care payment toward hybrid (part FFS, part capitated) models, and make them the default over time.

Ensure Access

• Payers should ask all covered individuals to declare a usual source of primary care annually and should assign nonresponding enrollees to a source of care. When community health centers, hospitals, and primary care practices treat people who are uninsured, they should assume and document an ongoing clinical relationship with them.

• The US Department of Health and Human Services (HHS) should target sustained investment in creating new health centers in areas with a shortage of primary care.

• CMS should revise and enforce its access standards for primary care for Medicaid beneficiaries and assist state Medicaid agencies in attaining these standards.

• CMS should permanently support the COVID-era rules that have facilitated integrated team-based care, enabled more equitable access to and payment for telephone and virtual visits, and eliminated other barriers to high-quality primary care.

Train Primary Care Teams

• Health care organizations and local, state, and federal government agencies should expand and diversify the primary care workforce, particularly in areas that are medically underserved and have a shortage of health professionals, to strengthen interprofessional teams and better align the workforce with the communities they serve.

• CMS, the US Department of Veterans Affairs, the Health Resources and Services Administration, and states should increase accountability for or increase funding to support interprofessional training in community-based, primary care practice environments.

• Organizations that train, hire, and finance primary care clinicians should ensure that the demographic composition of their primary care workforce reflects the communities they serve and that the care delivered is culturally appropriate.

Ensure Implementation

• The HHS secretary should establish a Secretary’s Council on Primary Care and a more permanent Office of Primary Care to support access to high-quality primary care for everyone.

• HHS should form an Office of Primary Care Research at the National Institutes of Health and prioritize funding of primary care research at the Agency for Healthcare Research and Quality, via the National Center for Excellence in Primary Care Research.

Source: 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

Notes

35. OECD. Health at a Glance 2017: OECD Indicators. OECD; 2017. doi:10.1787/health_glance-2017-en