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With primary care access diminishing, it is reasonable to start by asking if there is a sufficient supply of primary care clinicians in the United States. Despite the rise in demand for primary care — with chronic disease and mental illness incidence increasing over the past several years15 — the number of primary care physicians per capita is falling (Figure 2).
Data Source: Analyses of American Medical Association Masterfile (2012–2021), Centers for Medicare and Medicaid Services Physician and Other Practitioners data (2012–2021), and the American Community Survey Five-Year Summary Files (2012–2021).Notes: Primary care specialties included family medicine, general practices, internal medicine, geriatrics, pediatrics, and osteopathy.
Despite the rise in demand for primary care – with chronic disease and mental illness incidence increasing over the past several years – the number of primary care physicians per capita is falling.
Although the number of primary care physicians per capita is dropping, the number of NPs and PAs working in primary care is on the rise. As a result, the total number of primary care clinicians per capita is increasing (Figure 3), yet this clinician mix is evidently insufficient to meet demands. The patient population is growing, is aging, and has a higher chronic disease burden. Physicians tend to see more patients overall than NPs and PAs, and they also tend to see more complex patients on average.39,40 Therefore, while NPs and PAs are essential to the primary care team, they play different roles and have different skill sets than physicians, so they are not a one-to-one replacement when determining workforce sufficiency.
Even though the rise in total primary care clinicians is promising, the relative size of the workforce is still abysmal compared to other nations with better health outcomes. In the United States, the average primary care physician density per 100,000 population in 2021 was 67.2. When adding in nurse practitioners and physician assistants, the overall density of primary care clinicians rises to 105.6 per 100,000. By contrast, Switzerland, which has some of the best indicators of population health status of all the OECD countries,12 has a primary care physician density of 114 per 100,000 population.41
Data Source: Analyses of American Medical Association Masterfile (2012–2021), Centers for Medicare and Medicaid Services Medicare Provider Enrollment, Chain, and Ownership System data (2016–2021), National Plan and Provider Enumeration System data (2016–2021), Centers for Medicare and Medicaid Services Physician and Other Practitioners data (2012–2021), and the American Community Survey Five-Year Summary Files (2012–2021).Notes: Primary care specialties included family medicine, general practices, internal medicine, geriatrics, pediatrics, and osteopathy. Estimates of nurse practitioners and physician assistants working in primary care were calculated and are included in this figure. (See Appendix for detailed methodology.)
In addition, although the absolute number of clinicians of all specialties is growing overall in the US (see Appendix), the share of the clinician workforce in primary care has remained stagnant (Figure 4). The percentage of the total clinician workforce in primary care has hovered around 28% over the past several years.
Data Source: Analyses of Centers for Medicare and Medicaid Services Medicare Provider Enrollment, Chain, and Ownership System data, National Plan and Provider Enumeration System data, and Centers for Medicare and Medicaid Services Physician and Other Practitioners data, 2016–2021.Notes: Primary care specialties included family medicine, general practice, internal medicine, geriatrics, pediatrics, and osteopathy. Estimates of nurse practitioners and physician assistants working in primary care were derived and are included in this figure. (See Appendix for detailed methodology.)
In a country as large and demographically diverse as the United States, the distribution of primary careclinicians is perhaps a more important indicator to follow than average density or number of primary care clinicians per capita in the total population. It is well known that the social drivers of health such as housing, transportation, income, and educational attainment impact the health status of individuals.Specifically, people in areas of high social disadvantage have higher chronic disease rates and worsehealth than those in areas of less social disadvantage.42,10 Arguably, primary care should be moreprevalent in areas of high disadvantage given the higher disease burden. Using a validated index ofsocial drivers of health known as the Social Deprivation Index (SDI),43 we compared primary care density in areas of high social need with those of lower social need.
What Is the Social Deprivation Index? The 2023 Primary Care Scorecard used county-level medically underserved area (MUA) designations to identify areas of higher and lower socioeconomic need. This year, we shifted to using a more frequently updated and broader composite measure of area-level disadvantage called the Social Deprivation Index (SDI). The SDI is based on seven demographic characteristics collected in the American Community Survey, including “percent living in poverty, percent with less than 12 years of education, percent single-parent households, the percentage living in rented housing units, the percentage living in the overcrowded housing unit, percent of households without a car, and percentage nonemployed adults under 65 years of age.” For more information see https://www.graham-center.org/maps-data-tools/social-deprivation-index.html.
Data Source: Analyses of American Medical Association Masterfile (2012–2021), Centers for Medicare and Medicaid Services Medicare Provider Enrollment, Chain, and Ownership System data (2016–2021), National Plan and Provider Enumeration System data (2016–2021), Centers for Medicare and Medicaid Services Physician and Other Practitioners data (2012–2021), Robert Graham Center Social Deprivation Index (2012–2021), and the American Community Survey Five-Year Summary Files (2012–2021).Notes: Primary care specialties included family medicine, general practices, internal medicine, geriatrics, pediatrics, and osteopathy. Estimates of nurse practitioners and physician assistants working in primary care were derived and are included in this figure. (See Appendix for detailed methodology.)Abbreviations: NP, nurse practitioner; PA, physician assistant; PCP, primary care physician; SDI, Social Deprivation Index
The finding for this measure is unexpected but hopeful. In 2021, the overall density of primary carein areas with a higher-than-median (most disadvantaged) SDI was 111.7 per 100,000 and the PCPdensity in areas with a lower-than-median (least disadvantaged) SDI was 99.5 per 100,000 (Figure 3).Likewise, within states, many disadvantaged areas had higher primary care clinician density and less disadvantaged areas had lower primary care clinician density (Figure 4). This finding may be attributed,in part, to the success of the community health center movement, which aims to place clinicians inareas of highest social need.44–47 Still, this promising finding needs to be tempered by the reality that even this higher density of primary care clinicians may not meet patient demands given that people living in high-need areas tend to have higher levels of medical need.48
Alaska As of 2021, Alaska ranks highest in workforce equity. Alaska ranks second behind Idaho (38.2%) for having 36.2% of their clinician workforce in primary care overall (compared to 28.6% nationally) and first for primary care clinician (physicians, NPs, and PAs) density in the most disadvantaged areas, with 269 clinicians per 100,000 people (compared to 111.7 clinicians per 100,000 people nationally). Compared to the national averages of 66.8 physicians and 44.9 NPs/PAs per 100,000 people in areas of highest disadvantage, Alaska’s PCP density is 138 physicians and 131 NPs/PAs per 100,000 population. For more state data, see the data dashboard.
Community Health Centers Are Modeling Comprehensive Primary Care
By Christine Haran
This Scorecard’s findings suggest there are more primary care clinicians in areas of high socioeconomic need than in low-need areas, which may reflect the impact of federally qualified health centers like the Community Health and Social Services Center, or CHASS, in Detroit, Michigan. CHASS CEO Felix M. Valbuena Jr., MD, explains that community health centers, which offer affordable care to 1 in 11 people in the United States, holistically satisfy the often-complex needs of their communities because of the comprehensive array of services they provide to patients.
“It’s not just having the primary care provider managing patients’ chronic disease, making sure they get cancer screenings, and that the kids get their immunizations, but also being able to take care of their oral health, their behavioral health,” Dr. Valbuena says. “It’s about having community health workers or pregnancy doulas support them and having outreach and enrollment workers help them navigate their insurance.”
Certified medical assistants (MAs) are critical member of the CHASS team as well. CHASS MA Jessica Andrade, a former patient, explains that MAs manage immunization schedules and injections, take vitals, perform EKGs, and more.
Despite all that their teams do, community health centers have low profit margins to work within and are subject to congressional renewals of funding, which creates financial uncertainty for a prospective workforce. In addition, while health centers like CHASS partner with state medical schools to provide primary care residencies, they do not receive any graduate medical education funding. Nevertheless, the teams at community health centers provide patients with high-quality outcomes at lower costs. “As payment moves from volume to value,” Dr. Valbuena says, “I think that community health centers represent the model of primary health care for the nation.”
