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Primary care is not an attractive choice for trainees who see high levels of burnout,58 poor relative compensation,59 and unsustainable workloads.58, 60 To attract more people to primary care, and retain them, a larger financial commitment is required. Unfortunately, primary care spend, or the proportion of total health care expenditures going to primary care, remains unsustainably low.
Although investment varies by payer and state, we found low levels of investment (4.7%) persisted in 2021 when using the narrow definition of primary care spend (primary care physicians only) (Figure 9). Primary care investment by commercial payers and Medicaid dropped over the past decade, while Medicare’s investment in primary care was stagnant but low. Between 2019 and 2021, we find that primary care investment has decreased for all payers, and this decrease has been the most drastic for Medicare, which had a 15% drop. This rapid decline between 2019 and 2021 may have to do with decreased utilization of office-based visits during the pandemic,61 but it is a trend worth watching.
OregonAs of 2021, Oregon is the highest-ranked state for overall primary care spend, with 7.7% of all health care spending going to primary care, compared to the national average of 4.7%. The state is also highest ranked in primary care spending for commercial payers (9.1%) and Medicaid (9.2%), compared to the national averages of 5.6% and 4.7%, respectively. Oregon’s Medicare primary care spend is slightly lower at 7.3%, but still higher than the national average of 3.9%. For more state data, see the data dashboard.
Using the broad definition of primary care spend (PCPs and office-based spending for NPs, PAs, OB/GYNs, and behavioral health specialists), 13.5% of total spending was invested in primary care in 2021. It seems that higher spend using the broad definition is driven by spending for behavioral health services (see Appendix). Notably, this behavioral health spend is not necessarily for behavioral health integrated with primary care, which would improve access and reduce fragmentation. Instead, it includes all visits billed to behavioral health (physician and nonphysician) specialists.
Primary care physicians provide the most office visits and the most comprehensive set of health care services of any specialty,62 which in turn lowers total health care costs and improves utilization of health care services.63 It should come as no surprise that access to primary care is limited when we are spending, on average, only 5% of total health care expenditures on these services.
Data Source: Analyses of Medical Expenditure Panel Survey data, 2012–2021.Notes: The primary care narrow definition is restricted to primary care physicians only. Primary care specialties included family medicine, general practices, internal medicine, geriatrics, pediatrics, and osteopathy.
In addition, without appropriate investment in primary care, advances that could improve access are stalled. Team-based care,64–66 the use of technology,67, 68 and most recently, the incorporation of artificial intelligence into the primary care workflow69–73 all have the potential to expand access. Yet, these advances in care delivery all require upfront investments in infrastructure and payment models that compensate primary care teams for providing comprehensive care rather than compensating only doctors for providing specific services.
Community Health Workers: Key Primary Care Team Members
Brea Burke, Lead Community Health Worker, Healing Hands Health, Tennessee; Consultant, Impact, University of Pennsylvania
What led you to this line of work?
A lifetime of doing it! I was raised by a full-time pastor and a nurse, so helping the community is what we did. After my college closed, I became one of the telephone operators at the local hospital. I was the point of contact for people at the very beginning. I was trying to find resources like transportation to the hospital so they could see their family member. I got close to case management, so when they decided to start the community health worker (CHW) program in our area in 2019, I became the very first community health worker in my region of northeast Tennessee and southwest Virginia.
How do you work with the primary care teams?
In my current position, I am the lead community health worker at a communitybased organization that provides primary care and dental care to the uninsured and Medicaid patients. They have a social determinants of health form that people fill out when they come in. Based on that form, we get our referrals. Or the doctor or nursing staff will pick up on cues from their patients.
Working together as a team is so important. It’s important for me to be able to talk to the doctor, knowing that they respect my role. Some of my clients have said, I feel like the doctor isn’t listening to me. I need to be able to go back and say, “My client really feels like you’re not hearing their problems.” At Impact, we help train the whole staff on what CHWs do, how they do it – and how you need to be in a partnership.
How would you define your role?
I think a community health worker is a trusted member of the community who knows the people of the community and the resources available to them. They are very well versed on social determinants of health usually because they’ve been there, done that.
When we start working with a client, the doctor might say, “I’ve given them their blood pressure medication and they’re not compliant.” Our job is to find out why they’re not able to comply. Not to force them to take the medicine, but to figure out those other things to help them get to the point where their medicine’s important to them. It could be food, housing, transportation, or the fact that they’re taking care of their mother, or their kid has expensive medications.
What is your day-to-day work like?
Every day for us looks so different. On Monday, I had a client that was in a horrible situation, so I spent the entire day with one client. Today, I’ve seen five different clients and got to meet all their needs and get them connected to the resources they needed. When I started at my organization, the director of operations, who is phenomenal, didn’t really understand our work. She could not ever understand why I was never there when she went to my office. I explained: It’s my job. I’m with my clients. We are going to appointments with them, helping them fill out paperwork, and then giving them a road map to succeed once we close them out as clients. Until then, we’re walking through the trenches with them.
