The Health of US Primary Care: 2025 Scorecard Report — The Cost of Neglect

Visit the Primary Care Scorecard Dashboard — co-funded by the Milbank Memorial Fund and The Physicians Foundation and developed by the Robert Graham Center and HealthLandscape — to review, compare and export data on key primary care indicators for the nation and across states as the data were available. And join the Scorecard release webinar Feb. 18, at 12 pm ET.

Executive Summary

Patients in the United States are frustrated with their health care, despite living in a nation with the highest GDP investment in health care in the world. Primary care, when achieving its full potential, has the capacity to enhance life expectancy, improve health outcomes, and lower health care costs.^{4, 5} However, years of neglect and chronic underinvestment by the health care system have left US primary care in a position where it is increasingly unable to meet patients’ needs, particularly in rural and other underserved communities. Today, life expectancy in the United States is lower than in most developed nations that spend much less on health care, and rates of uncontrolled chronic disease are rising.

This combination of worsening primary care access and sicker patients has created a vicious cycle. Patients are driven to use more expensive services like emergency rooms, which raises health care costs and premiums, further reducing affordability and access. At the same time, overall health care spending continues to rise faster than economic indicators, while the crumbling primary care infrastructure receives only a small portion of these dollars.

It is clear that improving the health of patients in the United States depends on repairing primary care. In 2021, the National Academies of Sciences, Engineering, and Medicine (NASEM) released a landmark report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,⁶ which presented a comprehensive, evidence-based, and actionable plan to do just that: strengthen primary care. Shortly thereafter, the Health of US Primary Care Scorecard was created to track progress on achieving this goal. In its first year, the Scorecard reported baseline performance on primary care metrics in financing, workforce/access, training, and research and showed that primary care was in peril. In its second year, the Scorecard report, No One Can See You Now, used the same metrics to outline the reasons why access to primary care was deteriorating.⁷

This year, the Scorecard spotlights the downward cycle of financing for primary care, describing how persistent challenges in primary care arise from insufficient investment (or in the case of training, misplaced investment) and a fee-for-service (FFS) payment model that rewards volume rather than continuous, whole-person care. This report highlights how these systemic financial issues not only undermine the effectiveness of primary care delivery but, more importantly, jeopardize the overall health of our communities in the following ways.

I. Financing: Declining investment and fee-for-service payment are hindering primary care clinicians’ ability to meet growing patient needs

• Spending on primary care was under 5% in 2022 and continued its decline across all payers, with primary care spending in Medicare and Medicaid decreasing the most since the last Scorecard, down to 3.4% and 4.3% in 2022, respectively.
• Reimbursement rates for physician visits illustrate the way the US payment system rewards procedures over the comprehensive care of patients, undervaluing primary care. In 2022, primary care physicians’ reimbursement per visit averaged $259, compared to $1,092 for gastroenterology. This relative lack of revenue limits practice capacity to provide high-quality primary care and hinders the field’s ability to draw in new clinicians.

II. Workforce/Access: Insufficient funding is diminishing the primary care workforce and access to care

• The number of primary care clinicians (PCCs), including physicians, physician associates (PAs), and nurse practitioners (NPs), dropped from 105.7 per 100,000 in 2021 to 103.8 per 100,000 in 2022. The number of primary care physicians (PCPs) per 100,000 population remained flat at around 67 while the number of advanced practice providers per 100,000 population in primary care fell slightly (from 38 in 2021 to 37 in 2022).
• The percentage of NPs and PAs in primary care dropped to new lows of 30% and 24.3% in 2022, respectively, compared with 34% and 29.7% in 2021, respectively. More than 30% of US adults lacked a usual source of care (USC) in 2022 — the highest level in a decade, despite historically high rates of insurance coverage during this period. The percentage of children without a USC dropped from 13.6% in 2021 to 12.4% in 2022. 

III. Training: Misdirected graduate medical education funding is not producing enough new primary care physicians, exacerbating access issues for patients

• The disparity in growth in medical residents per capita between primary care and all other specialties continued to widen, with the rate of primary care residents remaining stagnant at 17 per capita between 2020 and 2022, while the rate for all other specialties increased from 29 to 30 per capita.
• In 2022, the percentage of new physicians entering primary care dropped to 24.4% (or 19.8% when excluding hospitalists), marking its lowest rate in a decade. While the percentage has been steadily decreasing over the past decade, 2022 marked a steeper decline from 2021 compared to previous years.
• There was an inverse relationship between Medicare and Medicaid graduate medical education (GME) funding at the state level and the percentage of new PCPs entering the physician workforce; the more GME funding into the state, the fewer new PCPs in that state.
• There was a marginal increase in the percentage of primary care residents training in community-based settings. Still, only 15.9% of primary care residents spent most of their training in a community-based setting in 2022 (compared with 15.2% in 2021). Only 5.1% of primary care residents were enrolled in either the Teaching Health Center program or a Rural Training Track — programs designed to provide training specifically in medically underserved communities. In addition, the FFS payment system does not provide for physician time to mentor trainees in community settings.

IV. Technology: The lack of investment in EHRs has led to burdensome systems that drain clinicians’ time, thereby reducing patient access to care

• Almost half of family physicians rated electronic health record (EHR) usability as poor or fair in 2023. Specifically, more than half found the usefulness of EHRs to be poor or fair, a growth of 4% since 2022. The ease of finding information remained stagnant in 2023, at 41%.
• Similarly, over one-quarter of family physicians remained “very dissatisfied” or “somewhat dissatisfied” overall with their EHR in 2023, with a slight increase in “very dissatisfied” respondents compared with 2022.
• While progress has been made throughout the realm of health information technology, primary care still seems to fall behind as progress is made in other sectors.^{8, 9} 

V. Research: The lack of research dollars to study the practice of primary care is limiting evidence-based improvements in care

• The federal research investment in primary care remains well below 1%, although spending increased marginally from 0.31% of total federal health care research budget in 2022 to 0.34% in 2023.

The fragility of primary care remains rooted in the lack of tangible progress on financing — specifically, how and how much primary care practices are paid. Yet, policy shifts at both federal and state levels have the potential to drive significant change in the years ahead. Recognizing the importance of these developments, this year’s report introduces key enhancements:

• New measures: We’ve added a measure that captures Medicare and Medicaid GME funding and primary care workforce production by state, providing critical insights into funding and capacity trends.
• Enhanced dashboard: Our improved Health of US Primary Care Scorecard Dashboard features interactive maps, state profiles, and now the ability to compare data across states. Users can also export data in various formats for deeper analysis.

Additionally, this report tracks progress on the policy recommendations outlined in the 2021 NASEM report. It also sheds light on issues affecting primary care that are not captured in the Scorecard, like the rise of private equity, as well as examples of strategic investments or state policies that are driving meaningful improvements. These enhancements illuminate a path forward toward a stronger, more sustainable primary care system that better serves communities. 

Introduction

In 2021, the National Academies of Sciences, Engineering, and Medicine (NASEM) released a landmark report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,⁶ which presented a comprehensive, evidence-based, and actionable plan to do just that: strengthen primary care. Shortly thereafter, the Health of US Primary Care Scorecard was created to track progress on achieving this goal. In its first year, the Scorecard reported baseline performance on primary care metrics in financing, workforce/access, training, and research and showed that primary care was in peril. In its second year, the Scorecard report, No One Can See You Now, used these metrics along with some new ones to outline the reasons why access to primary care was deteriorating.⁷ In both years, we also published a Health of US Primary Care Scorecard Dashboard displaying metric performance by state (where the data was available).

This year, the Scorecard spotlights the poor financing of primary care, describing how persistent challenges in primary care arise from insufficient investment (or in the case of training, misplaced investment) and a FFS payment model that rewards volume rather than the value of care. While providing updates on performance on the measures in each dimension, we analyze the impact of primary care financing, or the lack thereof, on primary care workforce/access, training, information technology, and research.

This report highlights how systemic financial issues not only undermine the effectiveness of primary care delivery but, more importantly, jeopardize the overall health of our communities. 

Notes

1. Save graduate medical education. American Medical Association website. https://www.ama-assn.org/education/gme-funding/save-graduate-medical-education. Published October 17, 2024. Accessed October 30, 2024.
2. Hospitalists: What is a hospitalist? American Academy of Family Physicians website. https://www.aafp.org/family-physician/practice-and-career/managing-your-career/hospitalists.html. Accessed October 30, 2024.
3. Shared savings program. Centers for Medicare and Medicaid website. https://www.cms.gov/medicare/payment/fee-for-service-providers/shared-savings-program-ssp-acos. Published October 29, 2024. Accessed October 30, 2024.
4. 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.
5. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quarterly. 2005;83(3):457. doi:10.1111/j.1468-0009.2005.00409.x.
6. NASEM. Implementing high-quality primary care: rebuilding the foundation of health care. https://www.nationalacademies.org/our-work/implementing-high-quality-primary-care. Published 2021. Accessed August 2, 2022.
7. Jabbarpour Y, Jetty A, Byun H, et al. No one can see you now: five reasons why access to primary care is getting worse (and what needs to change). The Physicians Foundation and Milbank Memorial Fund. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/2024-scorecard-final-report.pdf. Published 2024. Accessed January 16, 2025.