February 18, 2025

Report

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

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

Authors:

Yalda Jabbarpour 

Anuradha Jetty 

Hoon Byun 

Anam Siddiqi 

Jeongyoung Park 

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Underinvestment and fee-for-service payment leads to practice inefficiencies and decreased capacity

The ongoing lack of investment in primary care, combined with payment models that fail to support a strong primary care infrastructure, is one explanation for decreasing access to primary care in the US. Last year, we found that the percentage of Americans who report not having a usual source of care (USC) that they can turn to for their health care needs has been increasing over time. This year, despite the increase in insurance coverage rates, we found that the percentage of American adults who do not have a USC is the highest it has been in a decade of measurement, with nearly 31% reporting that they had no USC in 2022. For children there has been modest improvement since 2021, but still 12% do not have a usual source of care (Figure 4).

Demand for services that outpaces the number of visits available is at the core of this diminishing primary care access.19 The FFS payment system also creates inefficiencies in primary care delivery that contribute to poor access. FFS encourages clinicians to see more patients at a faster pace, which can lead to lower-quality care and repeated visits for unresolved issues. This churn not only impacts the clinician and patient experience, but also limits access for others because there are only so many appointments available each day. This can result in longer wait times, delays in receiving care, and an overall decrease in access.

Figure 4. Percentage of US Population Without a USC Rises to Highest Level in Decade (2012—2022)

Data Sources: Analyses of Medical Expenditure Panel Survey data, 2012–2022.

Notes: Usual source of care (USC) ascertained whether that is a particular doctor’s office, clinic, health center, or other place where the individual usually goes when sick or in need of health advice. No usual source of care includes those who reported no usual source of care and those who indicated the emergency department as their usual source of care.

Over the last 15 years, the requirements for each primary care visit have exploded…. Every one of the insurer metrics pretty much falls on primary care. Even if the patient is seeing an endocrinologist at another health system, their A1c number is tied to me. Or the patient can’t afford the $300 copay for their diabetes medication, or they are unhoused and don’t have fridge to store the insulin. So, there is a lot that we don’t have control over. I’m not saying we shouldn’t be evaluated for diabetes measures, but they throw out requirements without any support. We have three nurses for our entire health system and no social worker. The way primary care is right now, with employed primary care physicians, is 100% not sustainable.

— Lauren Herrmann, MD, family medicine physician, University of Louisville Health, and assistant professor, University of Louisville School of Medicine 

Increasing workloads and lower relative pay undercut growth in the primary care workforce

Primary care practices are underfunded and swamped with work. In addition to creating inefficiencies in resource utilization, the FFS payment system does not support all the members of the team that are required to provide comprehensive primary care.40 Without a team, we see increased clinician burnout and turnover.41–44

Along with having heavy workloads and few resources, primary care physicians are underpaid compared to their specialty physician counterparts.32 Why does it matter that PCPs are relatively underpaid and overworked? It directly impacts the workforce available to see patients. Studies have repeatedly shown that the workload and comparatively lower pay directly dissuade trainees from choosing primary care as a specialty.45–48 Furthermore, these conditions factor into PCPs’ decisions to move to nonclinical careers or retire early.49 As a result, we are not seeing growth in the primary care physician workforce, but rather a continued decline over time (Figure 5). Over the past several years, the total primary care clinician (PCC) workforce, which includes NPs and PAs, has been rising. However, in 2022, we saw a marginal drop in total PCCs (Figure 5).

Figures 5. Rate of Primary Care Physicians Continues to Decline as the Rate of Primary Care Clinicians Remains High (2016—2022)

Data Sources: Analyses of American Medical Association Masterfile (2016–2022), Centers for Medicare and Medicaid Services Medicare Provider Enrollment, Chain, and Ownership System data (2016–2022), National Plan and Provider Enumeration System data (2016–2022), Centers for Medicare and Medicaid Services Physician and Other Practitioners data (2016–2022), and the American Community Survey Five-Year Summary Files (2016–2022). 

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.) 

This drop in total clinicians in primary care is likely driven by more NPs and PAs leaving primary care for specialty care50–53 (Figure 6). Although it is too early to know for sure if the one-year decline in NPs and PAs in primary care is a new trend, or why this pattern may be emerging, it is reasonable to imagine that the same financial and workload pressures that physicians face are pushing NPs and PAs away from primary care.36, 54, 55 Altogether these workforce declines are resulting in a system where patients are unable to see their primary care clinicians in a timely manner or, for the 30% of Americans without a usual source of care, at all. Consequently, patients present with more advanced or preventable diseases and end up in higher-cost settings, such as the emergency room or hospital.

Figure 6. Percentage of NPs and PAs in Primary Care Drops to New Low (2016—2022)

Data Sources: 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, 2016–2022.

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.)

Community health centers: how investment can improve access

Although the decline in PCCs overall is concerning, we once again see greater primary care workforce density in areas of higher social disadvantage than in areas of lower social disadvantage (Figure 7). PCC density in high social deprivation index (SDI) regions, or highly disadvantaged areas, saw less of a decrease in workforce density in 2022 than did low SDI regions, or less socially disadvantaged areas. This could be because community health centers (CHCs) are working hard to mitigate gaps in primary care services for the medically underserved, including gaps in behavioral health care.56–59 Previous data show that CHCs significantly expanded access to medical care for uninsured patients, reducing the percentage of those reporting an inability to access care by nearly half, from 37% in 2009 to 20% in 2014.60 Medicaid has historically been the largest source of CHC revenue, reaching a high of $18.1 billion in 2022. Federal grants and COVID-19-related funding have also provided significant funding, which has enabled CHCs to expand their clinician workforce and provide care to more than 30 million people, or approximately 10% of the US population.59–61 

Figure 7. Smaller Decline in PCCs per Capita in More Disadvantaged Areas Than in Less Disadvantaged Regions (2016—2022) 


Data Sources: Analyses of American Medical Association Masterfile (2016—2022), Centers for Medicare and Medicaid Services Medicare Provider Enrollment, Chain, and Ownership System data (2016—2022), National Plan and Provider Enumeration System data (2016—2022), Centers for Medicare and Medicaid Services Physician and Other Practitioners data (2016—2022), and the American Community Survey Five-Year Summary Files (2016—2022). 

State Standout: Workforce/Access 

As of 2022, Vermont is the top state for primary care workforce density. With 216 primary care clinicians (PCPs, NPs, PAs) per 100,000 people, Vermont has the highest density of primary care clinicians of any state; the rate is more than double the national average of 103.8 (Figure 6). Vermont ranks third for primary care clinician density in the most disadvantaged areas (222 primary care clinicians per 100,000 people) and first for primary care clinicians per 100,000 population in the least disadvantaged areas (147); both density rates are higher than the national average (Figure 8). See the data dashboard for more state data. 

Progress on Policy Solutions: Workforce/Access

There has been some recent progress on policies that address access to care, particularly for the most vulnerable populations. 

ACTION 2.1: HHS should create new health centers, rural health clinics, and Indian Health Service facilities in shortage areas. 

  • No new health centers were created in the last year, but HHS has expanded funding for rural health clinics and Indian Health Services facilities in shortage areas to expand substance use disorder treatment and expand access to maternal health services.62 They also provided $12 million to three medical schools to help develop a primary care physician workforce in medically underserved rural and tribal communities.63 

ACTION 2.2: CMS should revise access requirements for primary care for Medicaid beneficiaries and provide resources to state Medicaid agencies for these changes. 

  • There has been significant movement in Medicaid for primary care but most of the important developments are not effective until 2025 and beyond. The changes are driven chiefly by two new rules on access that will affect transparency on payment rates, appointment wait-time standards, and quality rating of Medicaid managed care plans.64 

Managing Private Equity’s Risks to Primary Care 

By Christine Haran 

Over the past 15 years, private equity (PE) firms have been investing in physician practices, recently expanding from hospital-based specialty practices to primary care practices. For physicians, being a part of a larger entity can bring more stable revenue, administrative help, and better leverage in insurer negotiations. However, private equity-owned physician practices are associated with higher prices for consumers, threaten health care quality, and result in loss of professional autonomy and clinician burnout.i 

“The other thing to be concerned about is a pressure to ‘upcode’ the Medicare Advantage patients’ diagnoses [to make them appear sicker] to draw a higher risk-adjusted payment,” said Erin C. Fuse Brown, JD, MPH, professor of health services, policy, and practice at Brown University School of Public Health. “Clinicians feel pressured to make money . . . as opposed to provide the care they think is needed,” Brown said. “They end up asking themselves: ‘Who am I working for? Am I caring for my patient or the investors?’” 

Policymakers are starting to address the risk to patients and clinicians that the PE investment model,ii which incrementally adds practices and often evades regulatory review, appears to pose. “The Biden administration was heavily focused on the issue of corporatization of health care, and I don’t know if that is going to be a similar priority agenda [in the Trump administration],” Brown said. She notes that in fall 2024, the Federal Trade Commission established new transaction reporting thresholds under the Hart- Scott-Rodino Act (HSR) that subjects PE transactions to more disclosure,iii but the new administration and Congress could choose to reverse those new rules. 

Some states are taking action to improve oversight of health care market transactions involving PE. For example, the Massachusetts legislature passed a bill in December that requires changes in ownership or control that involve a “significant investor” be reported to and reviewed by its Health Policy Commission.iv Massachusetts legislature passes bill expanding healthcare industry oversight. The bill was partially a response to the PE-backed Steward Health System purchase and mismanagement of a number of the state’s hospitals and physician practices. 

Other states are considering bills to strengthen their long-standing corporate practice of medicine laws designed to protect physicians from corporate interests. These laws, which have been on the books for more than 75 years in some cases, state that a physician must control the majority of a physician practice. But PE “has been exploiting loopholes to comply with the law on paper, but not in spirit,” said Oregon state Representative Benjamin Bowman, who is planning to reintroduce Oregon’s HB 4130 in the 2025 legislative session to close these loopholes and ban some contractual practices that can limit physicians’ ability to speak out or leave a corporate-owned practice.v 

“The law will reestablish physician independence and decision making, so a patient can be sure decisions are made by the provider and not by people exclusively focused on the bottom line,” Representative Bowman said. 

i. Bursa A, Bejarano G, Moriah E, Doc Bruch J. Evaluating trends in private equity ownership and impacts on health outcomes, costs, and quality: systematic review. BMJ 2023;382:e075244. 

ii. Fuse Brown EC, Hall MA. Private equity and the corporatization of health care. Stanford Law Review. March 2026;76:528-596. https://review.law.stanford.edu/wp-content/uploads/sites/3/2024/03/Fuse-Brown-Hall-76- Stan.-L.-Rev.-527.pdf.

iii. Hart-Scott-Rodino Act (HSR). Federal Trade Commission. https://www.ftc.gov/terms/hart-scott-rodino-act-hsr. Accessed January 13, 2025. 

iv. Massachusetts legislature passes bill expanding healthcare industry oversight. JDSupra. https://www.jdsupra.com/legalnews/massachusetts-legislature-passes-bill-7118810. Published January 2, 2025. Accessed January 13, 2025. 

v. Legislators convene workgroup to address impact of corporate influence on healthcare in Oregon. Office of Representative Ben Bowman. https://www.oregonlegislature.gov/bowman/PressReleases/Legislators%20 Convene%20Workgroup%20to%20Address%20Impact%20of%20Corporate%20Influence%20on%20 Healthcare%20in%20Oregon_.pdf. Published May 7, 2024. Accessed January 13, 2025. 

Notes

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