February 18, 2025

Report

III. Training: Misdirected graduate medical education funding is failing to produce new primary care physicians, exacerbating patient access issues

Financially strained primary care practices discourage students from choosing primary care careers

Rebuilding the primary care workforce will require training the workforce of the future. Unfortunately, over the past decade, we have not seen a proportionate rise in the number of students choosing a primary care specialty compared to the number choosing non-primary care specialties (Figure 8). This has led to a widening of the gap between the density of primary care residents and residents in all other specialties and further exacerbation of the primary care workforce crisis.

Figure 8. Disparity Widens in Residents Per Capita Growth Between Primary Care and All Other Specialties (2012—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).

Medical students rotating through outpatient primary care are likely to see dysfunctional outpatient settings with underresourced practices and stressed clinicians.⁶⁵ This experience, coupled with the fact that PCPs are relatively underpaid compared to their subspecialty colleagues, is a well-documented reason that medical students do not choose primary care careers.^{46, 65}

Underinvesting in community-based training while prioritizing hospital-based programs drives trainees away from primary care

Even students who do enter primary care residencies do not end up staying in the primary care workforce^{.7, 66, 67}Many of the primary care residents represented in Figure 8 will end up going into subspecialty fellowships after residency, or working in an inpatient, hospital-only setting as hospitalists. In fact, only 19.8% of all physician residents (excluding hospitalists in 2022) end up working in primary care, whereas 24.4% of all residents (including hospitalists in 2022) are in primary care residencies (Figure 9).

Figure 9. Percentage of New Physicians Entering Primary Care Drops to Lowest Rate in a Decade (Hospitalists vs Non-Hospitalists) (2012—2022)

Data Sources: Analyses of the 2024 American Medical Association Historical Residency File, the 2024 American Medical Association Masterfile, and the 2012-2022 Center for Medicare and Medicaid Services Physician and Other Practitioners data

Notes: Primary care specialties included family medicine, general practices, internal medicine, geriatrics, and pediatrics. Specialty for doctors of osteopathy (DOs) are not always included in the American Medical Association Masterfile, so these data may be an underestimation of the true workforce. (See limitations in Appendix for more details.)

While unfavorable views of the primary care lifestyle and underpayment of PCPs contribute to this attrition, the way that the US graduate medical education (GME) system is financed also plays a role. A majority of the approximately $24 billion spent on GME comes from Medicare ($17.8 billion in 2021),⁶⁸ and a large portion comes from Medicaid ($7.38 billion).⁶⁹ Although there are other sources of GME funding, including the US Department of Veterans Affairs, the Department of Defense, private payers, and the Health Resources and Services Administration (HRSA), these sources are dwarfed by CMS. CMS GME funding is intended to develop a workforce to effectively and efficiently care for Medicare and Medicaid patients, but that goal is not being met. Despite the reality that most patient care occurs in primary care settings,⁷⁰Medicare and Medicaid funding is not effectively building a primary care workforce. Our state-level analysis shows a negative association between Medicare GME funding and the percentage of physicians entering primary care three years later: the more funding a state receives, the fewer physicians join primary care after three years (Figure 10). A similar, though weaker, association exists for Medicaid (Figure 11). For example, New York received the highest level of Medicare funding for GME in 2019 at $15.5 million, but had very low primary care production, with only 15% of its physicians entering primary care three years later. New York was also an outlier on the Medicaid side, receiving $8.3 million in Medicaid funding for GME in 2015, with only 17% of new doctors entering primary care three years later. By comparison, North Dakota received only $2.1 million in Medicare GME funding, but 43% of new physicians in the state entered primary care.

Figure 10. More Medicare GME Funding (2019) in a State Is Associated with Lower Percentage of New PCPs (2022)

Data Sources: Analyses of the 2019 RGC’s Graduate Medical Education For Teaching Hospitals; the 2019 Area Health Resource File; the 2024 American Medical Association Historical Residency File; the 2024 American Medical Association Masterfile; and the 2012-2022 Center for Medicare and Medicaid Services Physician and Other Practitioners data

Notes: DC was excluded. Primary care specialties included family medicine, general practices, internal medicine, geriatrics, and pediatrics. Hospitalists were excluded. Specialty for doctors of osteopathy (DOs) are not always included in the American Medical Association Masterfile, so these data may be an underestimation of the true workforce. (See limitations in Appendix for more details.)

Figure 11. More Medicaid GME Funding (2015) Leads to Lower Percentage of New PCPs (2018)

Data Sources: Analyses of the 2016 AAMC’s Medicaid Graduate Medical Education Payments: A 50-State Survey; the 2015 Area Health Resource File; the 2024 American Medical Association Historical Residency File; the 2024 American Medical Association Masterfile; and the 2012-2022 Center for Medicare and Medicaid Services Physician and Other Practitioners data.

Notes:DC and states with $0 Medicaid GME (AK, CA, MA, NC, ND, NH, RI, and WY) were excluded. Primary care specialties included family medicine, general practices, internal medicine, geriatrics, and pediatrics. Hospitalists were excluded. Specialty for doctors of osteopathy (DOs) are not always included in the American Medical Association Masterfile, so these data may be an underestimation of the true workforce. (See limitations in Appendix for more details.)

State Standout: Training

As of 2022, three western states stand out on Scorecard training measures: Montana, North Dakota, and Idaho. Montana is the highest-ranked state for community-based training, providing 65% of its training to primary care residents in community settings (broad definition); the national average is just 16% (Figure 12). North Dakota has the greatest share of new entrants in primary care, at 46.6% of all new physicians (or 43.1% when excluding hospitalists), nearly double the national average (Figure 10). Idaho has the largest share of total primary care clinicians, with the percentage of physicians, NPs, and PAs in primary care at 31%, 42%, and 41%, respectively. By comparison, the national averages are 27% of all physicians, 30% of all NPs, and 24% of all PAs. See the data dashboard for more state data.

Why is it that traditional GME funding from CMS is not contributing to the creation of a robust primary care workforce? One answer lies in where the money goes. Data suggest that how and where a physician trains dictates how and where they end up practicing.^71–75 At present, most GME funding is provided by Medicare and funneled directly to academic hospitals.^{76, 77} Consequently, the majority of CMS-funded residency training occurs in large academic hospitals rather than community-based settings, leading many physicians to pursue hospital-based specialties as opposed to community-based primary care.⁷⁸

Community-based training programs can bolster the primary care workforce — but low funding limits their reach

The Teaching Health Center (THC) program is one example of a training program that is primarily community-based. Residents in these programs end up staying in primary care and working with more vulnerable patient populations.⁷⁹ Unfortunately, funding for community-based programs such as THCs is low ($155 million in 2022)⁸⁰ and unstable.^{81, 82} As a result, most residents in the United States do not receive community-based training, with funding favoring traditional GME programs (Medicare-funded) in large academic hospitals over community-based programs like THCs. When examining the percentage of residents training in community-based settings — defined broadly as programs outside academic medical centers or hospitals affiliated with medical schools, or narrowly as rural training tracks or HRSA THC GME grant programs — we found that only 5.1% of primary care residents spent the majority of their training in outpatient settings with underserved populations (Figure 12). By not funding more community-based training, the GME system is failing to produce a workforce that meets the needs of the US population.

Figure 12. Increase in Percentage of Primary Care Residents Training in Community-Based Settings (2013—2022)

Data Sources: Analyses of Accredited Council of Graduate Medical Education program-level data to get counts for medical residents; FREIDATM American Medical Association Residency & Fellowship Program Database, a rural residency program list from the RTT Collaborative, and Health Resources and Services Administration Teaching Health Center Graduate Medical Education program dashboards to identify community-based training programs, 2013-2022.

Notes: Community-based training was identified if the majority of training does not take place in a university academic medical center or a hospital with a medical school affiliation (broad) or programs with rural training track or Health Resources and Services Administration Teaching Health Center Graduate Medical Education grant (narrow). Primary care specialties included family medicine, internal medicine, geriatrics, and pediatrics.

Progress on Policy Solutions: Training

ACTION 3.1: Health care organizations should strive to diversify the primary care workforce and customize teams to meet the needs of the populations they serve. Government agencies should expand educational pipeline models and improve economic incentives.

Some medical schools such as the University of California–Davis are investing in new pathway programs to recruit and retain medical students from underrepresented communities and prepare them for primary care residencies.
No pipeline expansion on the government side.

ACTION 3.2: CMS, [Veterans Affairs], HRSA, and states should redeploy or augment Title VII, Title VIII, and GME funding to support interprofessional training in community-based primary care practice environments.

The federal government has not yet rebalanced GME funding to prioritize training in community-based primary care practice environments, but new bipartisan draft legislation proposes creating new residency positions in primary care and public reporting on federal GME programs.
HRSA’s overall budget in 2024 was slightly less than the budget for 2023, but it did increase spending on “interdisciplinary, community based linkages”83 by $1 million.
CMS’s request for information on the “primary care exception” in the CY25 Medicare PFS indicates promising change on the horizon. The primary care exception allows resident physicians to perform limited services without the physical presence of a teaching physician while under the supervision of that physician. Not only does this allow for firsthand decision-making on the part of the resident, but it also allows for greater revenue for teaching practices in the community.
A Senate committee request for information on needed GME reform was sent to stakeholders. Roundtable discussions were convened with numerous stakeholders in primary care, including physician membership organizations such as the American Academy of Family Physicians.
The proposed Medicare PFS could also provide incentives for practicing physicians to serve as preceptors, bolstering educational opportunities in community-based settings.
Florida legislation passed in 2024 requires Medicaid GME-funded facilities to account for the number and type of physicians being trained and established a GME committee to use this data to oversee the use of funding to better meet the state’s needs.

Florida Brings Transparency to the Distribution of Medicaid GME Funding

By Christine Haran

The majority of graduate medical education for physician residents and fellows is taxpayer-funded. Given that Medicaid is the second-largest source of this funding behind Medicare, some states are taking steps to bring more transparency to the process of allocating these funds in ways that help to improve population health.

In 2024, Florida passed legislation to better track Medicaid GME dollars.ⁱ “We have between $1 billion and $2 billion a year going to residency programs or hospitals and the handful of outpatient clinics that have resident slots,” said Christopher Cogle, MD, chief medical officer at the Florida Agency for Health Care Administration. “We get very little information back from the training sites except for bills.”

The new legislation requires that the sites report on how the money is being used and account for the number and specialty type of their graduating physicians. Dr. Cogle explained that his agency will analyze these data to help a newly established state GME committee shape policy that will align the distribution of Medicaid GME dollars with the state’s needs by geography, specialty, and setting. The new data will help the state track, for the first time, the level of need for primary care residents as compared to other specialties.

The first accountability reports are due to the legislature in December 2025. “We’re doing this in a stepwise fashion,” Cogle said. “Everyone knows that we want to make data-informed decisions for improving Florida’s health.”

i. The 2024 Florida statutes. Online Sunshine website. http://www.leg.state.fl.us/Statutes/index.cfm?App_ mode=Display_Statute&Search_String=&URL=0400-0499/0409/Sections/0409.909.html. Accessed January 13, 2025.

Drawing More Medical Students to Primary Care Requires More than Free Tuition

By Mary Louise Gilburg

Given the urgent need to increase the primary care workforce, some medical schools are taking action through creative financing and admission processes to encourage more medical students to pursue primary care.

Major donations have allowed some medical schools to offer free tuition to all students.ⁱ Many hoped that reducing the financial burden of medical school would lead students to choose primary care residencies with lower compensation. Early residency match data from these schools does not support this theory. In the years following the free tuition program at NYU Grossman School of Medicine, for example, the residency match rates for primary care decreased,ⁱⁱ falling below the national average. The data suggest that making medical school tuition free led to a more competitive applicant pool and a more selective admissions process^.iiiThis trend favors high-income applicants who are more likely to specialize, while lower-income students from backgrounds underrepresented in medicine are more likely to go into primary care.

The new NYU Grossman Long Island School of Medicine, however, is one free tuition program that does appear to be increasing the number of primary care residents. Three years into offering free tuition, the primary care residency (including internal medicine, pediatrics, obstetrics and gynecology, and general surgery) match rate is over 60%.^iv This high percentage is due to the school’s focus on primary care and community-based primary care, said Dean Gladys M. Ayala, MD, MPH. The school recruits students who have experience working with primary care doctors and working in underserved areas and who are interested in patient advocacy.

In addition to offering free tuition, the medical school is accredited as a three-year program. “When we originally started this, one less year of medical school was already a way of reducing educational debt,” Dr. Ayala said. “The fact that we now have our own endowment to foster our tuition-free status is a great thing for us to continue to work on primary care shortage issues.”

Around 40 medical schools across the country offer a three-year medical education through an accelerated pathway, resulting in much lower lifetime loan repayment. The University of California– Davis School of Medicine offers an Accelerated Competency-based Education in Primary Care (ACE-PC) program that trains students who often have backgrounds that are traditionally underrepresented in medicine, such as students with low socioeconomic status, students from racial and ethnic minority groups, and students from rural areas. The school uses an internal scale that quantifies socioeconomic disadvantage and complies with the state’s 1997 affirmative action ban. Graduates from the program are more likely to practice primary care and serve in communities with high proportions of Medi-Cal patients.

The track was developed to address the primary care shortage, recognizing that one of the biggest barriers to medical education is finances, said Mark C. Henderson, MD, MACP, the associate dean for admissions. UC Davis has four other tracks focused on rural health, urban underserved community health, tribal health, and providing care to California’s Central Valley communities.^v

Both the NYU Grossman Long Island School of Medicine and UC Davis select for students who are poised to help alleviate the primary care shortage. “More and more we’ve emphasized the lived experiences of the students — where they grew up, what kind of community that was, [and] what kind of barriers were faced in that community — because these are many of the barriers that our patients face every day,” Dr. Henderson said.

i. Henderson MC, Fancher TL, Murin S. Holistic admissions at UC Davis—journey toward equity. JAMA. 2023;330(11):1037-1038.

ii. Emanuel EJ, Guido M. Free med school tuition won’t solve the shortage of primary care physicians. STAT First Opinion. https://www.statnews.com/2024/04/22/free-medical-school-tuition-primary-care-doctor-shortage. Published April 22, 2024. Accessed January 13, 2025.

iii. Horowitch R. The perverse consequences of tuition-free medical school. The Atlantic. https://www.theatlantic.com/ideas/archive/2024/10/perverse-consequences-tuition-free-medical-school/680321. Published October 22, 2024. Accessed January 13, 2025.

iv. Residency match day results for MD students. NYU Grossman Long Island School of Medicine website. https://medli.nyu.edu/education/md-degree/md-admissions/match-day-results. Accessed January 13, 2025.

v. REACH. US Davis School of Medicine website. https://health.ucdavis.edu/mdprogram/REACH-PRIME/about.html. Accessed January 13, 2025.

Notes

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.
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.
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.
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.
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.
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.
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.
Barker W, Gabriel M, Patel V. A decad e of data: progressing patient-centric care through health IT. Health IT Buzz. https://www.healthit.gov/buzz-blog/a-decade-of-data-examined/a-decade-of-data-progressing-patient-centric-care-through-health-it. Published October 31, 2024. Accessed November 18, 2024.
Barker W, Chang W, Everson J, et al. The evolution of health information technology for enhanced patient-centric care in the United States: data-driven descriptive study. J Med Internet Res. 2024;26(1):e59791. doi:10.2196/59791.
Gunja MZ, Gumas ED, Williams II RD. U.S. health care from a global perspective, 2022: accelerating spending, worsening outcomes. The Commonwealth Fund. Published January 31, 2023. Accessed January 16, 2025. doi:10.26099/8ejy-yc74.
Wager E, Cox C. International comparison of health systems. KFF. https://www.kff.org/health-policy-101-international-comparison-of-health-systems/?entry=table-of-contents-introduction. Published May 28, 2024. Accessed September 24, 2024.
Kochanek KD, Murphy SL, Xu J, Arias E. Mortality in the United States, 2022. CDC/National Center for Health Statistics. Published December 21, 2023. Accessed January 16, 2025. doi:10.15620/cdc:135850.
World Bank Group. Life expectancy at birth, total (years)—OECD members. World Bank Open Data. https://data.worldbank.org. Published 2022. Accessed November 14, 2024.
Access to primary care. Healthy People 2030 website. https://health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/access-primary-care#cit22. Accessed January 16, 2025.
Lee AV, Moriarty JP, Borgstrom C, Horwitz LI. What can we learn from patient dissatisfaction? Analysis of dissatisfying events at an academic medical center. J Hosp Med. 2010;5(9):514-520. doi:10.1002/jhm.861.
Fitzgerald M, Gunja MZ, Tikkanen R. Primary care in high-income countries: how the United States compares. The Commonwealth Fund. Published March 15, 2022. Accessed January 16, 2025. doi:10.26099/xz8y-3042.
Jabbarpour Y, Greiner A, Jetty A, et al. Investing in primary care: a state-level analysis. Robert Graham Center. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/Investing-Primary-Care-State-Level-PCMH-Report.pdf. Published July 2019. Accessed January 16, 2025.
Goldberg J, Lewis C, Lyons J, Summers C, Watkins LD. Increasing investment in primary care—lessons from states. The Commonwealth Fund. Published April 3, 2024. Accessed January 16, 2025. doi:10.26099/P1A3-H283.
Huffstetler A, Greiner A, Siddiqi A, et al. Health is primary: charting a path to equity and sustainability. Primary Care Collaborative and the Robert Graham Center. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/pcc-evidence-report-2023.pdf. Published November 2023. Accessed January 16, 2025.
Ansah JP, Chiu CT. Projecting the chronic disease burden among the adult population in the United States using a multi-state population model. Front Public Health. 2023;10:1082183. doi:10.3389/fpubh.2022.1082183.
SAMHSA. Section 10 PE Tables: Results from the 2020 National Survey on Drug Use and Health: Detailed Tables, SAMHSA, CBHSQ. https://www.samhsa.gov/data/sites/default/files/reports/rpt35323/NSDUHDetailedTabs2020v25/NSDUHDetailedTabs2020v25/NSDUHDetTabsSect10pe2020.htm. Published 2020. Accessed October 30, 2024.
Kyanko KA, Curry LA, Keene DE, Sutherland R, Naik K, Busch SH. Does primary care fill the gap in access to specialty mental health care? A mixed methods study. J Gen Intern Med. 2022;37(7):1641. doi:10.1007/s11606-021-07260-z.
Faghri NMA, Boisvert CM, Faghri S. Understanding the expanding role of primary care physicians (PCPs) to primary psychiatric care physicians (PPCPs): enhancing the assessment and treatment of psychiatric conditions. Ment Health Fam Med. 2010;7(1):17.
Ajinkya M, Petterson S, Westfall J, Jabbarpour Y. Family physicians continue to offer the most comprehensive care. Am Fam Physician. 2021;104(6):560-560.
Lochner KA, Goodman RA, Posner S, Parekh A. Multiple chronic conditions among Medicare beneficiaries: state-level variations in prevalence, utilization, and cost, 2011. Medicare Medicaid Res Rev. 2013;3(3):mmrr.003.03.b02. doi:10.5600/mmrr.003.03.b02.
How many children are losing Medicaid? Center for Children and Families. https://ccf.georgetown.edu/2023/09/27/how-many-children-are-losing-medicaid. Published September 27, 2023. Accessed November 15, 2024.
Sinsky CA, Dugdale DC. Medicare payment for cognitive vs procedural care: minding the gap. JAMA Intern Med. 2013;173(18):1733-1737. doi:10.1001/jamainternmed.2013.9257.
Laugesen MJ. Regarding “Committee Representation and Medicare Reimbursements: An Examination of the Resource‐Based Relative Value Scale.” Health Serv Res. 2018;53(6):4123. doi:10.1111/1475-6773.13084.
Gao YN. Committee representation and Medicare reimbursements—an examination of the resource‐based relative value scale. Health Serv Res. 2018;53(6):4353. doi:10.1111/1475-6773.12857.
McMahon LF, Song Z. Rebuilding the relative value unit–based physician payment system. JAMA. 2024;332(5):369. doi:10.1001/jama.2024.8478.
Clemens J, Gottlieb JD. In the shadow of a giant: Medicare’s influence on private physician payments. J Political Econ. 2017;125(1):1-39. doi:10.1086/689772.
Hsiang WR, Gross CP, Maroongroge S, Forman HP. Trends in compensation for primary care and specialist physicians after implementation of the Affordable Care Act. JAMA Netw Open. 2020;3(7):e2011981. doi:10.1001/jamanetworkopen.2020.11981.
Tai-Seale M, Dillon EC, Yang Y, et al. Physicians’ well-being linked to in-basket messages generated by algorithms in electronic health records. Health Aff (Millwood). 2019;38(7):1073-1078. doi:10.1377/hlthaff.2018.05509.
Medscape physician compensation report 2023: your income vs your peers’. Medscape website. https://www.medscape.com/slideshow/2023-compensation-overview-6016341. Accessed November 7, 2024.
Morgan P, Everett CM, Humeniuk KM, Valentin VL. Physician assistant specialty choice: distribution, salaries, and comparison with physicians. JAAPA. 2016;29(7):46. doi:10.1097/01.JAA.0000484301.35696.16.
Li Y, Holmes G, Fraher EP, Mark BA, Jones CB. Primary care nurse practitioner wage differences by employment setting. Nurs Outlook. 2018;66(6):528-538. doi:10.1016/j.outlook.2018.06.009.
Horstman C, Lewis C. Engaging primary care in value-based payment. The Commonwealth Fund. Published April 13, 2023. Accessed January 16, 2025. doi:10.26099/k3v8-0k69.
APM Measurement-Progress of Alternative Payment Models- HCPLAN. October 2, 2019. Accessed October 30, 2024. https://hcp-lan.org/apm-measurement-effort
State initiative map. PCC website. https://thepcc.org/policy/state-investment-hub/state-initiative-map. Accessed December 13, 2024.
National Academies of Sciences, Engineering, and Medicine, Health and Medicine Division, Board on Health Care Services, et al. Payment to support high-quality primary care. In: Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: National Academies Press; 2021. https://www.ncbi.nlm.nih.gov/books/NBK571821.
Khullar D. Burnout, professionalism, and the quality of US health care. JAMA Health Forum. 2023;4(3):e230024. doi:10.1001/jamahealthforum.2023.0024.
Sinsky CA, Shanafelt TD, Ristow AM. Radical reorientation of the US health care system around relationships: rebalancing the transactional model. Mayo Clinic Proceedings. 2022;97(12):2194-2205. doi:10.1016/j.mayocp.2022.08.003.
Gerteis J, Booker C, Brach C, De La Mare J. Burnout in Primary Care: Assessing and Addressing It in Your Practice. Agency for Healthcare Research and Quality. https://www.ahrq.gov/sites/default/files/wysiwyg/evidencenow/tools-and-materials/burnout-in-primary-care.pdf. Published February 2023. Accessed January 16, 2025.
National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on Systems Approaches to Improve Patient Care by Supporting Clinician Well-Being. Factors contributing to clinician burnout and professional well-being. In: Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. Washington, DC: National Academies Press; 2019. https://www.ncbi.nlm.nih.gov/books/NBK552615.
Bodenheimer T. Revitalizing primary care, part 1: root causes of primary care’s problems. Ann Fam Med. 2022;20(5):464. doi:10.1370/afm.2858.
Palmeri M, Pipas C, Wadsworth E, Zubkoff M. Economic impact of a primary care career: a harsh reality for medical students and the nation. Acad Med. 2010;85(11):1692. doi:10.1097/ACM.0b013e3181f5b754.
Phillips JP, Wilbanks DM, Rodriguez-Salinas DF, Doberneck DM. Specialty income and career decision making: a qualitative study of medical student perceptions. Med Educ. 2019;53(6):593-604. doi:10.1111/medu.13820.
Phillips J. The impact of debt on young family physicians: unanswered questions with critical implications. J Am Board Fam Med. 2016;29(2):177-179. doi:10.3122/jabfm.2016.02.160034.
Horstman C. A poor prognosis: more than one-third of burned-out U.S. primary care physicians plan to stop seeing patients. The Commonwealth Fund. Published December 6, 2024. Accessed January 16, 2025. doi:10.26099/EVWB-8T35.
Andrews M. Like doctors, more nurse practitioners are heading into specialty care. KFF Health News. June 17, 2024. https://kffhealthnews.org/news/article/health-brief-nurse-practitioners-leaving-primary-care. Accessed November 6, 2024.
Andrews M. The lure of specialty medicine pulls nurse practitioners from primary care. KFF Health News. May 17, 2024. https://kffhealthnews.org/news/article/nurse-practitioners-trend-primary-care-specialties. Accessed November 6, 2024.
Coombs LA. The growing nurse practitioner workforce in specialty care. J Nurse Pract. 2015;11(9):907-909. doi:10.1016/j.nurpra.2015.06.014.
Coplan B, Cawley J, Stoehr J. Physician assistants in primary care: trends and characteristics. Ann Fam Med. 2013;11(1):75. doi:10.1370/afm.1432.
Phillips RL Jr, Dodoo MS, Petterson S, et al. What influences medical student & resident choices? The Robert Graham Center. https://www.graham-center.org/dam/rgc/documents/publications-reports/monographs-books/Specialty-geography-compressed.pdf. Published March 2, 2009. Accessed January 17, 2025.
Budd GM, Wolf A, Haas RE. Addressing the primary care workforce: a study of nurse practitioner students’ plans after graduation. J Nurs Educ. 2015;54(3):130-136. doi:10.3928/01484834-20150218-21.
Horstman C, Lewis C, Bryan A, Federman S. Community health centers’ progress and challenges in meeting patients’ essential primary care needs. The Commonwealth Fund. Published August 8, 2024. Accessed January 17, 2025. doi:10.26099/wmta-a282.
Horstman C. How community health centers can meet the rising demand for behavioral health care. The Commonwealth Fund. March 7, 2024. Accessed January 17, 2025. doi:10.26099/GPQG-ZM68
Xue Y, Greener E, Kannan V, Smith JA, Brewer C, Spetz J. Federally qualified health centers reduce the primary care provider gap in health professional shortage counties. Nurs Outlook. 2018;66(3):263-272. doi:10.1016/j.outlook.2018.02.003.
Pillai A, Corallo B, Tolbert J. Recent Trends in community health center patients, services, and financing. KFF. https://www.kff.org/medicaid/issue-brief/recent-trends-in-community-health-center-patients-services-and-financing. Published April 19, 2024. Accessed November 7, 2024.
Rosenbaum S, Tolbert J, Sharac J, Shin P, Gunsalus R, Zur J. Community health centers: growing importance in a changing health care system. KFF. https://www.kff.org/report-section/community-health-centers-growing-importance-in-a-changing-health-care-system-issue-brief. Published March 9, 2018. Accessed November 7, 2024.
Table 5: staffing and utilization. Health Resources and Services Administration website. https://data.hrsa.gov/tools/data-reporting/program-data/national/table?tableName=5&year=2023. Published 2023. Accessed November 7, 2024.
Assistant Secretary for Public Affairs (ASPA). Biden-Harris administration announces $75 million investment in rural health care. U.S. Department of Health and Human Services. https://www.hhs.gov/about/news/2024/09/24/biden-harris-administration-announces-75-million-investment-in-rural-health-care.html. Published September 24, 2024. Accessed November 1, 2024.
Assistant Secretary for Public Affairs (ASPA). Biden-Harris administration announces nearly $100 million to grow the health workforce. U.S. Department of Health and Human Services. https://www.hhs.gov/about/news/2024/09/17/biden-harris-administration-announces-nearly-100-million-grow-health-workforce.html. Published September 17, 2024. Accessed November 1, 2024.
Ensuring access to Medicaid services final rule (CMS-2442-F). Centers for Medicare and Medicaid website. https://www.cms.gov/newsroom/fact-sheets/ensuring-access-medicaid-services-final-rule-cms-2442-f. Published April 22, 2024. Accessed November 1, 2024.
Keirns CC, Bosk CL. Viewpoint: the unintended consequences of training residents in dysfunctional outpatient settings. Acad Med. 2008;83(5). https://www.stonybrook.edu/commcms/bioethics/_pdf/unintendedconsequences.pdf
Long T, Chaiyachati K, Bosu O, et al. Why aren’t more primary care residents going into primary care? A qualitative study. J Gen Intern Med. 2016;31(12):1452. doi:10.1007/s11606-016-3825-9.
West CP, Dupras DM. General medicine vs subspecialty career plans among internal medicine residents. JAMA. 2012;308(21):2241-2247. doi:10.1001/jama.2012.47535.
Villagrana MA, Congressional Research Service (CRS). Medicare graduate medical education, 2024. Congressional Research Service (CRS). https://crsreports.congress.gov/product/pdf/IF/IF12583. Published 2024. Accessed January 17, 2025.
Henderson T. Medicaid graduate medical education payments: results from the 2022 50-state survey. AAMC. https://store.aamc.org/downloadable/download/sample/sample_id/590. Published 2023. Accessed January 17, 2025.
Petterson S, McNellis R, Klink K, Meyers D, Bazemore A. The state of primary care in the United States chartbook. Robert Graham Center. 2018. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCareChartbook.pdf. Published 2018. Accessed January 17, 2025
Phillips RL, Petterson S, Bazemore A. Do residents who train in safety net settings return for practice? Acad Med. 2013;88(12):1934-1940. doi:10.1097/ACM.0000000000000025.
Russell DJ, Wilkinson E, Petterson S, Chen C, Bazemore A. Family medicine residencies: how rural training exposure in GME Is associated with subsequent rural practice. J Grad Med Educ. 2022;14(4):441-450. doi:10.4300/JGME-D-21-01143.1.
Chen RM, Petterson SM, Bazemore AW. Projected impact of the primary care residency expansion program using historical trends in graduate placement. Am Fam Physician. 2014;89(7):518.
Fagan EB, Finnegan S, Bazemore A, Gibbons C, Petterson S. Migration after family medicine residency: 56% of graduates practice within 100 miles of training. Robert Graham Center. https://www.graham-center.org/content/brand/rgc/publications-reports/publications/one-pagers/migration-after-residency-2013.html. Published November 15, 2013. Accessed August 3, 2022.
Table C4: physician retention in state of residency training, by last completed GME specialty. AAMC website. https://www.aamc.org/data-reports/students-residents/data/report-residents/2023/table-c4-physician-retention-state-residency-training-last-completed-gme. Published 2023. Accessed January 17, 2025.
Eden J, Berwick D, Wilensky G. GME financing. In: Graduate Medical Education That Meets the Nation’s Health Needs. Washington, DC: National Academies Press; 2014. https://www.ncbi.nlm.nih.gov/books/NBK248024.
Phillips RL Jr, George BC, Holmboe ES, Bazemore AW, Westfall JM, Bitton A. Measuring graduate medical education outcomes to honor the social contract. Acad Med. 2022;97(5):643. doi:10.1097/ACM.0000000000004592.
Chen C, Xierali I, Piwnica-Worms K, Phillips R. The redistribution of graduate medical education positions in 2005 failed to boost primary care or rural training. Health Aff (Millwood). 2013;32(1):102-110. doi:10.1377/hlthaff.2012.0032.
Davis CS, Roy T, Peterson LE, Bazemore AW. Evaluating the Teaching Health Center graduate medical education model at 10 years: practice-based outcomes and opportunities. JJ Grad Med Educ. 2022;14(5):599-605. doi:10.4300/JGME-D-22-00187.1.
HHS awards over $155 million to expand training for primary care residents in underserved and rural communities. Health Resources and Services Administration (HRSA) website. https://www.hhs.gov/about/news/2022/07/01/hhs-awards-over-155-million-dollar-to-expand-training-for-primary-care-residents-in-underserved-rural-communities.html. Published July 1, 2022. Accessed January 17, 2025.
Brown E, Klink K. Teaching Health Center GME funding instability threatens program viability. Am Fam Physician. 2015;91(3):168-170.
Kurz T, Liaw W, Wingrove P, Petterson S, Bazemore A. Funding instability reduces the impact of the federal Teaching Health Center graduate medical education program. J Am Board Fam Med. 2017;30(3):279-280. doi:10.3122/jabfm.2017.03.160341.
Health Resources and Services Administration (HRSA). Health resources and services administration operating plan for FY 2024. https://www.hrsa.gov/sites/default/files/hrsa/about/budget/fy2024-hrsa-operating-plan.pdf. Published 2024. Accessed January 17, 2025.
Rotenstein LS, Apathy N, Edgman-Levitan S, Landon B. Comparison of work patterns between physicians and advanced practice practitioners in primary care and specialty practice settings. JAMA Netw Open. 2023;6(6):e2318061. doi:10.1001/jamanetworkopen.2023.18061.
Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy. 2011;4:47-55. doi:10.2147/RMHP.S12985.
Rotenstein LS, Holmgren AJ, Horn DM, et al. System-level factors and time spent on electronic health records by primary care physicians. JAMA Netw Open. 2023;6(11):e2344713. doi:10.1001/jamanetworkopen.2023.44713.
Budd J. Burnout related to electronic health record use in primary care. J Prim Care Community Health. 2023;14:21501319231166921. doi:10.1177/21501319231166921.
Holmgren AJ, Adler-Milstein J, Apathy NC. Electronic health record documentation burden crowds out health information exchange use by primary care physicians. Health Aff (Millwood). 2024;43(11):1538-1545. doi:10.1377/hlthaff.2024.00398.
Everson J, Hendrix N, Phillips RL, Adler-Milstein J, Bazemore A, Patel V. Primary care physicians’ satisfaction with interoperable health information technology. JAMA Netw Open. 2024;7(3):e243793. doi:10.1001/jamanetworkopen.2024.3793
Meyers D, Miller T, Mare JDL, et al. What AHRQ learned while working to transform primary care. Ann Fam Med. 2024;22(2):161. doi:10.1370/afm.3090.
Classen DC, Longhurst CA, Davis T, Milstein JA, Bates DW. Inpatient EHR user experience and hospital EHR safety performance. JAMA Netw Open. 2023;6(9):e2333152. doi:10.1001/jamanetworkopen.2023.33152.
Cost is biggest barrier to electronic medical records implementation, study finds. The Commonwealth Fund website. https://www.commonwealthfund.org/publications/newsletter-article/cost-biggest-barrier-electronic-medical-records-implementation. Published September 14, 2005. Accessed October 18, 2024.
Palabindala V, Pamarthy A, Jonnalagadda NR. Adoption of electronic health records and barriers. J Community Hosp Intern Med Perspect. 2016;6(5):32643. doi:10.3402/jchimp.v6.32643.
Frequently asked questions: the basics. HealthIT.gov website. https://www.healthit.gov/faq/how-much-going-cost-me. Published November 12, 2014. Accessed January 17, 2025.
The Agency for Healthcare Research and Quality (AHRQ). Time, effort, and infrastructure costs to use electronic health records. https://digital.ahrq.gov/sites/default/files/docs/page/Fleming_SS_508_20111021_d.pdf. Published October 2011. Accessed January 17, 2025
Miller DP Jr, Latulipe C, Melius KA, Quandt SA, Arcury TA. Primary care providers’ views of patient portals: interview study of perceived benefits and consequences. J Med Internet Res. 2016;18(1):e8. doi:10.2196/jmir.4953.
Arndt BG, Micek MA, Rule A, Shafer CM, Baltus JJ, Sinsky CA. More tethered to the EHR: EHR workload trends among academic primary care physicians, 2019-2023. Ann Fam Med. 2024;22(1):12-18. doi:10.1370/afm.3047.
Ghatnekar S, Faletsky A, Nambudiri VE. Digital scribe utility and barriers to implementation in clinical practice: a scoping review. Health Technol (Berl). 2021;11(4):803-809. doi:10.1007/s12553-021-00568-0.
Lin SY, Mahoney MR, Sinsky CA. Ten ways artificial intelligence will transform primary care. J Gen Intern Med. 2019;34(8):1626-1630. doi:10.1007/s11606-019-05035-1.
Jimma BL, Enyew DB. Barriers to the acceptance of electronic medical records from the perspective of physicians and nurses: a scoping review. Informatics in Medicine Unlocked. 2022;31:100991. doi:10.1016/j.imu.2022.100991.
Merelli A. NIH will bring clinical research into primary care offices with $30 million pilot. STAT. June 7, 2024. https://www.statnews.com/2024/06/07/nih-primary-care-clinical-research-30-million. Accessed November 1, 2024.

Report

Back to Publications

Cookie	Duration	Description
cookielawinfo-checkbox-advertisement	1 year	Set by the GDPR Cookie Consent plugin, this cookie is used to record the user consent for the cookies in the "Advertisement" category .
cookielawinfo-checkbox-analytics	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Analytics".
cookielawinfo-checkbox-functional	11 months	The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional".
cookielawinfo-checkbox-necessary	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookies is used to store the user consent for the cookies in the category "Necessary".
cookielawinfo-checkbox-others	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Other.
cookielawinfo-checkbox-performance	11 months	This cookie is set by GDPR Cookie Consent plugin. The cookie is used to store the user consent for the cookies in the category "Performance".
li_gc	2 years	LinkedIn - Used to store consent of guests regarding the use of cookies for non-essential purposes
viewed_cookie_policy	11 months	The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. It does not store any personal data.

Cookie	Duration	Description
__atuvc	1 year 1 month	AddThis sets this cookie to ensure that the updated count is seen when one shares a page and returns to it, before the share count cache is updated.
__atuvs	30 minutes	AddThis sets this cookie to ensure that the updated count is seen when one shares a page and returns to it, before the share count cache is updated.
bcookie	2 years	LinkedIn sets this cookie from LinkedIn share buttons and ad tags to recognize browser ID.
lang	session	This cookie is used to store the language preferences of a user to serve up content in that stored language the next time user visit the website.
lidc	1 day	LinkedIn sets the lidc cookie to facilitate data center selection.

Cookie	Duration	Description
_ga	2 years	The _ga cookie, installed by Google Analytics, calculates visitor, session and campaign data and also keeps track of site usage for the site's analytics report. The cookie stores information anonymously and assigns a randomly generated number to recognize unique visitors.
_ga_0JXFP3TZJG	2 years	This cookie is installed by Google Analytics.
_gat_UA-35374969-1	1 minute	This is a pattern type cookie set by Google Analytics, where the pattern element on the name contains the unique identity number of the account or website it relates to. It appears to be a variation of the _gat cookie which is used to limit the amount of data recorded by Google on high traffic volume websites.
_gcl_au	3 months	Provided by Google Tag Manager to experiment advertisement efficiency of websites using their services.
_gid	1 day	Installed by Google Analytics, _gid cookie stores information on how visitors use a website, while also creating an analytics report of the website's performance. Some of the data that are collected include the number of visitors, their source, and the pages they visit anonymously.
_hjAbsoluteSessionInProgress	30 minutes	No description available.
_hjFirstSeen	30 minutes	This is set by Hotjar to identify a new user’s first session. It stores a true/false value, indicating whether this was the first time Hotjar saw this user. It is used by Recording filters to identify new user sessions.
_hjid	1 year	This is a Hotjar cookie that is set when the customer first lands on a page using the Hotjar script.
_hjIncludedInPageviewSample	2 minutes	No description available.
_hjTLDTest	session	When the Hotjar script executes we try to determine the most generic cookie path we should use, instead of the page hostname. This is done so that cookies can be shared across subdomains (where applicable). To determine this, we try to store the _hjTLDTest cookie for different URL substring alternatives until it fails. After this check, the cookie is removed.
AnalyticsSyncHistory	1 month	LinkedIn - Used to store information about the time a sync with the lms_analytics cookie took place for users in the Designated Countries
at-rand	never	AddThis - Used by social sharing platform AddThis
CONSENT	16 years 3 months 17 days	These cookies are set via embedded youtube-videos. They register anonymous statistical data on for example how many times the video is displayed and what settings are used for playback.No sensitive data is collected unless you log in to your google account, in that case your choices are linked with your account, for example if you click “like” on a video.
uvc	1 year 1 month	Set by addthis.com to determine the usage of addthis.com service.
vuid	2 years	Vimeo installs this cookie to collect tracking information by setting a unique ID to embed videos to the website.
xtc	1 year 1 month	AddThis - Registers the users sharing of content via social media

Cookie	Duration	Description
_fbp	3 months	This cookie is set by Facebook to display advertisements when either on Facebook or on a digital platform powered by Facebook advertising, after visiting the website.
bscookie	2 years	This cookie is a browser ID cookie set by Linked share Buttons and ad tags.
fr	3 months	Facebook sets this cookie to show relevant advertisements to users by tracking user behaviour across the web, on sites that have Facebook pixel or Facebook social plugin.
IDE	1 year 24 days	Google DoubleClick IDE cookies are used to store information about how the user uses the website to present them with relevant ads and according to the user profile.
loc	1 year 1 month	AddThis sets this geolocation cookie to help understand the location of users who share the information.
personalization_id	2 years	Twitter sets this cookie to integrate and share features for social media and also store information about how the user uses the website, for tracking and targeting.
test_cookie	15 minutes	The test_cookie is set by doubleclick.net and is used to determine if the user's browser supports cookies.
UserMatchHistory	1 month	Linkedin - Used to track visitors on multiple websites, in order to present relevant advertisement based on the visitor's preferences.
VISITOR_INFO1_LIVE	5 months 27 days	A cookie set by YouTube to measure bandwidth that determines whether the user gets the new or old player interface.
YSC	session	YSC cookie is set by Youtube and is used to track the views of embedded videos on Youtube pages.
yt-remote-connected-devices	never	YouTube sets this cookie to store the video preferences of the user using embedded YouTube video.
yt-remote-device-id	never	YouTube sets this cookie to store the video preferences of the user using embedded YouTube video.
yt.innertube::nextId	never	These cookies are set via embedded youtube-videos.
yt.innertube::requests	never	These cookies are set via embedded youtube-videos.

III. Training: Misdirected graduate medical education funding is failing to produce new primary care physicians, exacerbating patient access issues

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

Authors:

Related Content:

2025 Primary Care Scorecard Dashboard

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

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