US primary care system suffering from 'chronic lack of adequate support,' scorecard report finds

Underinvestment, workforce shortages and limited access points are hampering primary care delivery across the country, according to what researchers are referring to as the “first national primary care scorecard.”

Published this week, the report answers a 2021 call from the National Academies of Sciences, Engineering, and Medicine for a scorecard that could act as a starting place and ongoing metric for initiatives to overhaul the U.S. primary care system.

The analysis outlines “a chronic lack of adequate support” for primary care across all five major category measures: financing, workforce, access, training and research.

“While performance on the metrics in this first report are not likely to change dramatically in a year or two, they point to the need to enact policies that support high-quality primary care now and sustain them to see improvements over time,” the Robert Graham Center, which prepared the report with financial support from the Milbank Memorial Fund and The Physicians Foundation, wrote in the report.

Specific performances for the five measures varied from state to state. See the interactive scorecard tool here for state-level breakdowns of the findings.

Nationally, the report found that spending on primary care (defined as outpatient and office-based expenditures to PCPs) across all insurance types declined from 5.8% of total healthcare expenditure in 2010 to 4.6% in 2020, with a high of 6.2% in 2013. Commercial payers were generally the biggest spenders (5.6% in 2020), followed by Medicaid (4.2% in 2020) and Medicare (3.5% in 2020).

“By comparison, Organization for Economic Co-operation Development (OECD) nations spent an average of 7.8% of total health care expenditures on primary care in 2016,” according to the report.

Much of the country is also facing a “shortfall” of PCPs, according to the report, which noted that just a fifth of all physicians who completed their residency were practicing primary care two years later.

“Overall, about 1 in 3 U.S. practicing physicians are PCPs, so the data point to a national need to strengthen the PCP pipeline to prevent the shortage from worsening,” the report’s authors wrote.

The report went on to highlight a “mismatch” between the geographic location of primary care training opportunities and the locations where new PCPs are entering the field. Specifically, states in the Northeast are seeing both the highest density of residents and the lowest proportion of physicians choosing to enter primary care.

In terms of access, the percentage of adults who reported no usual source of care aside from an emergency room rose from 23.6% in 2010 to 29% in 2019 before seeing a substantial dip to 27.1% in 2020, according to the report. The increase is particularly notable due to coinciding decreases in the country’s uninsurance rates because of Affordable Care Act coverage expansions, the Robert Graham Center authors wrote.

“Their source could be underinsurance, inadequate physician supply or changing patient behavior,” they wrote of the regular primary care access trends. “Regardless of the cause, there appear to be fewer of the long-term clinician-patient relationships considered intrinsic to the NASEM definition of high-quality primary care.”

The authors used these and other findings to advocate for policies to improve primary care delivery as well as stronger data collection and analytics. Though they acknowledged that the appropriate amount of spending or clinician supply for the field “is not fully understood … it’s abundantly clear that, in each circumstance, there is a need for improvement and reduced variation in performance across regions and populations, as well as more research,” they wrote in the report.