Primary care struggling, underinvested, report finds

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The primary care workforce is struggling to meet the population's demands, and doesn't receive enough investment despite diminishing supply and growing demand, a new report has found.

Developed by researchers at the American Academy of Family Physicians' Robert Graham Center, and co-funded by the Milbank Memorial Fund and the Physicians Foundation, The Health of US Primary Care: 2024 Scorecard report and data dashboard examine critical measures of primary care performance nationally and across all states.

Despite a rapidly aging population with higher levels of chronic disease, the number of primary care physicians per person has decreased, the report found. The share of all clinicians practicing primary care – including nurse practitioners and physician assistants – stagnated at around 28% between 2016 and 2021, and PCPs declined from 68.4 to 67.2 per 100,000 people between 2012 and 2021.

At the same time, there has been a 36% jump in the share of U.S. children without a usual source of care over the last decade and a 21% increase among adults. According to the report, demand for PCPs will only increase with time. The National Institute of Health estimates that the number of people 50 or older with at least one chronic disease will increase by 99.5%, from 72 million in 2020 to 143 million by 2050.

WHAT'S THE IMPACT?

The report also highlighted the lack of investment in primary care. The share of total U.S. health care spending devoted to primary care stayed under 6% from 2012 to 2021, data showed.

Since 2019, investment in primary care has steadily declined across all major healthcare payers. This decline has been most pronounced for Medicare reimbursements for primary care services and providers, which have dropped by 15%. The compensation gap between primary care physicians and specialists discourages residents from choosing primary care, the report concluded.

Meanwhile, the report describes an "exodus" among the primary care sector, which lacks real-world community training opportunities. In 2021, 37% of all physicians in training specialized in primary care, yet only 15% of all physicians were practicing primary care three to five years after residency. The remainder subspecialized or became hospitalists who do not work in community settings.

In 2020, only 15% of primary care residents spent a majority of their time training in community settings outside of hospitals and academic health centers – signaling that many residents may lack adequate experience practicing in real-world clinical environments. Also in 2020, fewer than 5% of primary care residents spent the majority of their training in Teaching Health Centers or rural training tracks, two programs that historically serve disinvested communities. Research indicates physicians who train in Teaching Health Centers are more likely to practice in underserved communities.

Research funding is also inadequate, the report maintained, which can impact primary care access and quality. Since 2017, only 0.3% of federal research funding (administered through the National Institutes of Health, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, and the U.S. Food and Drug Administration) per year has been invested in primary care research, limiting new information on primary care systems, delivery models and quality.

A lack of adequate data on the prevalence of hybrid primary care payment (a combination of fee-for-service and per-person payments) and the training of nurse practitioners and physician assistants, for example, makes it difficult to track progress on the implementation of high-quality primary care, the report found.

Lastly, researchers identified cumbersome electronic health records as a burden on primary care physicians. In 2022, more than 40% of family physicians rated the usability of their electronic health record systems as unfavorable. Over 25% reported overall dissatisfaction with their current EHR system.

According to the American Board of Family Medicine, 16% of family physicians reported spending four or more hours per day on EHRs, taking time away from patient care.

THE LARGER TREND

People are shifting away from traditional primary care providers, with about three in 10 foregoing primary care altogether between 2016 and 2022, according to FAIR Health's 2023 analysis of private claims data.

That number, though, ranged from a high of 43% in Tennessee to a low of 16% in Massachusetts, suggesting significant regional variations. Of the providers who performed primary care services in that time, 56% were physicians, while 44% were nonphysicians.

Nurse practitioners constituted the largest share of primary care providers by specialty (27%), followed by family medicine physicians (20%), internal medicine physicians (18%) and physician assistants (15%). Smaller percentages were accounted for by pediatricians, obstetricians/gynecologists and others.

People are increasingly turning to telehealth for their primary care needs. At 94%, the vast majority of patients are satisfied with their experience pursuing virtual primary care, and nearly four in five (79%) say it has allowed them to take charge of their health, according to a November 2022 survey released by Elevance Health.

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.