Primary Care Has Its Problems, but Also Opportunities to Improve

The field of primary care continues to face mounting challenges, but there is some room for optimism, according to several experts.

In 2019, there were about 229,000 primary care physicians in the U.S., “the largest primary care physician workforce we’ve ever seen and the largest primary care physician workforce per-capita we’ve ever seen,” said Andrew Bazemore, MD, senior vice president for research and policy at the American Board of Family Practice, at an event on the state of primary care sponsored by the American Academy of Family Physicians; Bazemore cited American Medical Association (AMA) data. However, he added, primary care physicians still make up only about 30% to 31% of the country’s total physicians.

Furthermore, “if you look at the training pipeline, you’re getting down into the 20%-to-25% range,” even though the Council on Graduate Medical Education said in 2010 that the country should move toward having a minimum of 40% of the physician workforce going into primary care, he continued. And yet, “that 30% is still taking care of the majority of visits and has the greatest complexity of care per visit … You’re really caring for a very complex population with a shrinking number of providers.”

Optimism Early On

There was some reason for optimism during the “post-Affordable Care Act” period, when “we saw some growth in physicians entering into primary care,” said Bazemore. “But what you don’t see is the rapid growth in osteopathic, allopathic, and offshore opportunities for physicians.” And the average age of primary care physicians is creeping up, with fewer than 25,000 primary care doctors under the age of 35 in 2019, compared with more than 35,000 ages 45 to 49 and around 33,000 ages 50 to 54, according to the AMA.

Equity and inclusion is another issue that primary care needs to deal with, according to Irene Dankwa-Mullan, MD, MPH, chief health equity officer at IBM. “The culture of equity and inclusion should also focus on anti-racism,” she said. “Primary care does well working in concert with public health and the community, and this needs to be an essential part of that culture … Addressing racism, addressing equity in all its forms, is critically important.”

Anti-racism training needs to be integrated into the medical education curriculum, she said. “Even our current learning model — from graduate medical education to board certification — includes very little or no efforts on race and racism.” In addition, “primary care research network efforts should prioritize evaluation of interventions to address racism with the same level of funding as we support scientific areas of inquiry.”

Diversity in the Workforce

In addition to making sure the primary care workforce is diverse enough, “one thing the primary care workforce needs to strive to: who are we training and how are we training them, and it has to be equitable,” said Dankwa-Mullan. “And we need to make sure the primary care leadership is diverse … and also need to make sure there is diversity in the degree to which we serve high-need patients — Medicaid beneficiaries, the uninsured, those with complex morbidities. So it’s good to increase the pipeline, but it’s even more valuable if we’re training the primary care workforce to have that competency.”

Having some diversity in your workforce helps when you’re trying to recruit more diverse employees, said Kyu Rhee, MD, senior vice president and chief medical officer at Aetna. “You can’t be what you can’t see,” he said. “You should seriously consider the composition of your own team as it relates to diversity. When you interview candidates, what do they see? If they don’t see diversity and they’re part of the groups that you’re looking to recruit and retain, if they don’t see people who look like them, they’re less likely to join.”

“As a minority myself, I often do notice that I’m the only minority in a panel or at a meeting,” he added. “When I make a comment, it’s not as well heard as if someone else does it. You wonder how much it’s related to the dynamics of race and potentially subtle bias.”

Payment models in primary care also leave a lot to be desired, said Ann Greiner, president and CEO of the Primary Care Collaborative. The “patient-centered medical home” model — which her group was founded to help promote — has improved quality and helped to reduce costs, “but we’re not satisfied because it hasn’t produced enough; we think it’s an underpowered model,” she said.

“It’s underpowered because primary care is still mostly paid on a fee-for-service system, and this hasn’t changed much; 60% to 70% of primary care revenue is fee-for-service,” she continued. “Studies show that because of this, primary care practices don’t evolve to truly team-based care and a comprehensive set of services and move away from this visit care to using all kinds of visit modalities.”

More Investment Needed

“We also have a problem with how much we’re investing in primary care — about 5% to 7%,” she said. “Our European counterparts spend double or more — 14% to 20%.” And even the spending that does happen in the U.S. varies greatly geographically and by payer. “There is a three-fold variation across states and across health plans,” said Greiner. “Higher-spending states on primary care have fewer avoidable hospitalizations, fewer ED [emergency department] visits, and fewer overall hospitalizations, so if you spend upstream, you reduce those more expensive and problematic outcomes downstream.”

Payment is also being affected by the consolidation in the healthcare marketplace, with more primary care doctors moving into large healthcare systems, Bazemore pointed out. “From 2010 to a survey done in the last 2 years, the proportion of primary care physicians practicing in these organizations has gone from about a quarter to over half, but at the clinician level, there’s still a large and diverse group of small and solo practices,” he said.

Those practices “are a source of vitality and innovation,” said Bazemore. “There is a disproportionate share of underrepresented minorities in small and solo practice, and a range of adaptive payment models, not just concierge care. We have to feed that and use policy to make sure we don’t lose that. Consolidation may be accelerating, but it’s neither inevitable nor entirely a good thing if we do enter its leadership. We have a pricing problem.”

Greiner agreed that these smaller practices have their benefits. “When a practice has local control, they make decisions about, can Mrs. Jones be offered a discount on her visit today because we know she just lost her job? At the health system level, that’s a different level of decision-making when it comes to being responsible to patient and community concerns.”

The healthcare incentive system in the U.S. is “completely upside down — not just in primary care, but at the health system level too,” Greiner said. “Until we change that, there is evidence that as primary care practices are absorbed into health systems, prices go up. We have to address these bigger-issue challenges.”