EB: Why did the National Academies of Sciences, Engineering, and Medicine (NASEM) call for development of a national primary care scorecard?
CN: The 2021 NASEM report opens with the sentence: “High-quality primary care is the foundation of a robust healthcare system and, perhaps more importantly, it is the essential element for improving the health of the US population.”1 In the almost 500-page report, NASEM carefully outlines how to achieve high quality primary care in the United States with five main objectives:
- Payment: Pay for primary care teams to care for people, not doctors to deliver services.
- Access: Ensure that high-quality primary care is available to every individual and family in every community
- Workforce: Train primary care teams where people live and work
- Digital Health: Design information technology that serves the patient, family, and interprofessional care team
- Accountability: Ensure that high-quality primary care is implemented in the United States
The national primary care scorecard was developed to provide accountability and to track the implementation of high-quality primary care in the United States and is an important step in examining the national data sets on primary care.2 This initial scorecard will serve as a baseline for future reports.
EB: How was the scorecard developed?
CN: The Milbank Memorial Fund and the Physicians Foundation partnered with the Robert Graham Center to develop the scorecard.2 The NASEM report outlined a measurement strategy based on already established measures of the healthcare system, few in number, easy for the public to understand, consistent over time, and preferably taken from publicly available data. The data set reviewed was from 2010-20, acknowledging that 2020 data was likely affected by the global pandemic. The developers used public data sets when possible, supplemented with proprietary data sets when public data was incomplete (e.g., workforce management data). The report authors note that despite the large amount of information collected and analyzed, there are still many gaps in the data, and this is a limitation of the analysis.
EB: What are the most important findings in the scorecard?
CN: The five main findings of the scorecard are as follows:
- Financing: The United States is systemically underinvesting in primary care. The United States is underinvesting in primary care across all payer types, at 3-8% of health care expenditures. Medicare payments for primary care are the lowest, and likely reflect the population’s use of specialists and hospital care. Medicaid payments for primary care have continuously dropped since 2014. Commercial entities spend the highest amount for primary care. Essentially no progress has been made toward mixed payer models (capitation used as a proxy).
- Workforce: The primary care physician workforce is shrinking and gaps in access to care appear to be growing. In 2010, 1 in 3 physicians specialized in primary care, and in 2020, that number was 1 in 5.
- Access: The percentage of adults reporting they do not have a usual source of care is increasing. Approximately 27% of Americans say they have no usual source of health care. This number has increased from 23% in 2010.
- Training: Too few physicians are being trained in community settings, where most primary care takes place. Physicians are primarily being trained in large urban settings. There are geographic discrepancies between where physicians are being trained, and where people live and work. In some states, only 6% of residents train in rural or medically underserved counties.
- Research: There is almost no federal funding available for primary care research. The National Institutes of Health allocates approximately 0.2% of its total budget to primary care research. This percentage was unchanged from 2017 to 2021.
It should be noted that this data does not consider physician burnout or the aging workforce. The report, while sobering, likely represents a more positive view than the real-world situation.
EB: What should SGIM do to act upon the findings?
CN: This scorecard shows that the nation has a long way to go to achieve the goals laid out in the NASEM report. While the data are quite troubling, the fact that we now have national data and a tracking system is an important step forward in restructuring our healthcare system. With the information provided in the scorecard, SGIM and other stakeholders and supporters of primary care can advocate for changes at the federal level. As changes will be needed broadly, Congressional hearings on the national report card findings may be needed.
- National Academies of Sciences, Engineering, and Medicine. 2021. Implementing high-quality primary care: Rebuilding the foundation of health care. Washington DC: The National Academies Press. https://doi.org/10.17226/25983. Accessed April 15, 2023.
- Jabbarpour Y, Petterson S, Jetty A, et al. February 2023. The health of US primary care: A baseline scorecard tracking support for high-quality primary care. Milbank Memorial Fund. https://www.milbank.org/wp-content/uploads/2023/02/Milbank-Baseline-Scorecard_final_V2.pdf. Published February 2023. Accessed April 15, 2023.
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