Saving America's primary care system requires bold action now

Olga Torres needed a primary care doctor but told NBC News there were none available. She recruited her cardiologist as a substitute. This didn't meet Olga's needs — and it distracted her cardiologist from his patients with advanced cardiovascular conditions. Olga's predicament highlights current access challenges. Ninety-two million people in the US live in areas where there's a shortage of primary care clinicians. The Health Resources and Services Administration (HRSA) estimates the nation will face a shortage of more than 70,000 primary care physicians by 2038.

These shortages matter, with research showing that primary care is the only part of the health care system where more investment is associated with better population health. Unfortunately, the United States has underinvested in primary care for decades, contributing to a boom in chronic conditions, ever-rising costs, and, worst of all, lagging life expectancy compared to peer nations.

These stark facts are driving policymakers to act on recommendations from a landmark 2021 National Academies of Science, Engineering and Medicine (NASEM) report urging stronger investment in primary care.

Regrettably, some have misinterpreted those efforts to strengthen primary care as an attack on specialists.

Investing more in primary care is not an attack on any other specialty. It is a necessary response to decades of underinvestment in the part of the system most closely associated with prevention, continuity, chronic disease management, and better population health outcomes.

Suggestions that actions to rebalance payment toward primary care are unfounded, belief-driven, or inherently detrimental to specialty care misrepresent the larger reality: patients need both strong primary care and timely specialty services, and those goals are mutually reinforcing. We should not be undermining primary care or efforts by policymakers working to correct the long-standing payment imbalance that has historically failed to adequately reimburse primary care clinicians for the care that drives improvements in health outcomes.

Correcting these payment distortions serves to strengthen the entire continuum of health care delivery including specialty care. Investing in primary care is perhaps one of the most significant evidence-based pathways to address the challenges patients face in our health care system: fragmented care delivery, barriers to access and difficulty navigating a complex system. Well-resourced primary care can and should serve as the foundation for any high-value health care system that efficiently and effectively manages and improves the nation's health.

If primary care continues to deteriorate, policymakers will not be able to rely on it as the engine that improves quality and reduces costs in value-based arrangements. Right now, value-based care is one of the few levers decisionmakers are pulling to drive our nation's underperforming health care system in a more positive direction. Without primary care, policymakers are sunk and so are we.

The Cost of Underinvestment

Our current system isn't delivering better health and is putting impossible strain on all parts of the health care system — including specialists. Despite almost $5 trillion spent on health care in 2023, Americans aren't getting healthier. And that's because we're spending money in the wrong place.

Since 2012, the United States has seen a decline in primary care investment. Today, primary care accounts for less than 5% of all health spending, and less than 4% of spending in Medicare, even though half of all office visits occur in a primary care setting.

That underinvestment has led to a dearth of primary care clinicians — leading to longer wait times, shorter visits and, in some cases, delayed or skipped care.

As a result, far too many Americans can't get the kind of high-quality, whole-person primary care we know can lead to better health and lower costs.

That lack of access contributes to why more than 60% of Americans live with a chronic condition — and more than 40% live with multiple chronic diseases. Meanwhile, visits to emergency departments are at an all-time high, as our health system fails at prevention and patients who have lost primary care seek routine care in hospital emergency departments and urgent care.

All of this has contributed to an overpriced, underperforming health system. The Commonwealth Fund's recent international report shows our nation's health care expenditures are more than double those of other high-income countries, while our performance ranking is dead last.

Instead of purchasing health and wellness, the US is largely purchasing expensive acute care and specialty services, which contribute to our nation's health care affordability crisis, medical debt crisis and Americans' overall angst that they can't purchase the care they need when faced with a serious medical condition.

The trajectory of our system isn't sustainable.

Policymakers Can — and Must — Act Now

That's why it's so critical that policymakers, especially at the Centers for Medicare and Medicaid Services (CMS), continue to explore every option available for strengthening primary care. After decades of neglect, the foundation of our health system is under enormous strain.

If policymakers and industry leaders continue to undervalue primary care, the access challenges and clinician shortages will mount. Americans' health will continue to decline, while urgent care centers and emergency departments will find themselves inundated with patients who are increasingly suffering from more complex chronic conditions, and specialists' waiting rooms will be overflowing — some with patients that really should be treated in primary care.

In short, we are fast approaching the crisis point for our health care system — and further delays may push us past the tipping point.

With declines in primary care spending over more than twelve years, it is clear that the system is rigged against upstream care. We are long overdue for a rebalancing of payment toward primary care without a need to study such intervention further.

How CMS Provides Relief

CMS is pulling a narrow but significant policy lever — changes to the Medicare Physician Fee Schedule — that begins to address our health system woes. Medicare is taking steps to strengthen our health care system's foundation by increasing how much primary care is paid and changing how it is paid.

Strengthening primary care investment in Medicare will provide primary care clinicians with resources and support needed to sustain and build their practices. It will also encourage other payers — including commercial health plans and Managed Care Organizations — who often follow Medicare's lead, to increase their compensation and adjust their payment structures for primary care.

The policies that CMS has begun to implement are not sufficient to fix the challenges impacting primary care — but they are an important step in reversing decades of underinvestment.

Big Challenges Require Bold Solutions

While these reforms are critical, we must do more. Our entire health care payment system needs to change so that all health care sectors — clinicians, hospitals, long-term care, pharmaceutical and device companies — are incentivized to focus on keeping people as healthy and well as possible.

With these kinds of more expansive reforms, Americans' life span could begin matching that of other wealthy countries. Our health span would also grow, costs would be checked, and trust in the US health care system would be restored.

It's reasonable to demand that our health care system does a better job in producing health instead of fueling a medical system whose costs are eroding family, state, and federal budgets. We seek a future where primary care clinicians, patients, employers, and other health care colleagues can partner with policymakers in finding a different and better way to restore the health of our nation.

Ann Greiner is president and CEO of the Primary Care Collaborative.

Jenny Goins is interim president and CEO of the National Alliance of Healthcare Purchaser Coalitions.

Anthony Wright is executive director of Families USA.