Why underpaying primary care costs the whole system

Adults with a chronic condition who have a usual source of primary care spend nearly 54% less on health care than adults who do not. Their odds of being hospitalized fall by about 20%. And the United States spends less than 5% of its total health care dollars on the specialty that produces those numbers.

That gap is the argument at the center of "Investing in Primary Care: The Missing Strategy in America's Fight Against Chronic Disease," published in February by the Milbank Memorial Fund, the Physicians Foundation and the Robert Graham Center.

Four of the people behind the report joined an episode of Off the Chart: A Business of Medicine Podcast: Yalda Jabbarpour, M.D., a family physician who is vice president and director of the Robert Graham Center and the report's lead author; Debra Lubar, Ph.D., president of the Milbank Memorial Fund; Morgan McDonald, M.D., national director for population health at the fund; and Ripley Hollister, M.D., a family physician in Colorado Springs, Colorado, and a board member of the Physicians Foundation.

The conversation has been edited for length and clarity.

How would you describe the state of primary care today?

Morgan McDonald, M.D.: Most primary care clinicians, myself included, would probably use the word threatened. Despite all the rewards of practicing in primary care, inadequate reimbursement from insurers, combined with increasing numbers of patients with chronic disease, mental health and social needs, as well as those growing mounds of paperwork, really combine to overburden primary care clinicians.

Ripley Hollister, M.D.: A lot of people might say that America's health care system is broken. What I would say is it's not really broken at all. It's just off balance.

Why is primary care best positioned to lead on preventing chronic disease?

Yalda Jabbarpour, M.D.: Prevention is nothing new for primary care. It is the cornerstone of primary care. There's probably no other specialty that wants to see patients before they have a disease. Our job is to prevent patients from getting that disease, whether it is through immunizations, counseling on diet and nutrition, counseling on smoking or doing those really essential screenings.

The prevention gaps in the data are wide. What stood out?

Jabbarpour: Patients who have a primary care physician were more likely to get screening for cardiovascular disease, one of the biggest killers in the nation. They were also more likely to get their cancer screening done, which is interesting, because cardiovascular screening happens when you're in your primary care doctor's office; mammograms and colon cancer screening don't. The fact that completion was higher was a little bit surprising, because it takes an extra step. That just speaks to the trust that is developed when you have a primary care physician.

Hollister: Children who have a usual source of primary care lower their odds of going to the emergency [room] or being hospitalized for a condition that could be treated in an outpatient setting by about 50%. These are big numbers.

What was the finding that most surprised you?

Debra Lubar, Ph.D.: That people with a usual source of primary care had nearly 54% lower health care costs. That's been a really hard thing to quantify, and this is one study, but we're seeing other studies verifying it. There's been this belief that primary care is a good investment because of the health outcomes. Increasingly, we're starting to see that there are actual savings.

Primary care still gets less than 5% of total spending. Has anything changed?

Jabbarpour: Unfortunately, no. What we have seen change is that states are taking the initiative to start measuring how much the payers in their state spend on primary care. You've got to start with measurement to know what your benchmark is. Some states have said, we're starting at 5% or 6%, and we want to double that.

McDonald: We published work by Asaf Bitton, M.D., the executive director of Ariadne Labs, calling for a doubling of primary care spend to 10% of total health care expenditures by 2030. That would put us much more in line with peer health systems that spend a whole lot less overall on health care but see better outcomes.

You say the money has to be spent differently, not just increased. What does that mean?

Jabbarpour: We need to move away from a fee-for-service system, a transactional system, because primary care is not a transactional model of care. When you are just paying for visits that happen inside the office, you're not reimbursing for the entire breadth of what a primary care clinician does, which really is population health. A lot of it is happening after hours, via the phone, via patient portals. And it's not only the doctor doing it, it's the entire office.

Hollister: Medicare pays for preventive services like preventive colonoscopy, and they pay for that 100%, so patients are really encouraged to use these services. If Medicare would improve that investment and look at primary care services as largely preventive, that would really open the floodgates for primary care practices to survive. They're dwindling as we speak.

What does the workforce picture look like on the ground?

McDonald: The vast majority of physician training now happens in academic medical centers, which are driven by RVUs [relative value units], and that's specialist-based. More than 80% of physicians wind up as specialist physicians because they see the payment. They're also not training where they see really high-quality primary care.

Hollister: In my clinic, it takes probably five staff members to take care of one full-time clinician. Ever since [the COVID-19 pandemic], it's been nearly impossible to have enough staff. Trying to hang on to these people and maintain them as employees has been quite difficult.

The report asks large employers to act. What should they be doing?

Jabbarpour: A lot of times, we’re looking for great access to the number-one hospital or the top specialists. But if the employer is looking to save money and make sure their employees are healthy, they should be negotiating with plans that have great primary care access and that adequately reimburse those offices.

The report has seven recommendations. If you could turn one on tomorrow, which would it be?

McDonald: Ongoing, increasing value reimbursement for primary care, with Medicaid and commercial payers going along with it. It gives practices a real financial underpinning to increase access, and it draws new residents, physician associates and nurse practitioners into primary care.

What would you say to the primary care physicians reading this?

Lubar: We see you, and we see the value, and we want to raise that up along with your care team members, so that you can do the job you trained to do and be the trusted source of care in your communities.

Jabbarpour: Sometimes it can feel lonely working in your office, feeling like no one is fighting for you. You're stuck with all this administrative burden, this burnout, and you're in charge of taking care of an entire population. Reading about some of the things we are trying to get movement on at a federal or state level can be somewhat reassuring.

Hear the whole conversation

This episode is one of more than 100 conversations Medical Economics and Physicians Practice have published on Off the Chart, which posts Monday and Thursday mornings.

Recent guests include Anders Gilberg of the Medical Group Management Association on the Medicare cuts proposed for 2027, Robert Wachter, M.D., on what the arrival of AI scribes means for documentation, Lisa Rotenstein, M.D., MBA, M.S., on why women physicians leave practice earlier, Ericka Adler, J.D., on the legal traps in converting to concierge care and Josh Umbehr, M.D., on what most physicians misunderstand about direct primary care.

Find the show by searching for Off the Chart wherever you get your podcasts.