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The federal government is under-investing in primary care, and the primary care workforce is shrinking while access to care is declining, according to a , which was commissioned by the Milbank Memorial Fund and the Physicians Foundation.

"Given declining life expectancy, racial and ethnic health disparities, the current epidemic of mental health needs, the ongoing COVID-19 pandemic, and other nationwide issues that primary care can help address, these findings represent an urgent call to policymakers and other stakeholders," wrote Yalda Jabbarpour, MD, and co-authors of the American Academy of Family Physicians' Robert Graham Center, which put together the report. "It is time to accelerate adoption of policies that will demonstrably increase investment in high-quality primary care, create a robust primary care workforce, and enable analysis and learning around the impact of primary care."

The report also found that the percentage of adults reporting that they don't have a usual source of care is increasing, and that too few primary care physicians are being trained in community settings even though that's where most primary care takes place. In addition, the report noted, "there are few federal funding opportunities for primary care research."

The report -- which used a scorecard to evaluate primary care in the U.S. -- elaborates on several points:

Under-investment in primary care. "From 2010 to 2020, the percentage of total healthcare spending allocated to primary care has been low, and little progress has been made over time," the authors wrote. "U.S. primary care spending for all insurance types over the decade varied from 6.2% in 2013 to 4.6% in 2020," while nations in the Organization for Economic Co-operation Development spent an average of 7.8% of total healthcare expenditures on primary care in 2016, according to a from the National Academies of Science, Engineering, and Medicine (NASEM).

A shrinking primary care workforce. "From 2012 to 2020, just 20% to 21% of all physicians completing their residency, or one in five, were practicing primary care 2 years later. Overall, about one in three U.S. practicing physicians are primary care physicians (PCPs), so the data point to a national need to strengthen the PCP pipeline to prevent the shortage from worsening," the report noted. The problem is particularly acute in medically underserved areas (MUAs): "Between 2012 and 2020, the number of PCPs in MUAs remained static, but the PCP supply in non-MUAs rose, increasing the gap in the number of PCPs per 100,000 people by 5%."

Adults lacking a source of primary care. Although studies have shown that having a usual source of care can improve patient outcomes, "27% of U.S. adults reported no usual source of care or reported that the emergency room was their usual source of care in 2020, up from less than one-quarter (23.6%) in 2010," the authors wrote. "It is notable that this trend occurred in spite of steadily decreasing rates of uninsurance, due to Affordable Care Act coverage expansions." The reason "could be underinsurance, inadequate physician supply, or changing patient behavior. Regardless of the cause, there appear to be fewer of the long-term clinician-patient relationships considered intrinsic to the NASEM definition of high-quality primary care."

Too few physicians training in community settings. "The mismatch between training opportunities and PCP supply signals that graduate medical education (GME) funding is not set up to support the growth of primary care but instead encourages subspecialty fields," the report noted. "In fact, most GME funding is allocated to the sponsoring institution (usually a hospital), even though primary care occurs in the community rather than the inpatient setting."

Too few funding opportunities for primary care research. "Traditionally, funding dedicated to primary care research has been limited, and investments in federal agencies that are tasked with researching primary care have been tenuous and inadequate," according to the report, which noted that the percentage of overall NIH funding devoted to primary care research remained flat, at 0.2%, from 2017 to 2021. "Tracking the research dollars that are invested in studying primary care will allow for accountability and should result in a shift of federal research dollars toward studying the only specialty that has been shown to decrease morbidity and mortality and improve the health of the population."

Frank Micciche, vice president for public policy and external relations at the National Committee for Quality Assurance (NCQA), wasn't too surprised by the findings. "These issues are not new, and not particularly improving," he said in a phone interview. NCQA, which develops quality metrics for healthcare organizations, is interested in the report because the committee developed the concept of a patient-centered medical home, which revolves around primary care providers.

Micciche expressed some surprise that the report, with data through 2020, didn't make more mention of the COVID-19 pandemic. "The biggest thing that happened to primary care [during that time] was COVID, in terms of the effect on practices, particularly practices that were fee-for-service," he said. "All of sudden they were seeing a lot fewer patients and receiving a lot fewer fees, so a lot of practices are still crawling out from under the rubble of the early days of COVID. And I think it's had a lot of ripple effects; I've seen more practices get into a risk-based or capitated payment system because it protects against the 'rug being pulled out from under you' experience they had at the beginning of COVID."

The authors said they hoped the report will serve as "a starting point both for policy advocacy and accountability measures to help ensure that the United States builds a strong foundation of primary care. Today's primary care clinicians struggle with insufficient payment, not enough trainees entering the workforce, and inadequate funding for community-based training and research needed to sustain and advance the field. Examining performance on each of the measures can inform federal and state official decisions about relative weaknesses and strengths -- and help identify policy priorities."

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