The federal government must aggressively bolster primary
care and connect more Americans with a dedicated source of care, the National
Academies of Sciences, Engineering and Medicine warn in a major report that
sounds the alarm about an endangered foundation of the U.S. health system.
The urgently worded report, which comes as internists,
family doctors and pediatricians nationwide struggle with the economic fallout
of the coronavirus pandemic, calls for a broad recognition that primary care is
a “common good” akin to public education.
The authors recommend that all Americans select a primary
care provider or be assigned one, a landmark step that could reorient how care
is delivered in the nation’s fragmented medical system.
And the report calls on major government health plans such
as Medicare and Medicaid to shift money to primary care and away from the
medical specialties that have long commanded the biggest fees in the U.S. system.
“High-quality primary care is the foundation of a robust
health care system, and perhaps more importantly, it is the essential element
for improving the health of the U.S. population,” the report concludes. “Yet,
in large part because of chronic underinvestment, primary care in the United
States is slowly dying.”
The report, which is advisory, does not guarantee federal
action. But reports from the national academies have helped support major
health initiatives over the years, such as curbing tobacco use among children
and protecting patients from medical errors.
Strengthening primary care has long been seen as a critical
public health need. And research dating back more than half a century shows
that robust primary care systems save money, improve people’s health and even
“We know that better access to primary care leads to more
timely identification of problems, better management of chronic disease and
better coordination of care,” said Melinda Abrams, executive vice president of
the Commonwealth Fund, a New York-based foundation that studies health systems
around the world.
Recognizing the value of this kind of care, many nations —
from wealthy democracies like the United Kingdom and the Netherlands to
middle-income countries such as Costa Rica and Thailand — have deliberately
constructed health systems around primary care.
And many have reaped significant rewards. Europeans with
chronic illnesses such as diabetes, high blood pressure, cancer and depression
reported significantly better health if they lived in a country with a robust
primary care system, a group of researchers found.
For decades, experts here have called for this country to
make a similar commitment.
But only about 5% of U.S. health care spending goes to
primary care, versus an average of 14% in other wealthy nations, according to
data collected by the Organization for Economic Co-operation and Development.
Other research shows that primary spending has declined in
many U.S. states in recent years.
The situation grew even more dire as the pandemic forced
thousands of primary care physicians — who didn’t receive the government
largesse showered on major medical systems — to lay off staff members or even
close their doors.
Reversing this slide will require new investment, the
authors of the new report conclude. But, they argue, that should yield big
“If we increase the supply of primary care, more people and
more communities will be healthier, and no other part of health care can make
this claim,” said Dr. Robert Phillips, a family physician who co-chaired the
committee that produced the report. Phillips also directs the Center for
Professionalism and Value in Health Care at the American Board of Family
The report urges new initiatives to build more health
centers, especially in underserved areas that are frequently home to minority
communities, and to expand primary care teams, including nurse practitioners,
pharmacists and mental health specialists.
And it advocates new efforts to shift away from paying
physicians for every patient visit, a system that critics have long argued
doesn’t incentivize doctors to keep patients healthy.
Potentially most controversial, however, is the report’s
recommendation that Medicare and Medicaid, as well as commercial insurers and
employers that provide their workers with health benefits, ask their members to
declare a primary care provider. Anyone who does not, the report notes, should
be assigned a provider.
“Successfully implementing high-quality primary care means
everyone should have access to the ‘sustained relationships’ primary care
offers,” the report notes.
This idea of formally linking patients with a primary care
office — often called empanelment — isn’t new. Kaiser Permanente, consistently
among the nation’s best-performing health systems, has long made primary care
central. (KHN is not affiliated with Kaiser Permanente.)
But the model, which was at the heart of managed-care health
plans, suffered in the backlash against HMOs in the 1990s, when some health
plans forced primary care providers to act as “gatekeepers” to keep patients
away from costlier specialty care.
More recently, however, a growing number of experts and
primary care advocates have shown that linking patients with a primary care
provider need not limit access to care.
Indeed, a new generation of medical systems that rely on
primary care to look after elderly Americans on Medicare with chronic medical
conditions has demonstrated great success in keeping patients healthier and
costs down. These “advanced primary care” systems include ChenMed, Iora Health
and Oak Street Health.
“If you don’t have empanelment, you don’t really have
continuity of care,” said Dr. Tom Bodenheimer, an internist who founded the
Center for Excellence in Primary Care at the University of California-San
Francisco and has called for stronger primary care systems for decades.
Bodenheimer added: “We know that continuity of care is
linked to everything good: better preventive care, higher patient satisfaction,
better chronic care and lower costs. It is really fundamental.”
Source: KHN (Kaiser Health News) is a national newsroom that
produces in-depth journalism about health issues. Together with Policy Analysis
and Polling, KHN is one of the three major operating programs at KFF (Kaiser
Family Foundation). KFF is an endowed nonprofit organization providing
information on health issues to the nation.