Primary care physicians play an important role for patients, but their field is in crisis.
Photo courtesy Fly View Productions, iStockphoto
“We need a major, dogmatic shift if we want to capture the entire value of primary care.”
— Eric Wiser
After years of trying to hold firm against rising costs and stagnant pay rates, family medicine doctor Sarah Mullins finally broke. The debt her private practice had accumulated was too much to bear. She was missing paychecks and on the verge of closing down.
“We were making small changes around the edges so we could make payroll and keep the lights on,” said Mullins, MD, whose practice has been caring for people in Pike Creek, Delaware, for more than 30 years. “But there’s only so long you can do that.”
In 2018, the financial burden forced Mullins to restructure. Four of the practice’s eight physicians left in the process. More than 2,000 letters were sent telling patients that the clinic could no longer serve as their primary care home.
“It was heartbreaking,” Mullins told The Nation’s Health. “The idea that we could no longer care for them — it just didn’t make sense.”
Mullins’ story is not an uncommon one in the U.S. primary care sector, which has been struggling for many years with underinvestment, low reimbursement rates, increasing patient needs and a shortage of providers. But the problem may be reaching a new tipping point. In February, the Milbank Memorial Fund and the Physicians Foundation released their annual primary care scorecard, warning that the U.S. primary care system is “crumbling” after years of neglect.
According to the analysis, payment to primary care physicians has declined among all health insurance providers, both public and private. And as of 2022, more than 30% of U.S. adults lacked a usual source of care — the highest rate in 10 years, the scorecard reported. The problem worsened even as the Affordable Care Act drove uninsured rates to new lows.
The situation is a stark contrast to the value of primary care, often described as the backbone of the health care system.
Research consistently shows that access to primary care — which includes a range of preventive and chronic disease services — is associated with lower health spending and better health outcomes. A study published in 2023 in JAMA Network Open found that more-frequent primary care visits actually yielded the highest savings.
Despite accounting for about a third of all health care visits, primary care receives only about 10% of health care spending — at best — with other estimates putting it closer to 5%.
“Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes,” said a 2021 report from the National Academies of Sciences, Engineering and Medicine that called for greater investment in primary care. “For this reason, primary care is a common good, making the strength and quality of the country’s primary care services a public concern.”
A handful of years later, primary care is still in dire straits. Findings from the February scorecard report highlight a sector facing diminished capacity and continued financial struggle without major policy action.
According to the report, spending on primary care was under 5% in 2022 and continued to drop among all payers, including public and private insurers. Primary care spending by Medicare and Medicaid declined the most, dropping to 3.4% and 4.3% in 2022, respectively.
The low rate means primary care physicians make far less than other specialties. In 2022, for example, the average reimbursement for a primary care visit was $259, compared to almost $1,100 for a gastroenterology visit, according to the report.
The gap makes it harder to attract new workers to the field, which is facing worsening provider shortages, the report warned. For example, the percentage of nurse practitioners and physician assistants in primary care dropped to new lows in 2022.
“For a primary care office, it means you’re under-resourced but overtaxed,” said report co-author Yalda Jabbarpour, MD, a family physician in Washington, D.C., and director of the Robert Graham Center, a nonprofit that studies primary care. “You can’t build an effective team to take care of your patients.”
Jabbarpour said there are a number of levers that policymakers can tap to address the problem, including adopting value-based payment models and changing the federal Medicare fee schedule, which has endured years of cuts. If the status quo persists, primary care could collapse, Jabbarpour said.
“I don’t think that’s an exaggeration,” she told The Nation’s Health. “We’re already on the brink.”
States take action, cuts risk progress
Work is underway to shore up primary care. But it may not be enough without federal action, especially on Medicare fees, which set the bar for other insurers, Jabbarpour said.
Stela Kostova, MD, checks a patient in Tustin, California, in February 2023. Primary care accounts for a third of health care visits, but receives less than 10% of health care spending.
Photo by Paul Bersebach, courtesy MediaNews Group/Orange County Register/Getty Images
More than a third of states have initiatives on primary care investments, including new spending targets and research to define the breadth of the field’s work, according to the Primary Care Collaborative. In California, for example, state officials recently set a target of 15% investment in primary care by 2034 for all health care payers.
Connecticut took a similar tack in 2020, setting out to increase the percentage of primary care spending to 10% of total health expenditures by 2025. The state has yet to reach its target.
In Arkansas, family medicine doctors are rallying around a state bill introduced in February that would establish a multi-year study of primary care services to help determine future investments. Lonnie Robinson, MD, a family medicine physician in Mountain Home, a small town in northern Arkansas, said he feels optimistic about its chances.
“You can’t change things unless you can measure them,” he told The Nation’s Health.
In the current payment environment, Robinson said, primary care doctors are often left with no choice but to increase their caseloads and spend less time one-on-one with patients. According to the scorecard, fee-for-service payment models typically undervalue primary care, incentivizing volume over more holistic care.
To overcome that gap, Randy Walker’s family medicine practice in De Queen, Arkansas, has latched onto every value-based payment model it can. Such models reward quality of care over volume. Without them, Walker, MD, said his practice — which serves thousands in the rural region — might have closed by now.
“Even 10 years ago, the financial margins were pretty slim,” Walker said.
In Delaware, Mullins said value-based payments, along with a 2018 state law that raised primary care payments, saved her teetering practice. She was able to pay down the practice’s debt and start rebuilding.
“Without legislative mandates, no one is required to invest in primary care,” Mullins said.
Fee-for-service still dominates primary care, according to the Commonwealth Fund, with fewer than half of physicians in a 2022 survey reporting value-based payments. Last year, a bipartisan bill in the U.S. Senate, the Pay PCPs Act, would have shifted Medicare primary care payments toward value-based models, but it did not make it out of committee.
Private practices are not the only primary care providers under pressure. Community health centers, which are located in underserved areas and care for the uninsured, are also feeling the strain, said Joe Dunn, chief policy officer at the National Association of Community Health Centers.
Dunn said over half of such safety-net clinics are operating within unsustainable financial margins and more than 40% have less than 90 days of cash reserves on hand. The temporary federal funding freeze that occurred in the early days of the Trump administration exposed the financial fragility of such health centers, with some considering layoffs and closures, he said.
Oregon passed new laws to address primary care investment a decade ago, and is now leading the country with about 7% of all health care spending going to primary care, according to the 2025 scorecard. Eric Wiser, MD, a family medicine physician in Portland and an assistant dean at Oregon Health & Science University, said the attention was a step forward, but still not enough to bridge the gap.
“We need a major, dogmatic shift if we want to capture the entire value of primary care,” he said.
For more information on the report, “The Cost of Neglect: How Chronic Underinvestment in Primary Care is Failing U.S. Patients,” visit www.milbank.org.
- Copyright The Nation’s Health, American Public Health Association