Primary care: When will we learn?

Primary care remains underfunded despite its association with decreased health care costs and improved health outcomes.

Primary care became a priority in the U.S. in the 1960s. During this era, when specialization was becoming more popular, there was a need to have physicians with a general knowledge base to oversee a patient's total health.

In the Millis Commission report, published in 1966, the term “primary physician” was meant to refer to a physician who served as the primary medical resource of a patient or family, focusing on the whole person and not a specific organ system. The term “primary” has been redefined in various ways over time. In 1978, the Institute of Medicine (now the National Academies of Sciences, Engineering, and Medicine [NASEM]) published a report titled “A Manpower Policy for Primary Health Care: Report of a Study,” which described primary care as “assessable, comprehensive, coordinated, and continual care.” In 1983, a report by Joseph H. Abramson and Sidney L. Kark brought to light the concept of community-oriented primary care, with the goal of integrating physicians with community health in a coordinated manner to better understand and address issues that we now refer to as social drivers of health. In 1996, the Institute of Medicine released a report called “Primary Care: America's Health in a New Era,” which fostered a goal of improving primary care's definition, value, financing, and infrastructure. In 2021, NASEM published a report called “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” and once again refined the definition of primary care.

There has been considerable and growing evidence to support the idea that access to primary care is associated with “higher quality of care, lower mortality rates, higher patient satisfaction, and lower total system costs,” as noted in ACP's New Vision for the U.S. Health Care System, published in Annals of Internal Medicine in January 2020. However, despite these benefits, the U.S. only contributes about 6% to primary care, according to “Investing in Primary Care: A State-Level Analysis,” published in 2021 by the Primary Care Collaborative.

It is no secret that the U.S. consistently ranks last in health outcomes compared to other industrialized peer countries that place greater emphasis on primary care, prevention, and access to care. This ranking has been repeatedly demonstrated in the Commonwealth Fund Report. One distinguishing feature of the countries that outperform the U.S. is their investment in primary care, which on average is at least twice our contribution. Thus I ask, why does primary care remain underfunded if associated with decreased health care costs and improved health outcomes?

This underfunding affects not only patient care but also the pathway of the primary care workforce. The focus on primary care in our current graduate medical education (GME) infrastructure is minimal. Ambulatory medicine should be as essential to the training paradigm as the inpatient service, which has dominated the GME training experience. Thus, it is not only our legislatures but also our GME curriculum that has faltered in the commitment to enhance primary care. Medical institutions have a system where faculty are compensated for their clinical duties to teach on the inpatient services, but most programs struggle to provide adequate compensation for ambulatory preceptors to provide a primary care experience. When it comes to the primary care experience, institutions typically seek volunteers from community physicians or offer a very nominal honorarium. Thus, the inpatient teaching experience is funded, but there is inadequate investment in the community ambulatory teaching experience. The majority of the approximately $15 million spent on GME is governmentally subsidized for hospital and VA systems, prioritizing the funding of inpatient medicine. Only a small percentage of those funds are directed toward primary care training.

As a primary care internal medicine physician, I truly valued my inpatient experience and am in no way suggesting a ranking of one experience over another, but rather a shift to better incorporate primary care as a valuable component of the clinical educational experience rather than as the bare minimum exposure to meet a check-box training criterion. If health care is true to the concept of being evidence-based, then we need to support the evidence that primary care is an asset to the health care system with actions, policy, funding priorities, pathway initiatives, and training curricula.

The COVID-19 pandemic has exposed the deficiencies in our health care system, and there is no better time for primary care to be elevated as a foundational structure for improved health care in the U.S. As described in the article “Training Tomorrow's Comprehensive Primary Care Internists: A Way Forward for Internal Medicine Education,” published in the Journal of Graduate Medical Education in 2013, the current training of internal medicine physicians is not congruent with what we know is the fundamental model and future for effective health care delivery. Primary care is the only discipline where “a greater supply equates to improved population health, life expectancy, and greater equity,” per NASEM. We need all components of medical education to be valued and adequately compensated to reap the benefit that each contributes to the health care system.

ACP has been active in its efforts to amplify primary care and improve the funding structure through collaboration and participation in the Primary Care Collaborative, Primary Care for America, and Primary Care Speaks As One. In addition, ACP was a cosponsor of the 2021 NASEM report “Implementing High-Quality Primary Care.” ACP has been intentional in including primary care representation in its governance and on its committees and councils.

Fifty-five years after the “primary” concept originated and 44 years after the Institute of Medicine's first attempt to transform primary care, professional societies and health care organizations are collaborating to speak with a louder voice that, along with NASEM's attempt to focus on implementation, will hopefully give primary care the appropriate value it deserves to improve health care for our patients and become an attractive pathway for our learners. We have over four decades of ideas about how to enhance primary care, but we continue to lack the investment needed to implement them. Our peer nations have demonstrated what works for an effective health care delivery system, and we continue to see the flaws, inefficiencies, and poor outcomes of our current system. When will we learn?