The Effectiveness of Policies to Improve Primary Care Access for Underserved Populations: An Assessment of the Literature

Multipayer Primary Care Network Primary Care Transformation Health Equity

Funding for this project was provided by the National Institute for Health Care Reform

Read a set of fact sheets summarizing the evidence for policy interventions in each dimension of primary care access.

Executive Summary

Primary care is a critical tool to prevent illness and death and to improve equitable distribution of health in populations. However, access to this important source of care is lacking, especially for many underresourced groups, such as communities of color and in rural areas. In 1981, researchers Roy Penchansky and J. William Thomas developed a model that breaks down the concept of primary care access into five composite and interconnected dimensions: availability of primary care clinicians; accessibility of primary care services geographically; accommodation in terms of appointment availability and hours; affordability; and acceptability in terms of comfort and communication between patient and clinician. The authors of this report reviewed the research literature to assess the evidence supporting whether policy initiatives targeting primary care access in each of these five dimensions have been effective in reducing health care disparities. The policy initiatives we considered vary widely in terms of the decision makers best suited to implement them and therefore will require multi-sector collaborative solutions to improve access to primary care in underserved areas.

Availability

The United States is facing a significant shortage of primary care physicians. The first set of policy initiatives we reviewed is designed to increase and redistribute the supply of primary care physicians and nonphysician clinicians to address this problem. This section also includes an evaluation of efforts to increase workforce diversity; significant evidence shows that physicians from communities underrepresented in medicine are likely to practice in medically underserved areas.

While many provider groups and researchers have argued that increasing payment for primary care services could incentivize more physicians to choose primary care professions, this review found that there is a dearth of evidence to support that claim. Nevertheless, some state-led efforts have successfully created more primary care residency spots in underserved areas and diversified the physician workforce. Federal government student loan forgiveness programs incentivizing practice in underserved areas and grant-making programs supporting medical schools and health centers to develop and sustain recruitment and retention programs for primary care in underserved areas have also demonstrated some success, but the scale of these efforts have been insufficient to meet our nation’s workforce needs.

Research shows that leveraging the skills of nonphysician clinicians by expanding their scope of practice could improve access, and more research is needed to evaluate the effects of transitioning to team-based care.

Accessibility and Accommodation

To be successful, primary care services need to be embedded in the communities they serve. They must be responsive to their community’s needs. Researchers found that expansion of nonhospital clinic sites like federally qualified health centers (FQHCs) and school-based health centers can significantly improve access for both rural and urban underserved communities. The increase in government funding for the FQHC program has been one of the most effective primary care policy initiatives, but emerging evidence shows that newer sites have been less likely to open in the areas with the highest need. Although the school-based health center model has shown success over the past two decades, it needs significant community investment and institutional support in order to fully meet the needs of underresourced communities. This review further found that while retail clinics might be able to provide quick and convenient services for simple health issues without sacrificing quality, they are most likely today to be located in higher-income, lower-need communities and therefore less likely to improve access for communities that are most in need.

As a result of the COVID-19 pandemic, state and federal governments as well as physician practices have made significant investments in telehealth that are likely to change the landscape of access. Our review found that telehealth programs tailored to the needs of specific communities have been successful at making telehealth accessible to populations with lower levels of comfort with and access to technology. While FQHCs are able to meet the after-hours needs of the communities they serve, more research is needed to find ways to bring after-hours care to other kinds of clinical settings.

Affordability

Removing cost-related barriers to primary care is essential to ensuring access. Some evidence suggests that making primary care available with low or no cost sharing can improve the utilization of these services, but administrative burdens, and in some cases, even enrollee pushback can act as significant barriers to the implementation of these solutions. For example, network adequacy requirements can be a tool to ensure that those covered under insurance have timely and affordable access to primary care physicians near them. However, current laws and regulations governing network adequacy may not be sufficient to meet this goal.

Acceptability

One of the most challenging barriers to primary care access is that many individuals do not trust or feel comfortable engaging with the health care system. Interventions like practicing patient-centered communication and deploying community health workers show some promise in improving community trust and comfort, but this is an area where significantly more research is needed to develop the most effective programmatic and policy interventions.

Conclusion

While the research literature suggests strong evidential support for several of the policy interventions discussed in this report, many of the most conceptually promising have been insufficiently studied to determine their effect on primary care access for underresourced communities. More research is needed before policymakers can effectively assess optimal and cost-effective approaches to expanding primary care access.

Read the report


Citation:
Kona M, Houston M, Gooding N. The Effectiveness of Policies to Improve Primary Care Access for Underserved Populations: An Assessment of the Literature. The Milbank Memorial Fund. Published January 24, 2021.



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