Policy Solutions

The 2021 NASEM report, Implementing High-Quality Primary Care, made 16 policy recommendations to strengthen primary care in the United States, organized under five objectives:

1. Payment: Pay for primary care teams to care for people, not doctors to deliver services
2. Access: Ensure that high-quality primary care is available to every individual and family in every community
3. Workforce: Train primary care teams where people live and work
4. Digital Health: Design information technology that serves the patient, family, and interprofessional care team
5. Accountability: Ensure that high-quality primary care is delivered in the United States

Each of the reasons identified in this report to explain why patients are having difficulty accessing primary care could be addressed by implementing policy solutions recommended in the NASEM report. In this section, we discuss how those solutions could ameliorate the identified problems and offer examples of recent supportive federal and state policy activity.

Reason 1: The primary care workforce is not growing fast enough to meet population needs.

Reason 2: The number of trainees who enter and stay on the professional pathway to primary care practice is too low, and too few primary care residents have community-based training.

Relevant NASEM report recommendations:

Action 3.1: Health care organizations should strive to diversify the primary care workforce and customize teams to meet the needs of the populations they serve. Government agencies should expand educational pipeline models and improve economic incentives.

Action 3.2: CMS, the VA, HRSA, and states should redeploy or augment Title VII, Title VIII, and GME funding to support interprofessional training in community-based primary care practice environments.

Private and public sector attention to how well the racial and ethnic composition of the health care workforce reflects the communities they serve could not only improve patient experience⁷⁷ and outcomes,⁷⁸ but also the size and retention of the primary care trainee pipeline. More strategic and accountable deployment of current and additional federal and state workforce funding to support community-based primary care practices would also have a profound effect on the size of the current primary care workforce and number of trainees who enter and stay on the primary care pathway.

In 2022, Congress authorized an additional $174 million in funding to support primary care training in community health centers (CHCs) through the Teaching Health Center (THC) program.⁷⁹ This pales in comparison to the $16 billion that Medicare spends annually, without special authorization, on hospital based Medicare GME programs.⁸⁰ Congress and Medicare have the opportunity to improve the public’s understanding of what kind of workforce it is getting for its GME funding.

As of the publication of this report, the THC program, a more accountable pool of training funds, has yet to be reauthorized; neither has the National Health Service Corps, the federal health care professional loan forgiveness program.

With increasing concerns about the status of the health care workforce in general, and the primary care workforce in particular, some state legislatures are turning their attention to the issue.⁸¹

Reason 3: The United States continues to underinvest in primary care

Relevant NASEM report recommendations:

Action 1.1: Payers should evaluate and disseminate payment models based on their ability to promote the delivery of high-quality primary care, not short-term cost savings.

Action 1.2: Payers using fee-for-service models for primary care should shift toward hybrid reimbursement models, making them the default over time. For risk-bearing contracts, payers should ensure that sufficient resources and incentives flow to primary care.

Action 1.3: CMS should increase the overall portion of health care spending for primary care by improving the Medicare fee schedule and restoring the RUC [Relative Value Scale Update Committee] to its advisory nature.

Action 1.4: States should facilitate multi-payer collaboration and increase the portion of health care spending for primary care.

Action 2.2: HHS should create new health centers, rural health clinics, and Indian Health Service facilities in shortage areas.

Action 2.3: CMS should revise access standards for primary care for Medicaid beneficiaries and provide resources to state Medicaid agencies for these changes.

The United States is underinvesting in primary care, and Medicare’s fee schedule — which lists fees for services — is the chief culprit. With input from the American Medical Association’s Relative Value Scale Update Committee (RUC), it undervalues primary care services relative to specialty services and pays on a per visit basis, discouraging nonvisit services like emails and phone calls as well as care from other members of the primary care team.⁸² Reimbursing primary care practices with hybrid payments, in which a portion of their revenues is covered predictably and prospectively based on the number of patients in their practice, promotes team-based care and less reliance on in-person visits, which would improve patient access and make the practice of primary care more professionally rewarding.⁸³

Reforming how and how much Medicare pays for primary care will ultimately depend on congressional action. CMS, in the meantime, continues to make incremental supportive changes to the fee schedule, and the Center for Medicare and Medicaid Innovation (CMMI) has introduced two new payment models, Making Care Primary (MCP).⁸⁴ and Advancing All-Payer Health Equity and Development (AHEAD),⁸⁵ that are consistent with these payment recommendations. In March 2022, the Primary Care Collaborative launched the Better Health — NOW campaign focused on implementing the NASEM payment recommendations and expects to see a new optional primary care payment model introduced by CMMI in 2024.⁸⁶

Even though over half of Medicare beneficiaries received their benefits from a Medicare Advantage plan in 2023,⁸⁷ very little is known about how or how much these plans pay for or promote primary care. CMS is investigating greater public access to Medicare Advantage plans’ data.⁸⁸

In addition, a congressional commitment to increasing the number of community health centers — which now serve 1 in 11 people in the country⁸⁹ — would likely bolster the primary care workforce and the government’s investment in primary care. As of the publication of this report, Congress had not reauthorized the CHC program at existing or expanded levels. At the state level, to date 22 states have passed legislation measuring primary care spending in Medicaid and/or commercial insurance or mandating an increase.⁹⁰ A network of public and private sector officials has been convened to organize and advance this work.

Medicaid is the country’s largest payer by population and second largest by payment.⁹¹ Although precise levels vary by state, Medicaid consistently pays for primary care at rates that are 66% or less of Medicare’s already low rates.⁹² Massachusetts’ new 1115 Medicaid waiver implements per capita primary care payments; this is one of several important and much needed efforts to integrate CHCs into these advanced payment models. In 2023, several states asked for section 1115 authority to pay for health-related social needs as a Medicaid benefit; CMCS conditioned its approval on these states increasing their primary care fee schedules — an appropriate and important use of its waiver approval authority.⁹³

In 2023, CMCS released interim comprehensive regulations regarding access to care, including primary care, for Medicaid beneficiaries enrolled in fee-for-service and managed care programs.⁹⁴ These regulations are consistent with NASEM recommendations, and compliance will likely result in increased primary care investment.

Reason 4: Technology has become an added burden to primary care

Relevant NASEM report recommendations:

Action 2.4: CMS should permanently support COVID-era rule revisions.

Action 4.1: The Office of the National Coordinator (ONC) for Health Information Technology and CMS should develop the next phase of digital health certification standards that support relationship-based, continuous, and person-centered care; simplify the user experience; ensure equitable access and use; and hold vendors accountable.

Action 4.2: ONC and CMS should adopt a comprehensive aggregate patient data system that is usable by any certified digital health tool for patients, families, clinicians, and care team members.

Efforts to promote the use of telehealth, and other rule changes, made providing services to Medicare beneficiaries less burdensome for primary care providers during the public health emergency.⁹⁵ Yet, as discussed in this report, HIT has emerged as a time-consuming burden that often leads to less access for patients and increased provider discontent.

While Medicare has retained some of the Covid-era rule changes regarding telehealth, state and federal officials have not been active in digital health oversight, leaving it to the private sector to attempt to develop industry standards and management innovations to address these issues.⁹⁶

Reason 5: Primary care research to identify, implement, and track novel care delivery and payment solutions is lacking

Relevant NASEM report recommendations:

Action 5.1: The HHS secretary should establish a Secretary’s Council on Primary Care to coordinate primary care policy, ensure adequate budgetary resources for such work, report to Congress and the public on progress, and hear guidance and recommendations from a Primary Care Advisory Committee that represents key primary care stakeholders.

Action 5.2: HHS should form an Office of Primary Care Research at NIH and prioritize funding of primary care research at AHRQ.

Action 5.3: Primary care professional societies, consumer groups, and philanthropies should assemble, regularly compile, and disseminate a “High-quality primary care implementation scorecard” to improve accountability and implementation.

Coordinated federal administration attention to the status of primary care would lead to more effective public policies to address the issues that this report identifies as limiting access to primary care: payment and investment, workforce supply and training, technology, and research funding.

After an 18-month process, an issue brief released in the fall of 2023 by the US Department of Health and Human Services summarized the many current activities across HHS — some of them discussed earlier —to strengthen primary care.⁹⁷ The brief did not, however, commit to further actions or, more importantly, to a much-needed department-wide coordinating and accountability structure and process.

A new NASEM Standing Committee on Primary Care was created in 2023 to advise HHS on these efforts and may help keep HHS accountable for progress in primary care, as well as serve as a private sector advisor and partner.⁹⁸

Conclusion

Primary care is the foundation of a high-performing health system, yet fewer and fewer Americans report that they are seeing a clinician on a regular basis. This loss of a trusted source for routine care negatively affects the opportunity for all Americans to live long and healthy lives.

This year’s Scorecard identifies five reasons why access to primary care is declining. There is clear evidence to show what needs to be done to improve access to primary care — and some promising policy activity. Private and public sector leaders, however, must prioritize and accelerate their efforts if the trends identified here and their bleak consequences are to be reversed.

Notes

76. HHS is taking action to strengthen primary care. US Department of Health and Human Services Issue Brief. https://www.hhs.gov/sites/default/files/primary-care-issue-brief.pdf. Published November 7, 2023. Accessed January 31, 2024.
77. Takeshita J, Wang S, Loren AW, et al. Association of racial/ethnic and gender concordance between patients and physicians with patient experience ratings. JAMA Netw Open. 2020;3(11):e2024583. doi:10.1001/jamanetworkopen.2020.24583.
78. Greenwood BN, Hardeman RR, Huang L, et al. Physician–patient racial concordance and disparities in birthing mortality for newborns. Proc Natl Acad Sci. 2020;117(35)21194-21200. doi:10.1073/pnas.1913405117.
79. Hawes E, Rains J, Chen C, et al. Training the primary care workforce to deliver team-based care in underserved areas: the Teaching Health Center program. The Milbank Memorial Fund. https://www.milbank.org/publications/training-the-primary-care-workforce-to deliver-team-based-care-inunderserved-areas-the-teaching-health-center-program. Published June 2023. Accessed February 5, 2024.
80. Congressional Research Service. Medicare graduate medical education payments: an overview. https://crsreports.congress.gov/product/pdf/IF/IF10960. Published September 29, 2022. Accessed February 5, 2024.
81. Healthcare workforce resources. National Conference of State Legislatures website. https://www.ncsl.org/health/health-care-workforce-resources. Published January 27, 2024. Accessed February 5, 2024.
82. Calsyn M, Twomey M. Rethinking the RUC: reforming how Medicare pays for doctors’ services. Center for American Progress. https://www.americanprogress.org/article/rethinking-the-ruc. Published July 13, 2018. Accessed February 5, 2024.
83. National Academies of Sciences, Engineering, and Medicine. Implementing high-quality primary care: rebuilding the foundation of health care. https://www.nationalacademies.org/our-work/implementing-high-quality-primary-care. Published 2021. Accessed August 2, 2022.
84. Making Care Primary (MCP) Model. Centers for Medicare and Medicaid Services website. https://www.cms.gov/priorities/innovation/innovation-models/making-care-primary. Accessed February 5, 2024.
85. States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model. Centers for Medicare and Medicaid Services website. https://www.cms.gov/priorities/innovation/innovation-models/ahead. Accessed February 5, 2024.
86. Better Health Now. Primary Care Collaborative website. https://thepcc.org/better-health-now. Accessed February 5, 2024.
87. Ochieng N, Fuglesten Biniek J, Freed M, et al. Medicare Advantage in 2023: enrollment update and key trends. KFF. https://www.kff.org/medicare/issuebrief/medicare-advantage-in-2023-enrollment-update-and-key-trends. Published August 9, 2023. Accessed February 5, 2024.
88. Centers for Medicare and Medicaid Services. Medicare program; request for information on Medicare Advantage data. https://www.govinfo.gov/content/pkg/FR-2024-01-30/pdf/2024-01832.pdf. Published January 30, 2024. Accessed February 5, 2024.
89. Health center program: impact and growth. Health Resources and Services Administration website. https://bphc.hrsa.gov/about-health-centers/healthcenter-program-impact-growth. Published August 2023. Accessed February 5, 2024.
90. State primary care investment initiatives. Primary Care Collaborative website. https://thepcc.org/primary-care-investment/legislation. Accessed February 5, 2024.
91. Vanka P. Total Medicaid enrollment, 1966–2022. Statista. https://www.statista.com/statistics/245347/total-medicaid-enrollment-since-1966. Published January 12, 2024. Accessed February 5, 2024.
92. Zuckerman S, Skopec L, Aarons J. Medicaid physician fees remained substantially below fees paid by Medicare in 2019. Health Aff (Millwood). 2021;40(2).doi:10.1377/hlthaff.2020.00611.
93. Guth M. Section 1115 waiver watch: approvals to address health-related social needs. KFF. https://www.kff.org/medicaid/issue-brief/section-1115-waiver-watch-approvals-to-address-health-related-social-needs. Published November 15, 2022. Accessed February 5, 2024.
94. US Centers for Medicare and Medicaid Services. Summary of CMS’s Access-Related Notices of Proposed Rulemaking: Ensuring Access to Medicaid Services (CMS 2442-P) and Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality (CMS-2439-P). https://www.cms.gov/newsroom/fact-sheets/summary-cmss-access-related-notices-proposed-rulemaking-ensuring-access-medicaid-services-cms-2442-p. Published April 27, 2023. Accessed February 5, 2024.
95. Bipartisan Policy Center. The future of telehealth after COVID-19—new opportunities and challenges. https://bipartisanpolicy.org/download/?file=/wpcontent/uploads/2022/09/BPC-The-Future-of-Telehealth-After-COVID-19-October-2022.pdf. Published October 2022. Accessed February 5, 2024.
96. Telehealth policy changes after the COVID-19 public health emergency. Health Resources and Services Administration website. https://telehealth.hhs.gov/providers/telehealth-policy/policy-changes-after-the-covid-19-public-health-emergency. Published December 19, 2023. Accessed February 5,2024.
97. Department of Health and Human Services. HHS is taking action to strengthen primary care.https://www.hhs.gov/sites/default/files/primary-careissue-brief.pdf. Published November 7, 2023. Accessed February 5, 2024.
98. Standing committee on primary care. National Academies of Sciences, Engineering, and Medicine website. https://www.nationalacademies.org/ourwork/standing-committee-on-primary-care. Accessed February 5, 2024.