The Role of Primary Care in Improving Population Health

Centennial Issue
Population Health Primary Care

Policy Points:

  • Systems based on primary care have better population health, health equity, and health care quality, and lower health care expenditure.
  • Primary care can be a boundary-spanning force to integrate and personalize the many factors from which population health emerges.
  • Equitably advancing population health requires understanding and supporting the complexly interacting mechanisms by which primary care influences health, equity, and health costs.

In widely quoted ecological analyses, primary care is associated with population health.1,2 Not only with population health,3,4 but with health equity,5,6 health care quality,7,8 and lower health care expenditure1,4,9,10—a pretty good definition of value.11 Yet, there is a paradox about primary care.12 Despite these desirable population-level attributes, at the disease level at which we typically measure, incentivize, and organize the work of health care, when assessed with one-disease-at-a-time quality measures, primary care does not perform as well as care focused on a single disease.

What is going on here? In caring for patients’ individual diseases, primary care appears to offer lower quality than specialty care. But at the population level of countries, systems, and municipalities—if we organize around primary care, we get better health, equity, quality, and value?12,13 How can this be?

Apparently there are some emergent properties of primary care in which a relationship with the whole—person, family, community—is more than the sum of its parts.14,15 Not understanding this paradox, indeed feeling threatened by it, leads us to act on many potential health drivers in ways that do not have the intended effects on the health of people and populations and that indeed often make things worse.15–17

This paper explores the ways in which primary care might influence population health by serving as a force for integration18 across the often fragmented systems19 influencing population health. In the course of that exploration, we will examine the complexly related mechanisms by which the craft of general practice, as a vital component of primary health care, leads to the emergent properties of health, equity, quality, and sustainable resource use. Then, we will consider two informative stories—one of a person living with multiple chronic conditions and social disadvantage, and a second person who is overserved and whose problems and opportunities do not fit neatly into little boxes. Next, we will examine how primary care might helpfully interact with the other influencers of population health investigated in this special issue of Milbank Quarterly. We close with policy recommendations for federal, state, and health care system leaders.



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  2. Kringos DS, Boerma W, van der Zee J, Groenewegen P. Europe’s strong primary care systems are linked to better population health but also to higher health spending. Health Affairs. 2013;32(4):686-694.
  3. Macinko J, Starfield B, Shi L. Quantifying the health benefits of primary care physician supply in the United States. Int J Health Serv. 2007;37(1):111-26.
  4. Starfield B. Primary Care: Concept, Evaluation, and Policy. Oxford University Press; 1992.
  5. Starfield B. Primary care and equity in health: the importance to effectiveness and equity of responsiveness to people’s needs. Humanity Soc. 2009;33(1/2):56-73.
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  9. Starfield B. Primary care and health: a cross-national comparison. JAMA. 1991;266(16):2268-2271.
  10. Bazemore A, Petterson S, Peterson LE, Bruno R, Chung Y, Phillips RL, Jr. Higher primary care physician continuity is associated with lower costs and hospitalizations. Ann Fam Med. 2018;16(6):492-497.
  11. National Academies of Sciences, Engineering and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. The National Academies Press; 2021.
  12. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):293-299.
  13. Ferrer RL, Hambidge SJ, Maly RC. The essential role of generalists in health care systems. Ann Intern Med. 2005;142(8):691-699.
  14. Stange KC. The paradox of the parts and the whole in understanding and improving general practice. Int J Qual Health Care. 2002;14(4):267-268.
  15. Casalino LP. The unintended consequences of measuring quality on the quality of medical care. N Engl J Med. 1999;341(15):1147-1150.
  16. Bujold E. When practice transformation impedes practice improvement. Ann Fam Med. 2015;13(3):273-275.
  17. Hoff T. Next in Line: Lowered Care Expectations in the Age of Retail and Value-Based Health. Oxford University Press; 2017.
  18. Stange KC. Forces for integration. Ann Fam Med. 2018;16(3):192-194.
  19. Stange KC. The problem of fragmentation and the need for integrative solutions. Ann Fam Med. 2009;7(2):100-103.

Stange KC, Miller WL, Etz RS. The Role of Primary Care in Improving Population Health. Milbank Q. 2023;101(S1): 795-840.