Introducing a Scorecard to Improve Primary Care — By Alison Huffstetler, MD

This Primary Care Scorecard can help policymakers and health systems ensure a stronger primary care system and better patient care.

 How does it work?

 Developed by the Milbank Memorial Foundation and the Robert Graham Center, the Primary Care Scorecard is a tool to aid in monitoring and evaluating the implementation of recommendations from the 2021 report, “Implementing High Quality Primary Care.” In this report, the National Academies of Science, Engineering, and Medicine (NASEM) proposed five solutions to improve the foundation of primary care in the U.S. and ensure accountability: 1. Pay for team-based care, 2. Ensure all individuals are able to access primary care, 3. Train clinical staff in community settings 4. Design health information technology with the users in mind, and 5. Ensure this is delivered in the U.S. The scorecard is designed to monitor and evaluate implementation of these recommendations.

 It’s important to define what “high-quality” primary care is. High-quality is defined as “the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.” The scorecard addresses these areas and provides benchmarks for how systems provide for them.

What has use of the scorecard shown about U.S. primary care?

The U.S. does not invest enough in primary care. In 2019, only 4.6% of total healthcare spending was spent on primary care. This is not a new problem. Spending on primary care has been scant for over a decade, despite significant evidence that such spending is associated with improved health outcomes and health equity. Spending, however, does not correlate with team-based care or whole-person care. Today, the most common payment model for primary care continues to be the fee-for-service model, which pays clinicians for services, and therefore encourages clinicians to provide more services that may not address patient-specific needs. Capitation and hybrid models, which emphasize value-based care or volume, have not grown significantly this decade (fully capitated primary care clinician visits: 8.7% in 2010 vs 9.6% in 2018).

Primary care is not serving the communities and people who need it. Between 2012 to 2020, there was only a 1% increase in the total proportion of physicians who entered primary care. During the same time period, the population grew by approximately 5%. In the U.S. overall, there are approximately 55.8 primary care clinicians per 100,000 residents in medically underserved areas, compared to 79.7 primary care clinicians per 100,000 in non-medically underserved areas. This disparity among underserved communities may be due to decreased primary care clinicians in these areas.

Training, retention, and opportunities for community care such as establishing community health centers in medically underserved areas may be a solution to access and community accountability. Yet, community-based training of primary care clinicians is not the norm. While some states (Washington, Idaho, and Alabama) make an effort to train most of their physicians in rural and medically underserved communities, this is uncommon; most medical students train in urban and academic settings and do not become primary care clinicians.

 Many adults do not have a primary care clinician. Over 70% of U.S. adults do have a primary care clinician (27.1% of adults reported not having a primary care clinician in 2020). This situation is worse for minoritized populations. Access to care, mortality, maternal outcomes, and prevalence of disease vastly differ by community. Black and Brown communities, people living in rural areas, and those with lower socioeconomic status face rising inequities in health.

 There is next to no federal funding for primary care research nationally. While investment in primary care research is difficult to tease out, family medicine research received less than 0.2% of NIH funding annually in 2017-2021, which is less than $10 million. Without active and specific investment in sciences that study implementation and scale of high-quality care practices, the specialty will fall behind in scientific advancement, and the population will suffer.

Why is the scorecard important?

Primary care teams that have the needed resources, time and training can reduce healthcare inequities in the U.S.

This first iteration of the Primary Care Scorecard serves as starting point for assessing the function and equity of the primary care system in the U.S. Having the data to measure these and other attributes of our primary care system allow policy makers to understand and advocate for system features that promote the health of individuals, families and communities in the U.S.