Yet it is also the specialty of medicine that is among the most undervalued and underfunded in the United States. In fact, although primary care is responsible for 50% of medical visits each year, the United States invests only 6 cents for every dollar spent on health care in primary care, 50% less than any other developed country. This obvious misalignment of misinvestment in a system with such valuable outcomes has put the country’s health outcomes in the middle of the pack at best, despite the fact that the country spends considerably more per person on health care than any other country in the world.
The past two years have placed a financial and emotional burden on primary care that may have tipped this balance irrevocably. At the start of the COVID-19 pandemic, when people lacked access to care for routine or even urgent health conditions, many small primary care practices across the country were forced to close. The CARES Act provided relief funds to keep some practices open, but still not enough to fund and maintain the multiple new roles that primary care providers now had to fill. These roles include everything from emergency providers caring for breathless patients, to palliative and end-of-life care providers, to public health messengers on all things COVID-19 – including the politicized importance of COVID-19 vaccines – to sleuths who are tracking down IV immunoglobulin therapy and, now, oral antiviral drugs such as Paxlovid.
The ever-expanding set of tasks given to primary care physicians, including managing increased mental health needs, dealing with housing and employment crises, food insecurity, rising drug prices and, of course, chronic disease care that escalated as a result of poor access to care for more than two years produced unprecedented levels of burnout. Before the pandemic, more than 50% of primary care clinicians reported being burnt out. In a recent national survey conducted by the Green Center, this number has now increased to 71 percent.
Given these high rates of burnout and exodus in primary care, Americans may soon find themselves with a great shortage of providers. Dr. Asaf Bitton, director of Ariadne Labs and primary care physician at Brigham and Women’s Hospital, said in an interview recently: “Primary care is like oxygen. You only start noticing it in its absence.”
Is there a way forward? In their 2022 report “Reaching and Sustaining the Next Normal: A Roadmap for Living with COVIDa group of 53 academics highlighted the urgent need for a strong primary care workforce and highlighted some possible levers needed to support primary care in the future. These included strategies such as investing in systems that automate much of the overwhelming administrative burden, continuing to improve telemedicine capabilities, training more community health workers and providing primary care clinicians with adequate support for their physical and mental well-being. Simultaneously, efforts must be made to ensure an adequate pipeline of new primary care clinicians by providing additional incentives to enter this critical line of work, such as waiver of medical student loans and more equitable salaries across all departments. specialties.
In Massachusetts, Governor Charlie Baker last month announced his commitment to increase state investment in primary care and mental health by 30% over the next three years.. This legislation, originally proposed in the fall of 2019, is more urgent than ever. In addition to helping primary care rebuild some of what has been lost and stem the mental health crisis, it will also target systemic cost drivers and create access to better coordinated care. It even creates a new role of “dental therapist,” a provider licensed to perform procedures typically performed by dentists, in an effort to fill a critical gap in oral health care delivery.
However, a law like this is just the beginning. In order to truly care for the whole person, a primary care clinician must be surrounded by a team of nurses, advanced practice providers, social workers, community health workers, health coaches , addiction recovery coaches, medical scribes and pharmacists. Primary care clinicians must have the flexibility to create new models of care – including longer visits, group visits, video/phone visits, after-hours/weekend visits, and home visits – to meet the needs of our patients. These models of care are not possible in the current fee-for-service system, which pays based on services rendered rather than taking care of a patient as a whole.
The 2021 NASEM report endorses a dramatic increase in investment in primary care and a payment model that shifts from fee-for-service to a patient-based approach. However, to achieve these ambitious goals, legislative strategies must be bold and forward-thinking. More than 10 states have passed or are proposing legislation to double investment in primary care. Nationally, multidisciplinary groups such as the Primary Care Collaborative are working to advance these investments and reforms.
While we are in a primary care crisis, this is also an opportunity for non-incremental change. As the late Leonard Cohen sang, “There’s a crack in everything. This is how light penetrates. Massachusetts leaders must strengthen the light of primary care by investing more in our current and future workforce now – before it’s too late.
Dr. Katherine Gergen Barnett is Vice President of Primary Care Innovation and Transformation in the Department of Family Medicine at Boston Medical Center and Associate Clinical Professor at Boston University School of Medicine. Dr. Wayne Altman is Professor of Family Medicine and Jaharis Chair in Family Medicine at Tufts University School of Medicine.