How to Strengthen U.S. Primary Care

Fans of the TV emergency-room hit The Pitt might watch the chaos onscreen and conclude, “We need more ERs.”

They’d be wrong.

Many of the medical crises portrayed in the series are real, urgent, and often gruesome. But far too many emergency-room visits in the United States are tied to a deeper problem: inadequate insurance coverage and poor access to primary care for the people who need it most.

As the Commonwealth Fund noted in its September 2024 analysis, “A Portrait of the Failing U.S. Health System, “years of underinvestment and underpayment have produced nationwide shortages of primary care clinicians—the very professionals who help manage chronic illness, reduce unnecessary specialty and hospital care, and keep patients out of the ER when possible.

So how do we strengthen U.S. primary care? There are many possible strategies, but three stand out:

1. Train more primary care physicians.

2. Reform physician reimbursement.

3. Support emerging models of primary care.

Each initiative matters. None is sufficient on its own. To rebuild primary care, we need all three.

One major barrier is the cost of medical education. In the United States, four years of medical school can cost more than $235,000 before housing, food, and books are included. That level of debt is a powerful disincentive for students considering primary care, where compensation is significantly lower than in the specialties.

How can we encourage more medical students to choose primary care? Several strategies would help:

· Targeted selection: Admissions committees can explicitly seek applicants with a demonstrated interest in primary care.

· Longitudinal mentoring: Medical schools can pair students with dedicated primary care mentors throughout training who can provide crucial insights and emotional support.

· Curriculum reform: Students should rotate through primary care and community health settings and participate in population-health work that shows the broad impact of primary care.

· Debt relief: Scholarships and loan-forgiveness programs can reduce or eliminate debt for students who commit to primary care, especially in health professional shortage areas.

There is also a subtler disincentive. In many medical schools and academic centers, specialty care—especially procedural and surgical specialties—carries more prestige than primary care. Primary care can be treated, implicitly or explicitly, as a path for underachievers. Given the central role primary care plays in high-performing health systems, that culture needs to change.

Early exposure to outpatient primary care, education about emerging models such as the medical home and team-based care, and stronger representation of primary care faculty in leadership positions would all help signal that primary care is foundational - not second tier.

Training more primary care physicians will not be enough if the payment system continues to undervalue their work.

The traditional fee-for-service model is one reason U.S. health care is so expensive. It rewards volume and procedures more reliably than prevention, coordination, relationship-building, and chronic disease management - the core work of primary care and the critical foundation of any health system.

The Relative Value Unit system, which helps determine physician reimbursement, systematically disadvantages primary care and other “cognitive” services by favoring procedural and technical specialties. A major reason is the influence of the American Medical Association’s Relative Value Scale Update Committee, or RUC, where specialists constitute the overwhelming majority of members. Although the RUC is advisory to the Centers for Medicare & Medicaid Services, CMS has historically adopted most of its recommendations, and the committee has long been criticized for specialty bias and lack of transparency.

Several reforms could begin to correct this imbalance:

· Create an alternative payment-review committee: A CMS-funded committee could take a more balanced look at the work performed in primary care and other cognitive specialties, recognizing their contribution to quality, coordination, and outcomes.

· Recognize longitudinal care: Payment should account for the expertise required to care for patients with complex needs and multiple chronic conditions over time. One option would be a cognitive-services modifier that adds payment for evaluation, diagnosis, counseling, and care coordination.

· Allocate funding by category of care: CMS could set a target share of total spending for primary care, then allocate payments within that amount. This would allow primary care investment to rise from the current level of less than 5 percent toward a target closer to 8–10 percent (it is 14% in Europe.)

· Expand global primary care payments: CMS should continue testing prospective monthly payments per patient, building on prior demonstration projects such as Comprehensive Primary Care, with larger payments tied to improved outcomes.

Together, these reforms would move payment away from narrow transactional encounters and toward the ongoing work that keeps people healthier.

Peer nations devote an average of roughly 14 percent of total health care spending to primary care. The United States spends less than 5 percent. By underfunding primary care, we make comprehensive care harder to deliver, diminish its value, and reinforce the mistaken belief that “anyone” can provide it.

Strengthening primary care requires more than training more clinicians. We also need to redesign how care is delivered- and then support those models financially and operationally. Two models are especially important: the patient-centered medical home and team-based care.

The patient-centered medical home is a collaborative care model designed to strengthen the doctor-patient relationship. Its key elements include:

· Patient-centered care: Clinical decisions respect patients’ preferences, needs, and cultural values.

· Comprehensive care: The care team is accountable for most of a patient’s health needs, including prevention, acute care, and chronic disease management.

· Coordinated care: The model integrates care across the health system, supported by digital information technology.

· Accessible care: Patients have shorter wait times, expanded access, and 24/7 electronic or telephone connection to the care team.

· Quality and safety: Care is grounded in evidence-based medicine, shared decision-making, and continuous quality improvement.

If that sounds like a lot of work, it is. Primary care physicians now spend an estimated 61.8 hours per week managing a standard patient panel. About 40 hours are spent on direct patient care; the rest is consumed by EHR charting, inbox management, care coordination, and other administrative tasks. The shortage of primary care providers make patient access a critical challenge (“Why can’t I find a primary care provider?”).

No single clinician can do all this alone. Team-based care makes comprehensive primary care possible. In this model, diverse health professionals work together with the patient toward shared health goals, with each team member practicing at the top of their training and scope.

A strong primary care team typically includes:

· Primary care clinicians: Physicians, nurse practitioners, and physician assistants focus on complex medical decision-making, with physicians available for consultation to the team on more challenging cases.

· Nursing staff and medical assistants: Medical assistants gather data, take preliminary histories, and support patient education, while registered nurses often lead chronic care management efforts.

· Extended team members: Pharmacists, dietitians, social workers, behavioral health clinicians, and community health workers help address chronic disease, behavioral health, medication management, and socioeconomic needs.

Team care allows clinicians to spend less time on administrative tasks and more time on the work only they can do on behalf of patients. Delegation can also create more appointment availability, shorten wait times, reduce burnout, and improve chronic disease management and preventive care.

If we want better health outcomes and a more affordable health care system, we need to invest up front in how primary care is trained, paid for, delivered, and supported. More ER capacity may treat the symptoms of a broken system. Stronger primary care would treat one of its root causes.

In the next post, I’ll look at how hospitals can prepare for the future of health care.