Progress, Challenges, and Policies to Promote Primary Health Care
Cynthia Haq, Alison Huffstetler and Andrew Bazemore
History and Definition
In a remarkable show of solidarity, health leaders from 194 nations recently gathered in Kazakhstan to renew their commitments to primary health care (PHC)1. Forty years earlier, in 1978, a similar group had gathered in Alma Ata to define PHC as a cornerstone of effective health care systems2.
Health leaders agreed that promoting health was a public good. They recognized that health was a prerequisite for, as well as a byproduct of social and economic development. PHC was defined as first-contact, continuous, comprehensive, and coordinated health services to address acute, chronic, preventive, and community health care needs. Services were to be equitably distributed, scientifically based, cost-effective, culturally acceptable, affordable, and accountable to address the most common needs of the population served. Leaders agreed to work towards the aspirational goal of ensuring “Health for All.”
Today, people are living healthier lives and longer than ever3.Improvements in living conditions and public health measures such as immunizations have saved millions of lives. Yet this progress is unequally distributed both within and between countries. More than half of the world’s population still lack access to PHC.1 Life expectancy and years of healthy life differ drastically between and within countries, and by as much as 30 years between communities in the United States4.
PHC in the United States
The United States ranks first in the world for health care spending, but forty-third in life expectancy5. Tragically, life expectancy is declining for the first time since World War I 6. The most influential upstream determinants of health are economic and social circumstances. Yet access to health care remains an important contributor to health outcomes. More than half of US counties and many low-income urban communities still face shortages of primary care professionals7. Despite the Affordable Care Act, millions of Americans continue to face financial and/or geographic barriers to health care8. People who are unable to access PHC are less likely to receive essential preventive services and are more likely to present to emergency departments and hospitals with more advanced and costly conditions and/or experience premature mortality9,10.
Why doesn’t the US ensure universal access to PHC like most other middle and high-income nations? While PHC is the front door to the US healthcare system, why is our entry point inadequate? What policies would be most likely to promote access to primary health care and to improve the health of the US population?
Challenges to PHC
While some note existing and looming shortages, others point to the maldistribution, skills, and composition of the US primary care workforce11–13. Primary care physicians (PCPs including family physicians, general internal medicine, and pediatric physicians) reduce the costs of patient care, improve the quality of care and patient satisfaction, and reduce mortality rates 14,15. Nurse Practitioners and Physicians Assistants (NPs and PAs) can address many primary care needs, yet PCPs remain essential to provide high-quality, comprehensive PHC services.
US health policies are inadequate to recruit, train, distribute, and retain an adequate primary care workforce to address the needs of the population. PCPs comprise approximately one-third of the total physician workforce in the US, a smaller percentage than most other high-income nations16. The number of PCPs completing post-graduate training has shown little growth in the past 20 years 16,17. In the period from 2005-2015, the proportion of PCPs in the US workforce declined from 44% to 37% while the proportion of sub-specialists grew from 56% to 63% 18.
Disparities persist between the racial and ethnic characteristics of PCPs and those they serve19. Physician-patient demographic concordance results in higher levels of preventive screening and increased patient satisfaction20,21. Similarities in personal beliefs, values, and communication styles lead to stronger doctor-patient relationships22. Preliminary steps to increase the diversity of PCPs have not yet produced sufficient numbers of physicians whose characteristics reflect the demographics of the US population23.
Additionally, PCP’s scope of practice is narrowing. For example, family physicians are trained to care for patients from ‘womb to tomb’ including care for pregnant women, children, adults and the elderly. Yet most do not practice their full scope of skills 24–26. The diminishing scope of primary care results in more patient visits to sub-specialists and increases the costs of care.
Policy measures to strengthen PHC
Three policy measures could strengthen PHC in the United States: targeted training, increased loan repayment, and payment reforms.
Graduate medical education (GME) training could be adjusted to meet the needs of the population. A National Health Workforce Planning Committee was proposed in 2014 but was never launched. The proposed mission included evaluating the supply of health care professionals as well as identifying factors likely to influence specialty choice and location. These comprehensive assessments and recommendations are sorely needed.
Preparing and deploying an adequate supply of PCPs is needed to alleviate gaps in distribution and scope of practice. Specifically, increasing graduate medical education (GME) programs in rural sites and federally qualified community health centers would prepare a greater number of physicians to care for underserved populations. Physicians who train in rural areas are more likely to remain in rural areas27,28. GME linked to social accountability and expectations to provide essential PHC services would increase access to PCPs in medically underserved communities.
Educational debt strongly influences medical students’ specialty choice and practice location. The National Health Service Corps (NHSC) matches graduates to health professional shortage areas in exchange for loan repayment and enables PCPs to serve medically underserved populations without jeopardizing their financial futures29. Expanding the NHSC would increase the numbers of physicians serving underserved populations.
Health care financing policies could shift physician reimbursement from fee-for-service (FFS) payments to place a greater emphasis on value-based payments with partial capitation. FFS payments tend to reward medical procedures resulting in perverse incentives to pursue unnecessary interventions and undermine the value of primary care30. Payment models that combine value-based care with partial capitation can improve patient outcomes, lower costs, and support integration of behavioral health into primary care31,32.
Finally, universal health insurance coverage has improved health access and outcomes in other high and middle-income nations. Ensuring access to PHC for every American would decrease health care costs and improve population health33,34.
PHC has the potential to address and reduce health care disparities that prevent the US from achieving health for all. A focused policy agenda that situates primary care physicians as the cornerstone of equitable care will increase access, improve health outcomes, and decrease healthcare spending.
About the Authors
Dr. Andrew Bazemore is a practicing family physician and the Director of the Robert Graham Center, which he joined in 2005. He oversees and participates in the Center's research with a particular interest in access to care for underserved populations, health workforce & training, and spatial analysis. Dr. Bazemore has authored over 150 peer-reviewed publications, while leading the Center's emphasis on developing tools that empower primary care providers, leaders, and policymakers. He is an elected member of the National Academy of Medicine(NAM), and appointed member of the federal Council on Graduate Medical Education (COGME).
Dr. Cynthia Haq is Professor and Chair of Family Medicine at the University of California, Irvine. She has provided full-scope primary health care and served as a champion for health equity for more than 30 years. Dr. Haq designs and leads medical education programs to prepare health professionals to promote health with medically underserved communities. She has developed and led training programs in Pakistan, Uganda, Ethiopia, with the World Health Organization, and with governmental and non-governmental organizations. She was the founding director of the University of Wisconsin Center for Global Health.
Dr. Alison Huffstetler is a family physician in Washington DC. She is the Robert L. Phillips, Jr. Health Policy Fellow at the Robert Graham Center in conjunction with Georgetown University. Dr. Huffstetler completes research on primary health care access, workforce, reimbursement, and social determinants of health. Prior to her fellowship, she completed family medicine residency at the University of Virginia. Dr. Huffstetler teaches medical students at Georgetown University and works in the family medicine residency at Georgetown University.
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- World Health Organization. Declaration of Alma-Ata. Alma-Ata, USSR: International Conference on Primary Health Care; 1978:159-161. http://link.springer.com/10.1057/palgrave.development.1100047. Accessed January 2, 2019.
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- Central Intelligence Agency. The World Factbook. https://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.html. Accessed January 2, 2019.
- Nancy Clanton TAJ-C. CDC: Life expectancy in US declines for second year in a row. ajc. https://www.ajc.com/lifestyles/health/cdc-life-expectancy-declines-for-second-year-row/uEYI54lyoUpOj279HCufnO/. Accessed January 2, 2019.
- Bureau of Health Workforce. Shortage Designation. Heath Resources and Services Administration Website. https://bhw.hrsa.gov/shortage-designation. Accessed January 2, 2019.
- Kaiser Family Foundation, 2018. Key Facts about the Uninsured Population. Henry J Kais Fam Found. December 2018. https://www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/. Accessed January 2, 2019.
- Partnership for Prevention. Preventive Care: A National Profile on Use, Disparities, and Health Benefits. Washington D.C.: Robert Wood Johnson Foundation; 2007. https://www.rwjf.org/en/library/research/2007/08/preventive-care-national-profile-on-use.html. Accessed January 2, 2019.
- Petterson S, Rabin D, Phillips R, Bazemore A, Dodoo M. Having a Usual Source of Care Reduces ED Visits. Washington D.C.: Robert Graham Center; 2009. https://www.graham-center.org/rgc/publications-reports/publications/one-pagers/usual-care-reduces-ed-visits-2009.html. Accessed January 2, 2019.
- Results of the 2015 Medical School Enrollment Survey - Data and Reports - Workforce - Data and Analysis - AAMC. https://www.aamc.org/data/workforce/reports/439210/undergraduateandgraduatemedicaleducationtrends.html. Accessed October 29, 2018.
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- Hofer AN, Abraham JM, Moscovice I. Expansion of coverage under the Patient Protection and Affordable Care Act and primary care utilization. Milbank Q. 2011;89(1):69-89. doi:10.1111/j.1468-0009.2011.00620.x
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- American Medical Association (AMA). AMA Physician Masterfile. https://www.ama-assn.org/life-career/ ama-physician-masterfile. Accessed January 2, 2018.
- Petterson S, McNellis R, Klink K, Meyers D, Bazemore A. The State of Primary Care in the United States: A Chartbook of Facts and Statistics.; 2018.
- Barbey C, Sahni N, Kocher R, Chernew M. Physician Workforce Trends And Their Implications For Spending Growth. Health Affairs Blog. https://www.healthaffairs.org/do/10.1377/hblog20170728.061252/full/. Published July 20, 2017. Accessed October 29, 2018.
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