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JAMA Forum Archive, 2012-2019: Health policy commentary from leaders in the field
JAMA Forum

Primary Care for All

Democratic candidates for president have been actively debating the merits of “Medicare for all.” This term is used differently by the candidates, and what has been left unsaid is whether they endorse a particular model of care. Medicare for all would have enormous implications for how health care is financed, but ensuring that primary care is the foundation of the US health care delivery system is what is needed to have a significant impact on the population’s health.

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Primary care refers to a delivery model in which a designated clinician, often in association with other members of a care team at a practice site, is responsible for providing patients with timely access to a comprehensive set of health care services and for coordinating care as needed outside of the practice. Primary care occurs in the context of a continuing relationship between a clinician and patient that allows the patient to become educated over time about relevant health care options and to share in health care decision making with a trusted clinician partner. Physicians who provide primary care services in the United States are most often trained in family medicine, general internal medicine, and general pediatrics, but in some cases this role may be fulfilled by a physician trained in another specialty or by a nonphysician, such as a nurse practitioner.

Comparing Countries

International comparisons have demonstrated that the degree to which a country’s health care system is oriented toward primary care contributes to better health outcomes and health equity, as well as lower total health care costs. Primary care practices that are able to provide rapid access to care, promote prevention, support care coordination, facilitate patient decision-making, and engage patients in self-management of chronic care conditions are the most effective in improving health outcomes and lowering costs. The United States has long been an outlier relative to other industrialized countries in its relatively lower percentage of physicians who are primary care practitioners, higher per capita total health care costs, and worse health outcomes.

The availability of universal coverage as would occur under a Medicare-for-all policy does not guarantee a primary care delivery model. Medicare, which already provides nearly universal coverage for those older than 64 years, does not emphasize the role of primary care in furnishing health care services. In fact, compared with other payers, Medicare spends a substantially lower percentage of its total health care expenditures on primary care. This is despite the fact that states that are more oriented toward primary care tend to provide Medicare beneficiaries with higher-quality care and have lower health care utilization and costs compared with states that are more reliant on specialists to furnish services. The typical employer-sponsored preferred provider organization plan in the United States spends an average of 7.7% of total health care expenditures on primary care, whereas the percentage in Medicare is only 2.1%. Medicare’s percentage of spending on primary care is well below the national average of 6.8% observed among 22 European countries.

Infusion of Funding Needed

Primary care cannot achieve its potential to return value to the US health care system without policy changes that include a significant infusion of funding. The Affordable Care Act (ACA) created a time-limited 10% Medicare primary care payment bonus, but this expired after 2015. Since then, the Centers for Medicare & Medicaid Services (CMS) has focused more on proposing changes in how primary care clinicians can bill for services rather than on the amount they are reimbursed for providing care.

Last year, one of CMS’s proposed primary care policies was to collapse the number of evaluation and management codes as a way to simplify billing procedures. CMS is now abandoning this proposal before it is implemented because primary care practitioners raised concerns that it would create a financial disincentive for caring for high-need, complex patients.

The agency has also proposed an advanced alternative payment model for primary care with 2-sided risk called Primary Care First. It would provide primary care clinicians capitation and fee-for-service payments for the care of a defined population of Medicare beneficiaries. Although Primary Care First would provide primary care clinicians some flexibility in how they could align their effort with patients’ needs, it would not rectify the long-standing issue of underpayment to primary care clinicians. The proposal is essentially cost neutral for primary care practitioners compared with the current fee-for-service payment approach, and there is concern that as a result it will be unsuccessful in encouraging primary care clinicians to build and sustain the necessary capacity to provide population-based care.

Recent experience related to non–face-to-face billing codes such as those for chronic care management illustrates the problem. Primary care clinicians have had the opportunity to bill for chronic care management services since 2015, but many do not bill for services based on these codes because they perceive that the size of the investment they would need to make in their practice to do so is too great, given the current reimbursement rate structure in primary care.

CMS also discourages primary care by charging Medicare beneficiaries the same 20% co-payment for primary care that it charges for most other services. The ACA removed this co-payment for preventive care services, but Medicare has not applied this to primary care, even though it could result in overall health care cost savings.

The United States lags other industrialized nations not only in its lack of universal coverage but also in the extent of its investment in primary care as a fundamental component of its delivery system. Ensuring the availability of primary care for all could be accomplished through policies that create incentives such as loan forgiveness to encourage graduates of health professional training programs to become primary care clinicians, that diminish the large disparities in payment between primary care and specialist physicians, that eliminate financial barriers such as co-payments for the use of primary care services, and that provide resources and incentives for primary care clinicians to furnish population-based care. A commitment to universal health care coverage is fundamental to creating a just and equitable society, but it will not achieve its potential if it is not built on a foundation of primary care for all.

About the author: Andrew Bindman, MD, is professor of medicine and epidemiology & biostatistics based within the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco (UCSF). He is a former Director of the Agency for Healthcare Research and Quality and a member of the National Academy of Medicine. (Image: Ted Grudzinski/AMA)