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September 2, 2022

Strengthening Primary Care to Improve Health Outcomes in the US—Creating Oversight to Address Invisibility

Author Affiliations
  • 1Farley Health Policy Center, Department of Family Medicine, University of Colorado School of Medicine, Aurora
  • 2Department of Family Medicine, Oregon Health & Science University, Portland
  • 3The Center for Professionalism & Value in Health Care, American Board of Family Medicine Foundation, Washington, DC
JAMA Health Forum. 2022;3(9):e222903. doi:10.1001/jamahealthforum.2022.2903

In the US federal government, no single agency oversees primary care, collects consistent data about its clinicians and performance, or considers how it is integral to achieving the nation’s health goals. This gap creates a fundamental lack of understanding of what primary care is and what its capacities and capabilities are. The absence of a comprehensive perspective on primary care creates invisibility and confusion in federal policy.

The Invisibility of Primary Care

Primary care funding and policy making are spread across multiple federal agencies, and these efforts are rarely coordinated. Funding and technical assistance for innovative primary care models are provided through the Center for Medicare & Medicaid Innovation. Safety-net practices and related workforce issues are addressed by the Health Resources and Services Administration. The vast majority of funding for graduate medical education that produces the primary care workforce to care for patients, families, and communities across the US flows from the Centers for Medicare & Medicaid Services. This diffusion of leadership and responsibility for primary care persists without a clear federal role—and the necessary authority and resources—to coordinate and integrate policies designed to strengthen primary care and its ability to solve pressing health problems.

As a result, many senior governmental leaders may not understand the full spectrum and variety of primary care practices (eg, physician-owned, hospital- and health system−owned, solo and small practices, and those that serve rural communities) that are essential for the nation’s health.1 Government leaders also may not understand the reliance of the public on primary care for most health care services and the challenges these practices face in providing them. Currently, leaders tend to focus on federally qualified health centers (FQHCs). The FQHCs are critical to the health care safety net, caring for 1 in 11 people in the US,2 but the diversity of primary care practices across the country is one of the system’s strengths. We need federal leadership that fosters this diversity because it is vital to the health of our nation and to ensuring health equity. Presently, there is no government entity or infrastructure to support the wide range of primary care, including its strengths and needs. This gap results in an incomplete and unorganized understanding of primary care, how it functions, and who it serves. Without this full insight and oversight, federal investment in resources and accountability for outcomes are insufficient and inadequate.

This lack of leadership creates the potential for misunderstandings to emerge that can threaten the health and well-being of patients. For example, the incorrect idea has surfaced that primary care can be delivered exclusively via telehealth. This idea has been allowed to grow, owing in large part to the rapid expansion of telehealth during the pandemic. National health surveys suggest that people in the US make nearly 500 million visits to primary care every year. Telehealth services function best when connected to and supported by healing relationships. To put forth new primary care models, as many payers are doing, that engage people in telehealth divorced from underlying clinical relationships will not provide the comprehensive primary care that people need. Yet without clear leadership at the highest level, no federal agency is capable of articulating this concern and addressing it.

Forming a Secretary’s Council on Primary Care and an Advisory Committee

Potential solutions to these problems were identified in a May 2021 consensus report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” produced by the National Academies of Sciences, Engineering, and Medicine (NASEM).3 The prior NASEM report solely dedicated to primary care was published in 1996.4 The new report calls for the creation of a Secretary’s Council on Primary Care within the US Department of Health and Human Services (DHHS) that would be tasked with advancing “whole-person, integrated, accessible, and equitable primary care.” This Council would be composed of federal agency representatives and supported by a federally appointed advisory committee of key external stakeholders, including patients. The Council would be responsible for working across federal agencies within and beyond DHHS to integrate primary care policy related to payment, workforce, research, technology, metrics, innovation, and the social determinants of health. The Council would be a mechanism to ensure that the NASEM report recommendations were implemented across the country, including paying primary care teams to care for patients; training teams in communities where people live and work; designing information technology that benefits patients, families, and care teams; and ensuring that every individual is connected to high-quality primary care. The Council’s critical coordination and leadership would elevate understanding of primary care to the highest levels of DHHS, promoting cross-agency solutions that achieve broad health goals and priorities, such as improving health equity, expanding access to mental health services, ending the opioid epidemic, and addressing maternal morbidity and mortality. Primary care is integral to solving each of these challenges.

A Secretary’s Council on Primary Care could achieve more through leadership, coordination, and collaboration than would be possible for any single agency to accomplish alone. The Council would identify interagency functions and needs, connect and weave together related policies to tackle priorities, and provide a collaboration space for sustained focus and iteration. The advisory committee would create public-private partnerships to identify critical gaps and innovations and the solutions or support needed for scaling up. The DHHS has some strong primary care muscles, such as FQHCs, but it lacks connective tissue and a nervous system for doing the work of improving health. The Council would purposefully aim to work on the anatomy, and the advisory function would accelerate that, creating functional feedback loops.

The idea for this Council is not without precedent. The Interagency Workgroup establishing the Long-Term Recovery and Resilience Plan to help communities nationwide move ahead through COVID-19 engaged more than 25 federal agencies to align policy actions that “identify interdependencies, increase coordination, and remove barriers to foster long-term contributions toward community resilience.”5 This example provides a useful roadmap for a Secretary’s Council on Primary Care.

Gaining Momentum

In direct response to the NASEM report, the DHHS Assistant Secretary for Health, Admiral Rachel L. Levine, MD, announced the formation of the Initiative to Strengthen Primary Health Care, in September 2021.6 The Initiative is using the NASEM report as a playbook in working with DHHS partners to develop a plan for a Council to be delivered to Secretary Xavier Becerra this year. The National Academies and Office of the Assistant Secretary for Health cohosted a workshop series in March 2022 to bring internal and external stakeholders together to frame the aims of a Secretary’s Council and to emphasize its potential to address the nation’s health priorities.7 The Initiative recently released a formal Request for Information8 to gather more external input.

The NASEM report re-emphasized that primary care is the only sector of the health care system for which there is evidence for producing better population health outcomes, including longer lives.9 The report called for primary care to be a common good, available to anyone who wants it. The report also provided evidence that primary care is in crisis, losing workforce especially in underserved and rural areas and in the context of the COVID-19 pandemic. Several of the report’s 5 key objectives are getting traction, but formation of both a Secretary’s Council and an advisory committee are key for rebuilding this critical foundation of health and health care.

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Article Information

Accepted for Publication: July 13, 2022.

Published: September 2, 2022. doi:10.1001/jamahealthforum.2022.2903

Correction: This article was corrected on October 14, 2022, to add the subtitle that had been omitted.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Hughes LS et al. JAMA Health Forum.

Corresponding Author: Lauren S. Hughes, MD, MPH, MSc, Farley Health Policy Center, University of Colorado School of Medicine, Anschutz Health Sciences Bldg, 1890 N Revere Ct, Box L603, Aurora, CO 80045 (lauren.hughes@cuanschutz.edu).

Conflict of Interest Disclosures: Dr Phillips reported co-authorship of and fundraising for the National Academies of Sciences, Engineering, and Medicine report cited in this Viewpoint—there is no perceived or real suggestion that Dr Phillips would serve on the advisory committee nor would any related funds benefit Dr Phillips. No other disclosures were reported.

The Robert Graham Center. The State of Primary Care in the United States: A Chartbook of Facts and Statistics. Accessed May 1, 2022. https://www.graham-center.org/content/dam/rgc/documents/publications-reports/reports/PrimaryCareChartbook.pdf
Health Resources & Services Administration. Health Center Program: Impact and Growth. Reviewed August 2021. Accessed May 1, 2022. https://bphc.hrsa.gov/about/healthcenterprogram/index.html#:~:text=Health%20centers%20serve%201%20in,care%20costs%20for%20America's%20taxpayers
The National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Accessed May 1, 2022. https://www.nationalacademies.org/our-work/implementing-high-quality-primary-care
The National Academies of Sciences, Engineering, and Medicine. Primary Care: America’s Health in a New Era. 1996. Accessed August 5, 2022. https://www.ncbi.nlm.nih.gov/books/NBK232643/
Federal Long-Term Recovery and Resilience Plan Development. Mid-Course Update. Accessed May 1, 2022. https://thriving.us/federal-long-term-recovery-and-resilience-plan-development-mid-course-update/
McDevitt  S. Initiative to Strengthen Primary Health Care. Immediate Office of the Assistant Secretary for Health. March 2022. Accessed May 1, 2022. https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/graduate-medical-edu/meetings/20220324/mcdevitt-strengthen-primary-health-care.pdf
The National Academies of Sciences, Engineering, and Medicine. Strengthening Primary Health Care. Accessed May 1, 2022. https://www.nationalacademies.org/event/03-22-2022/strengthening-primary-health-care
US Department of Health and Human Services. Request for Information: HHS Initiative to Strengthen Primary Health Care. Accessed July 11, 2022. https://www.federalregister.gov/documents/2022/06/27/2022-13632/request-for-information-rfi-hhs-initiative-to-strengthen-primary-health-care
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