Primary Care Spending in the United States, 2002-2016 | Health Care Economics, Insurance, Payment | JAMA Internal Medicine | JAMA Network
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Figure.  Trends in Spending for Select Types of Medical Carea
Trends in Spending for Select Types of Medical Carea

NP indicates nurse practitioner.

aData from the Medical Expenditure Panel Survey, 2002-2016 (https://www.meps.ahrq.gov/mepsweb/).

Table.  Change in Medical Expenditures, 2002-2016a
Change in Medical Expenditures, 2002-2016a
1.
Koller  CF, Khullar  D.  Primary care spending rate—a lever for encouraging investment in primary care.   N Engl J Med. 2017;377(18):1709-1711. doi:10.1056/NEJMp1709538PubMedGoogle ScholarCrossref
2.
Koller  CF, Brennan  TA, Bailit  MH.  Rhode Island’s novel experiment to rebuild primary care from the insurance side.   Health Aff (Millwood). 2010;29(5):941-947. doi:10.1377/hlthaff.2010.0136PubMedGoogle ScholarCrossref
3.
Phillips  RL  Jr, Bazemore  AW.  Primary care and why it matters for US health system reform.   Health Aff (Millwood). 2010;29(5):806-810. doi:10.1377/hlthaff.2010.0020PubMedGoogle ScholarCrossref
4.
Oregon Health Authority. Primary care spending in Oregon: a report to the Oregon State Legislature. Published February 2017. Accessed April 14, 2020. https://www.oregon.gov/oha/HPA/ANALYTICS/PCSpendingDocs/2017-Oregon-Primary-Care-Spending-Report-Legislature.pdf
5.
Primary Care Collaborative. Primary care investment. Accessed April 2, 2019. https://www.pcpcc.org/primary-care-investment
6.
Basu  S, Berkowitz  SA, Phillips  RL, Bitton  A, Landon  BE, Phillips  RS.  Association of primary care physician supply with population mortality in the United States, 2005-2015.   JAMA Intern Med. 2019;179(4):506-514. doi:10.1001/jamainternmed.2018.7624PubMedGoogle ScholarCrossref
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    1 Comment for this article
    EXPAND ALL
    MEPS DATA
    Paul Nelson, MS, MD | Family Health Care, P.C. retired
    The MEPS DATA originate from an annual survey of @10,000 households that are relatively stable population from year to year. These households exclude military and institutionalized citizens. Their estimates of "total annual health care expenditures" for MEPS should be informed by the actual total health spending of $1,600 billion during 2002 and $3,300 billion during 2016.

    Missing in all of these related observations is a reliably identifiable and nationally sanctioned definition of Primary Healthcare. Any improvement of the capitalization for Primary Healthcare must be related to a decrease in each community's hospital utilization. In short,
    true healthcare reform must "begin" with collaborative strategies in every community to reduce the social dilemmas encountered by too many families that degrade their survival.

    Ultimately, true healthcare reform must also be augmented by a strategy to improve our nation's social cohesion. Maternal mortality, childhood maltreatment, pediatric obesity, adolescent suicide/homicide, substance abuse/mortality, homelessness, mass shootings, mid-life depression/disability, and senile dementia will not improve without it. Remember, annual longevity at birth has been stagnant since 2010.
    CONFLICT OF INTEREST: None Reported
    READ MORE
    Research Letter
    Health Care Policy and Law
    May 18, 2020

    Primary Care Spending in the United States, 2002-2016

    Author Affiliations
    • 1Santa Rosa Family Medicine Residency Program, Santa Rosa, California
    • 2American Board of Family Medicine, Lexington, Kentucky
    • 3Center for Professionalism and Value in Health Care, Washington, DC
    • 4Robert Graham Center, Washington, DC
    JAMA Intern Med. 2020;180(7):1019-1020. doi:10.1001/jamainternmed.2020.1360

    Insufficient investment in primary care is one reason that the US health care system continues to underperform relative to the health systems in other high-income countries.1 States and countries with greater access to primary care clinicians and more robust primary care services have better outcomes and lower costs.2,3 For this reason, Rhode Island and Oregon have mandated measurement and targeting of primary care expenditures, and other states are considering related legislation.2,4,5

    Despite consistent evidence of cost savings, variations in definitions of primary care make comparisons of spending difficult, both in the US and other countries. We used national US health care survey data to assess primary care expenditures relative to other sources of health care spending.

    Methods

    Using Medical Expenditure Panel Survey (MEPS) data from 2002 to 2016, we estimated total annual expenditure from an aggregate of 10 subcategories: inpatient, outpatient, office based, prescriptions, dental services, vision services, mental health, home health, emergency department, and other medical. We further divided outpatient and inpatient spending using clinician type and physician specialty. Primary care physicians were defined as physicians coded as practicing family medicine, general practice, geriatrics, general internal medicine, and general pediatrics. This study was exempt from institutional review board approval owing to use of publicly available, deidentified data. Data analysis used Stata, version 14.1 (StataCorp) and was performed from October 2018 through April 2019.

    Results

    Total annual health care expenditures in the US, based on MEPS data, increased from $810 billion in 2002 to $1617 billion in 2016 (Table). Inpatient expenses were the largest spending category; although these expenses increased, they became a smaller percentage of total expenses owing to more rapid increases in other categories, notably spending on prescriptions and subspecialist care. Prescription spending was the second largest category, increasing from 18.6% to 23.6% of total expenditures and accounting for 28.6% of the increased spending. Specialty care was the third largest category, accounting for 17.9% of the increase in spending.

    In contrast, primary care spending accounted for 6.5% of total expenditures in 2002 and 5.4% in 2016 (Table). As a proportion of total expenditures, primary care spending was similar throughout the study period (Figure). On average, office and outpatient visits to primary care physicians accounted for 6.6% of total health care expenditures from 2002 through 2016. Even when all nurse, nurse practitioner, and physician assistant expenditures were added to primary care spending—an overestimate given that a majority of this care is provided in specialty settings—there was no upward or downward trend (data not shown).

    Discussion

    Using MEPS data, we found that spending on inpatient services, specialty care, and prescriptions combined accounted for about two-thirds of the increase in total US health care expenditures from 2002 to 2016. In contrast, primary care accounted for 4.2% of the total increase in health care expenditures, while declining as a proportion of all expenditures. There are many reasons to increase investment in primary care, including its beneficial effects on quality of care, access to care, and mortality.6 Our results bring attention once again to the many opportunities in the US to increase spending on primary care.

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    Article Information

    Accepted for Publication: March 24, 2020.

    Corresponding Author: Andrew W. Bazemore, MD, MPH, American Board of Family Medicine, 1016 16th St NW, 7th Floor, Washington, DC 20036 (abazemore@theabfm.org).

    Published Online: May 18, 2020. doi:10.1001/jamainternmed.2020.1360

    Author Contributions: Drs Martin and Petterson and Mr Levin had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Study concept and design: Martin, Phillips, Petterson, Bazemore.

    Acquisition, analysis, or interpretation of data: Martin, Phillips, Levin, Bazemore.

    Drafting of the manuscript: Martin, Phillips, Petterson, Bazemore.

    Critical revision of the manuscript for important intellectual content: Martin, Phillips, Levin, Bazemore.

    Statistical analysis: Martin, Petterson, Levin.

    Obtained funding: Phillips.

    Administrative, technical, or material support: Phillips, Levin.

    Study supervision: Petterson, Bazemore.

    Conflict of Interest Disclosures: None reported.

    References
    1.
    Koller  CF, Khullar  D.  Primary care spending rate—a lever for encouraging investment in primary care.   N Engl J Med. 2017;377(18):1709-1711. doi:10.1056/NEJMp1709538PubMedGoogle ScholarCrossref
    2.
    Koller  CF, Brennan  TA, Bailit  MH.  Rhode Island’s novel experiment to rebuild primary care from the insurance side.   Health Aff (Millwood). 2010;29(5):941-947. doi:10.1377/hlthaff.2010.0136PubMedGoogle ScholarCrossref
    3.
    Phillips  RL  Jr, Bazemore  AW.  Primary care and why it matters for US health system reform.   Health Aff (Millwood). 2010;29(5):806-810. doi:10.1377/hlthaff.2010.0020PubMedGoogle ScholarCrossref
    4.
    Oregon Health Authority. Primary care spending in Oregon: a report to the Oregon State Legislature. Published February 2017. Accessed April 14, 2020. https://www.oregon.gov/oha/HPA/ANALYTICS/PCSpendingDocs/2017-Oregon-Primary-Care-Spending-Report-Legislature.pdf
    5.
    Primary Care Collaborative. Primary care investment. Accessed April 2, 2019. https://www.pcpcc.org/primary-care-investment
    6.
    Basu  S, Berkowitz  SA, Phillips  RL, Bitton  A, Landon  BE, Phillips  RS.  Association of primary care physician supply with population mortality in the United States, 2005-2015.   JAMA Intern Med. 2019;179(4):506-514. doi:10.1001/jamainternmed.2018.7624PubMedGoogle ScholarCrossref
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