Revitalizing Primary Care, Part 1: Root Causes of Primary Care's Problems.

Abstract

This 2-part essay offers a discussion of the health of primary care in the United States. Part 1 argues that the root causes of primary care's problems are (1) the low percent of national health expenditures dedicated to primary care (primary care spending) and (2) overly large patient panels that clinicians without a team are unable to manage, leading to widespread burnout and poor patient access.Information used in this essay comes from my personal clinical and policy experience bolstered by summaries of evidence. The analysis leans heavily on my visits to dozens of practices and interviews with hundreds of clinicians, practice leaders, and practice staff.In 2016, the United States spent approximately 5.4% of total health expenditures on primary care, compared with an average among 22 Organization for Economic Co-operation and Development (OECD) countries of 7.8%. With average US primary care panel size around 2,000, it would take a clinician without an effective team 17 hours per day to provide good care to that panel. Low primary care spending and excessive panel sizes are related because most medical students avoid careers featuring underfunded practices with unsustainable work-life balance.Over the past 20 years, many initiatives-explored in Part 2 of this essay-have attempted to address these problems. Part 2 argues that to revitalize primary care, 2 fundamental changes are needed: (1) increased spending dedicated to primary care and (2) creating powerful teams that add capacity to care for large panels.