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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

Implementing High-Quality
Primary Care

Rebuilding the Foundation of Health Care

Linda McCauley, Robert L. Phillips, Jr., Marc Meisnere,
and Sarah K. Robinson, Editors

Committee on Implementing High-Quality Primary Care

Board on Health Care Services

Health and Medicine Division

A Consensus Study Report of

images

THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by contracts between the National Academy of Sciences and the Academic Pediatric Association, Agency for Healthcare Research and Quality, Alliance for Academic Internal Medicine, American Academy of Family Physicians, American Academy of Pediatrics, American Board of Pediatrics, American College of Physicians, American Geriatrics Society, Blue Shield of California, The Commonwealth Fund, Family Medicine for America’s Health, Health Resources and Services Administration, New York State Health Foundation, Patient-Centered Outcomes Research Institute, Samueli Foundation, Society of General Internal Medicine, and U.S. Department of Veterans Affairs. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-68510-8
International Standard Book Number-10: 0-309-68510-9
Digital Object Identifier: https://doi.org/10.17226/25983
Library of Congress Control Number: 2021937669

Additional copies of this publication are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2021 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2021. Implementing high-quality primary care: Rebuilding the foundation of health care. Washington, DC: The National Academies Press. https://doi.org/10.17226/25983.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. John L. Anderson is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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Image

Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

COMMITTEE ON IMPLEMENTING HIGH-QUALITY PRIMARY CARE

LINDA McCAULEY (Co-Chair), Dean and Professor, Neil Hodgson Woodruff School of Nursing, Emory University

ROBERT L. PHILLIPS, JR. (Co-Chair), Founding Executive Director, The Center for Professionalism & Value in Health Care, American Board of Family Medicine

ASAF BITTON, Executive Director, Ariadne Labs

TUMAINI RUCKER COKER, Associate Professor of Pediatrics, University of Washington School of Medicine

CARRIE COLLA, Professor, Geisel School of Medicine, Dartmouth College

MOLLY COOKE, Professor of Medicine, University of California, San Francisco

JENNIFER E. DeVOE, Sherrie & John W. Saultz MD Endowed Professor and Chair, Department of Family Medicine; Director, Center for Primary Care Research and Innovation, Oregon Health & Science University

REBECCA S. ETZ, Associate Professor, Family Medicine and Population Health, Virginia Commonwealth University

SUSAN FISHER-OWENS, Clinical Professor of Pediatrics, University of California, San Francisco, School of Medicine; Clinical Professor of Preventative and Restorative Dental Sciences, University of California, San Francisco, School of Dentistry

JACKSON GRIGGS, Chief Executive Officer, Heart of Texas Community Health Center, Inc.

SHAWNA HUDSON, Professor, Rutgers University

SHREYA KANGOVI, Associate Professor of Medicine, University of Pennsylvania

CHRISTOPHER F. KOLLER, President, Milbank Memorial Fund

ALEX H. KRIST, Professor, Family Medicine and Population Health, Virginia Commonwealth University

LUCI K. LEYKUM, Executive Associate Chair, Professor, Department of Internal Medicine, Dell Medical School, The University of Texas at Austin; Center Lead, The Elizabeth Dole Center of Excellence for Veteran and Caregiver Research, South Texas Veterans Health Care System

BENJAMIN OLMEDO, Physician Assistant, Family Medicine and Clinical Informatics, Dignity Health

BRENDA REISS-BRENNAN, Director, Mental Health Integration, Intermountain Healthcare

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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HECTOR P. RODRIGUEZ, Henry J. Kaiser Endowed Chair, Professor of Health Policy and Management, University of California, Berkeley

MARY ROTH McCLURG, Executive Vice Dean, Chief Academic Officer, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill

ROBERT J. WEYANT, Associate Dean for Dental Public Health and Community Outreach, School of Dental Medicine, University of Pittsburgh

Study Staff

MARC MEISNERE, Program Officer, Study Director

TRACY A. LUSTIG, Senior Program Officer

SARAH K. ROBINSON, Research Associate

SAMIRA ABBAS, Senior Program Assistant

MICAH WINOGRAD, Senior Finance Business Partner

SHARYL NASS, Senior Director, Board on Health Care Services

JENNIFER PUTHOTA, Christine Mirzayan Science & Technology Policy Graduate Fellow (until April 2020)

National Academy of Medicine Fellows

KAMERON MATTHEWS, U.S. Department of Veterans Affairs

LARS PETERSON, American Board of Family Medicine

DIMA M. QATO, University of Southern California School of Pharmacy

Consultants

JOE ALPER, Science Writer

ROBERT BERENSON, Institute Fellow, Urban Institute

RICHARD G. FRANK, Margaret T. Morris Professor of Health Economics, Department of Health Care Policy, Harvard Medical School

WILLIAM MILLER, Chair Emeritus, Department of Family Medicine, Lehigh Valley Health Network Professor of Family Medicine, Morsani College of Medicine, University of South Florida

KURT STANGE, Director, Center for Community Health Integration, School of Medicine, Case Western Reserve University

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

Reviewers

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

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Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations of this report nor did they see the final draft before its release. The review of this report was overseen by MARSHALL H. CHIN, The University of Chicago, and ANTONIA M. VILLARRUEL, University of Pennsylvania. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

Preface

The National Academies of Sciences, Engineering, and Medicine (the National Academies) has a long history of issuing independent reports that provide evidence and recommendations from national experts that address the directions the country should take to meet challenges that confront us. The Institute of Medicine (IOM) Study of the Future of Primary Care was launched in early 1994 with the intent to influence what was a maelstrom of health care reform at that time. In 1991, the Bush administration started a conversation about health reform that became a plank of Bill Clinton’s presidential campaign and a main focus of the Clinton administration’s political efforts. In addition to President Clinton’s proposal, more than 70 proposals from both sides of the aisle and beyond were considered before health reform foundered in 1994. Beyond the political failure to achieve consensus, considerable experimentation was happening in the marketplace that emphasized primary care. The preface to the IOM’s 1996 report Primary Care: America’s Health in a New Era speaks to the optimism and opportunity that the committee operated to influence:

After decades of relative neglect in a health care system that placed most of its emphasis on specialization, high technology, and acute care medicine, the value of primary care is again being recognized as part of the wave of reform that is sweeping the U.S. health care industry. There are numerous indications of the increasingly important role being played by primary care.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

By the time that report was released, political paths to health reform were closed and managed care was also in trouble. What had been fallow ground for primary care was politically salted, and the report’s recommendations remained largely unimplemented. It is hard to imagine how primary care, and health care generally, would be different had even some of the 1996 report’s recommendations taken root. More than a decade later, the Patient Protection and Affordable Care Act in 2010 aided primary care through expansion of federally qualified health centers, Medicaid expansion, and health information technology support, but most of the 1996 report’s recommendations were still not addressed. A 2012 IOM report on integrating primary care and public health also highlighted the lack of relationships between these important community-based agents of population health and opportunities to purposefully heal this schism. The recommendations of this report also went largely unheeded.

Thus, the charge to the current committee was not to relitigate the evidence underpinning these prior reports and recommendations, nor was it simply to produce new recommendations, as is common with most consensus studies of the National Academies. Instead, this consensus committee had the unusual and specific charge to develop an implementation plan for recommendations, using the 1996 report as a starting point.

This study launched in January 2020 and ran headlong into the novel coronavirus pandemic, which quickly highlighted a host of problems in primary care:

  • the perils of fee-for-service funding for supporting the health care platform where most people turn for heath advice and care;
  • the dangers of the long-standing schism between public health and primary care to communicating a consistent message to the public;
  • the lack of inclusion of primary care in national epidemic planning;
  • the lack of understanding or inclusion of primary care in congressional COVID-19 relief bills;
  • the bizarreness of not supporting telehealth prior to the pandemic; and
  • the profound effect that social determinants have on the probability that a person will live or die.

In addition to the lens that the coronavirus pandemic offered to the committee, it was obvious early in the deliberations that major societal factors were framing the importance of a robust system of primary care. Several themes emerged that were critically important in our discussions with clinicians, health system experts, community advocates, and patients themselves. One major difference today compared to 1996 is the emergence of health information technology. Another change is the increased

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

recognition that health care teams, which today are more inclusive of non-clinician team members, ought not to be bounded by clinical walls but should be able to reach into and partner with communities. Similarly, issues of unequal access, health equity, and social determinants of health were commonly used to describe the current challenges and opportunities before us. These themes all informed the committee’s recommendations on how we measure, value, and support primary care’s capacity to respond to these changes.

As co-chairs, we are indebted to the dedication and critical thinking of the committee members who shaped this report. The volunteer committee comprised of 20 members from a diversity of backgrounds but with a shared commitment to primary care as a common good. We are also indebted to the patients and patient advocacy groups that met with us and whose suggestions and experiences helped shape this report; we hope they see their voices in these pages.

The committee wishes to acknowledge the superb support it received from the National Academies staff. Study Director Marc Meisnere, Senior Program Officer Tracy Lustig, Research Associate Sarah Robinson, Senior Program Assistant Samira Abbas, and Sharyl Nass, Senior Director of the Board on Health Care Services, were essential to the work behind meeting our unusual charge and contributing to the management and writing of the report. The committee also appreciates the considerable help of three National Academy of Medicine fellows, Drs. Kameron Matthews, Lars Peterson, and Dima Qato.

We are sensitive to the fact that 1996 report recommendations and those of subsequent IOM reports dealing with primary care remain fallow. Primary care was reinvented in the United States in the late 1960s, embraced by the world at Alma Ata in 1978, reported on by the IOM in 1978, 1983, 1996, and 2012, and emphasized by most efforts at health reform in the United States. We believe that some of the challenges we address in this report are at the root of the major differences in population health in the United States compared to our global neighbors. The evidence is there, the public values are clear, and care teams want to change the way that they function today. All that is needed is meaningful action to begin the change. We hope that this report will provide clear guidance on the actions we need to take to provide to the public what is necessary to improve lives and promote health. If there is one key message that readers should take away from this report, it is that the committee firmly believes that primary care should be a common good, available to all and sufficiently valued and resourced to repair health equity in the United States.

Linda McCauley and Robert L. Phillips, Jr., Co-Chairs
Committee on Implementing High-Quality Primary Care

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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Acknowledgments

This Consensus Study Report would not have been possible without the invaluable contributions from many experts and stakeholders dedicated to primary care. The committee would like to thank all of the speakers and participants who played a role in the public meetings conducted for this study, as well as the many others who provided valued insight and responded to rapid requests for information to accommodate our short and demanding timeline, including the individuals who shared their personal stories from the patient perspective with the committee.

Many of these contributors, with their affiliations at the time of their presentations to the committee, are listed below:

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

The committee appreciates the sponsors of this study for their generous financial support: Academic Pediatric Association, Agency for Healthcare Research and Quality, Alliance for Academic Internal Medicine, American Academy of Family Physicians, American Academy of Pediatrics, American Board of Pediatrics, American College of Physicians, American Geriatrics Society, Blue Shield of California, The Commonwealth Fund, Family Medicine for America’s Health, Health Resources and Services Administration, New York State Health Foundation, Patient-Centered Outcomes Research Institute, Samueli Foundation, Society of General Internal Medicine, and U.S. Department of Veterans Affairs. The committee thanks Richard Frank for his invaluable consultation and the following individuals who provided commissioned papers: Robert Berenson, Adele Shartzer, and Roslyn Murray from the Urban Institute for their paper on primary care payment models; William Miller for his account on the history of primary care; and Kurt Stange for his paper on the effects and consequences of the COVID-19 pandemic on primary care.1 The committee gives special thanks to Joe Alper for his writing and editing contributions and Casey Weeks for his graphic design expertise.

Finally, deep appreciation goes to staff at the National Academies of Sciences, Engineering, and Medicine for their efforts and support in the report process, especially to Joe Goodman, Andrew Grafton, Megan Kearney, Sarah Kwon, Stephanie Miceli, Maryjo Oster, Devona Overton, Tina Seliber, Lauren Shern, Leslie Sim, Cyndi Trang, Dorothy Zolandz, and the staff of the National Academies Research Center, including Christopher Lao-Scott, Rebecca Morgan, Maya Thomas, and Colleen Willis.

___________________

1The commissioned papers can be found at https://www.nap.edu/catalog/25983.

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Acronyms and Abbreviations

AAFP American Academy of Family Physicians
AAMC Association of American Medical Colleges
AAP American Academy of Pediatrics
ACA Patient Protection and Affordable Care Act
ACO accountable care organization
AHRQ Agency for Healthcare Research and Quality
AIMS Ambulatory Integration of the Medical and Social
AMA American Medical Association
APRN advanced practice registered nurse
BPHC Bureau of Primary Health Care
CDC Centers for Disease Control and Prevention
CDPHP Capital District Physician Health Plan
CHGME Children’s Hospitals Graduate Medical Education
CHIP Children’s Health Insurance Program
CHIPRA Children’s Health Insurance Program Reauthorization Act of 2009
CHT community health team
CHW community health worker
CMMI Center for Medicare & Medicaid Innovation (CMS Innovation Center)
CMS Centers for Medicare & Medicaid Services
CNM certified nurse-midwife
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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CPC Comprehensive Primary Care
CPC+ Comprehensive Primary Care Plus
CTSA Clinical and Translational Science Awards
ED emergency department
EHR electronic health record
FFS fee-for-service
FQHC federally qualified health center
GAO U.S. Government Accountability Office
GIS geographic information system
GME graduate medical education
GNE graduate nurse education
GRACE Geriatric Resources for Assessment and Care of Elders
GRECC Geriatric Research, Education and Clinical Center
HCC hierarchical condition category
HHS U.S. Department of Health and Human Services
HIE health information exchange
HIPAA Health Insurance Portability and Accountability Act
HIT health information technology
HITECH Health Information Technology for Economic and Clinical Health
HPSA Health Professional Shortage Area
HRSA Health Resources and Services Administration
HSR health services research
IHS Indian Health Service
IMPaCT Individualized Management for Patient-Centereds Targets
InCK Integrated Care for Kids
IOM Institute of Medicine
IPEC Inter-professional Education Collaboration
LCSW licensed clinical social worker
LPN licensed practical nurse
MACRA Medicare Access and CHIP Reauthorization Act
MAPCP Multi-Payer Advanced Primary Care Practice
MCO managed care organization
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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MedPAC Medicare Payment Advisory Commission
MLP Medical–Legal Partnership
MU Meaningful Use
MUA Medically Underserved Area
NAMCS National Ambulatory Medical Care Survey
NCEPCR National Center for Excellence in Primary Care Research
NCQA National Committee for Quality Assurance
NHSC National Health Services Corps
NIH National Institutes of Health
NMHC nurse-managed health center
NP nurse practitioner
NQF National Quality Forum
OECD Organisation for Economic Co-operation and Development
ONC Office of the National Coordinator for Health Information Technology
PA physician assistant
PACE Program of All-Inclusive Care for the Elderly
PACT Patient-Aligned Care Team
PBRN practice-based research network
PCIP primary care incentive payment
PCMH patient-centered medical home
PCORI Patient-Centered Outcomes Research Institute
PCP primary care physician
PCPCH patient-centered primary care home
PCR primary care research
PFS physical fee schedule
PPS prospective payments system
PRO patient-reported outcome
RHC rural health clinic
RN registered nurse
ROI return on investment
RUC Relative Value Scale Update Committee
RVU relative value unit
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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SBHC school-based health center
SCF Southcentral Foundation
SDOH social determinants of health
SES socioeconomic status
SMART on FHR Substitutable Medical Applications and Reusable Technologies on Fast Health Interoperability Resources
THCGME Teaching Health Center Graduate Medical Education
VA U.S. Department of Veterans Affairs
WHO World Health Organization
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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High-quality primary care is the foundation of the health care system. It provides continuous, person-centered, relationship-based care that considers the needs and preferences of individuals, families, and communities. Without access to high-quality primary care, minor health problems can spiral into chronic disease, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, preventive care lags, and health care spending soars to unsustainable levels.

Unequal access to primary care remains a concern, and the COVID-19 pandemic amplified pervasive economic, mental health, and social health disparities that ubiquitous, high-quality primary care might have reduced. Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes. For this reason, primary care is a common good, which makes the strength and quality of the country's primary care services a public concern.

Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care puts forth an evidence-based plan with actionable objectives and recommendations for implementing high-quality primary care in the United States. The implementation plan of this report balances national needs for scalable solutions while allowing for adaptations to meet local needs.

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