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Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (2021)

Chapter: Appendix E: The Health of Primary Care: A U.S. Scorecard

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Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×

Appendix E

The Health of Primary Care: A U.S. Scorecard

The committee was given the task of creating an implementation plan in addition to the typical task of developing recommendations. An implementation plan needs a set of metrics to track how well it is going and whether its aims are achieved over time. To that end, the committee offers this scorecard of selected measures that would meet both purposes and could be managed by one or more of the sponsoring organizations, federal agencies, or other interested stakeholders. The scorecard covers most report recommendations as objectives and offers data sources and example data, where possible, for dimension-related measures for each objective.

Very few of the 1996 report recommendations, or those for most past Institute of Medicine reports about primary care, have ever been actualized. Tracking on these scorecard dimensions will help achieve the intentions of the report sponsors and stakeholders and the committee’s recommendations, strengthening the foundation of America’s health care system.

SCORECARD PRINCIPLES

The committee proposes suggested measures for this scorecard using the following principles:

  • The measures should be previously developed—as opposed to proposed new measures—and each should track the committee’s objectives, either directly or indirectly.
Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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 measures should be few, easily understood by the general public, and consistent over time.
  • Data for the measures must be collected regularly, comprehensively, and reliably for producing assessment at relevant scope or geography; preferably, data will be publicly available and non-proprietary.
  • Accountable unit—the measure should be available at the national and state levels, so as to engage advocates and policy makers.

These principles result in a small number of measures and do not address all the committee’s recommendations. Assessing the implementation status of a number of recommendations cannot currently be reliably accomplished. Additional research to accomplish this is a different task from monitoring: the work of developing and testing additional measures is not as important to implementation accountability as effectively deploying existing measures.

For each measure, the committee lists data sources and sample performance from those data sources. The committee does not propose a single data source for those measures where multiple are available. Despite the committee’s emphasis on team-based care and training throughout the report, robust data sources for non-physician team members and team-based care itself continue to pose a challenge. This reality is reflected in the proposed measures below.

The scorecard development process (see Action 5.3 in Chapter 12) should include selecting the appropriate data, prioritizing the frequency and reliability of source data. A comment section for each objective discusses the proposed measures, data sources, and where additional measures are needed.

The committee is not proposing targets for each measure. Establishing a baseline and documenting changes over time are critical to assessing implementation efforts.

Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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 HEALTH OF PRIMARY CARE: A PROPOSED U.S. SCORECARD

Objective 1: Pay for primary care teams to care for people, not doctors to deliver services.

Measure 1.1: Percentage of total spend going to primary care—commercial insurance
Potential data sources: Sample performance:
 
Medical Expenditure Panel Survey (MEPS) (AHRQ, 2021) MEPS data (2011–2016):
6.0 percent (narrow definition1 of primary care)
10.2 percent (broad definition2 of primary care)
State-level analysis also available (Jabbarpour et al., 2019)
 
Health Care Cost Institute (HCCI) (HCCI, 2020) HCCI data (2017):
4.35 percent (narrow definition)3
8.04 percent (broad definition)4 (Reiff et al., 2019)
 
Truven Health MarketScan (IBM, 2020) (proprietary) Truven Health MarketScan data (2018)
5.95 percent (The Commonwealth Fund, 2020b)
Measure 1.2: Percentage of total spend going to primary care—Medicare
Potential data sources: Sample performance:
 
MEPS (AHRQ, 2021) MEPS data (2011–2016):
4.4 percent (narrow definition)
6.9 percent (broad definition)
State-level analysis also available (Jabbarpour et al., 2019)
 
Medicare Master Beneficiary Summary File (MMBSF) (CMS, 2020c) MMBSF data (2015):
2.12 percent (narrow definition)5
4.88 percent (broad definition)6
(Reid et al., 2019)
 
Centers for Medicare & Medicaid Services (CMS) Limited Data Set (LDS) (CMS, 2020b) The Commonwealth Fund (2017)
5.66 percent (The Commonwealth Fund, 2020a)
Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×
Measure 1.3: Percentage of total spend going to primary care—Medicaid
Potential data source: Sample performance (2011–2016):
 
MEPS (AHRQ, 2021) 6.0 percent (narrow definition)
11.2 percent (broad definition)
State-level analysis also available (Jabbarpour et al., 2019)
Measure 1.4: Percentage of primary care patient care revenue from capitation
Potential data source: Sample performance:
 
National Ambulatory Medical Care Survey (NAMCS) (CDC, 2020a)
 
MEPS (AHRQ, 2021) MEPS (2013): 5.3 percent of office-based visits (Zuvekas and Cohen, 2016)

Comments:

Definitions are important when calculating the percentage of total health care spending directed to primary care; differences in the definitions used are listed below. The source data also differ, sometimes even within a source; for example, The Commonwealth Fund estimates for Medicare spending derive from the CMS LDS file, which is easier to access and analyze than the MMBSF. The LDS and the MMBSF estimates are not too dissimilar, but the difference may be related to nuanced definitional choices that are more readily assessed using the MMBSF. The percentage of total health spending in primary care for children is typically higher, as children have less chronic care and lower use of high-cost care settings. Medicaid data are important for this assessment of federal payments to primary care, but access to aggregate, national Medicaid data has been difficult until recently.

The scorecard measures related to paying for team-based care and moving away from fee-for-service, volume-based funding focuses on the current insufficiency of funding, points to sources of data about primary care investment across payer types, and also creates a tracking mechanism for capitated, or population-based, payment. The MEPS is a reliable source for longitudinally tracking primary care investment and claims data that are useful for looking at particular sectors, such as the investment made in caring for children (Medicaid) versus older persons (Medicare). The NAMCS also has relevant questions about practice financing and organization. While these data elements are captured by the MEPS and the NAMCS, they are

Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×

not typically reported by federal agencies and are currently dependent on outside researchers to produce them from the data.

Apart from the survey sources listed here, with the large number of private and public payers in the United States, no reliable comprehensive source yet exists for more detailed information for how primary care physicians are paid, a key recommendation of the committee.

1 Jabbarpour et al.’s narrow definition of primary care is restricted to physicians practicing family medicine, general practice, geriatrics, general internal medicine, and general pediatrics.

2 Jabbarpour et al.’s broad definition includes the narrow definition plus nurses and nurse practitioners, physician assistants, obstetrician-gynecologists, general psychiatrists, psychologists, and social workers.

3 Reiff et al.’s narrow definition includes evaluation and management visits, vaccinations, care planning, “and other related services” rendered by family practice, geriatric medicine, gynecology, internal medicine, or pediatric physicians; physician assistants; or nurse practitioners.

4 Reiff et al.’s broad definition includes all services rendered by those same primary care clinicians.

5 Reid et al.’s narrow definition involves services to Healthcare Common Procedure Coding System codes on professional claims, including evaluation and management visits, preventive visits, care transition or coordination services, and in-office preventive services, screening, and counseling rendered by physicians practicing family medicine, general practice, general internal medicine, and general pediatrics.

6 Reid et al.’s broad definition includes all services rendered in the narrow definition plus nurses and nurse practitioners, physician assistants, obstetrician-gynecologists, and geriatricians.

Objective 2: Ensure that high-quality primary care is available to every individual and family in every community.

Measure 2.1: Percentage of adults without a usual source of health care
Potential data source: Sample performance:
 
National Health Interview Survey (NHIS) (CDC, 2021) 14.6 percent (2018) (CDC, 2018)
Measure 2.2: Percentage of children without a usual source of health care
Potential data source: Sample performance:
 
NHIS (CDC, 2021) 4.3 percent (2018) (CDC, 2020b)
Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×
Measure 2.3: Primary care physicians per 100,000 people in medically underserved areas
Data sources: No known score
 
Health Resources and Services Administration (HRSA) area resource file (HRSA, 2019), HRSA Medically Underserved Area (MUA) shape files (HRSA, 2020a)
Measure 2.4: Primary care physicians per 100,000 people in areas that are not medically underserved
Data sources: No known score
 
HRSA area resource file (HRSA, 2019), HRSA MUA shape files (HRSA, 2020a)

Comments:

While reliably predictive, these measures do not fully address a key goal of this objective, which is to ensure access to high-quality primary care when needed.

Several efforts have been made to measure high-quality primary care, and this report offers several related recommendations. The committee offers a new definition for high-quality primary care, but there are no established measures to assess its availability.

Regarding need, as discussed in Chapter 3, some recent studies based on national health surveys suggest that visits to primary care have declined significantly in recent years, often associated with a rise in high-deductible health plans (Chou et al., 2019; Ganguli et al., 2019, 2020; Rao et al., 2019; Ray et al., 2020). This reduction is a source of concern if it is also associated with not receiving care when needed, avoiding preventive care, or seeking care in more expensive settings. Wait times for sick and new care-seeker visits could be another way to assess access; however, outside of the U.S. Department of Veterans Affairs, the committee is not aware of any measures that meet its criteria to be included in this scorecard.

Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×

Measures 2.3 and 2.4 require further analysis to determine performance; however, this could be done by overlaying HRSA’s MUA shape file over HRSA’s area resource file.

Objective 3: Train primary care teams where people live and work.

Measure 3.1: Percentage of physicians trained in community-based settings, rural areas, Critical Access Hospitals (CAHs), MUAs
Potential data sources: Sample performance:
 
Medicare Claims Public Use Files (CMS, 2020a) More than 3,400 physicians in residency training were identified as having spent time during residency in federally qualified health centers (FQHCs), rural health clinics (RHCs), or CAHs while training between 2001 and 2005, or 2009 using Medicare claims data and the AMA Physician Masterfile (Phillips et al., 2013). While this study did not do so, the AMA Physician Masterfile could be used to determine the total number of residents in a given year to calculate the percentage who trained in FQHCs, RHCs, or CAHs
American Medical Association (AMA) Physician Masterfile (AMA, 2021)
Measure 3.2: Percentage of physician (PAs) working in primary cares, nurses, and physician assistants
Potential data sources: Sample performance:
 
AMA Physician Masterfile (AMA, 2021) Physicians (2017): 31.9 percent (Petterson et al., 2018)
 
HRSA National Sample Survey of Registered Nurses (HRSA, 2020b) Nurses (2018): 14.5 percent of registered nurses, 28.8 percent of advanced practice registered nurses (HHS et al., 2020)
 
National Commission on Certification of Physician Assistants (NCCPA) Statistical Profile of Certified Physician Assistants (NCCPA, 2020b) PAs (2019): 25.0 percent (NCCPA, 2020a)
Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×
Measure 3.3: Percentage of new physician workforce entering primary care each year
Potential data source: Sample performance:
 
AMA Physician Masterfile (AMA, 2021) 25.2 percent (2006–2008) (Chen et al., 2013)
Measure 3.4: Residents per 100,000 population by state
Potential data source: Sample performance:
 
Medicare Provider Cost Report Public Use Files (CMS, 2019) New York (2010): 77.1 residents in training per 100,000 population North Dakota (2010): 11.5 per 100,000 (Mullan et al., 2013)

Comments:

The funding for physician training is closely tied to hospitals and not to community-based settings, where most primary care is delivered. No single measure captures training in community-based settings, but Measure 3.1 highlights data sources that could be used together to estimate the proportion of trainees who train in safety net settings. The committee is not aware of comparable data sources for other professions, highlighting the difficulty of measuring progress across the primary care workforce. Measure 3.3’s sample score includes hospitalists and is thus an overestimate. Measure 3.4 highlights the uneven distribution of physician trainees relative to the population. While not primary care specific, this is important because trainees are more likely to practice in locations where they trained.

Objective 4: Design information technology that serves the patient, family, and interprofessional care team.

The committee is not aware of adequate measures or data sources that capture the use or availability of person-centered digital health in primary care (or any health care) settings, underscoring the urgency for further research in this area.
Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×

Objective 5: Ensure that high-quality primary care is implemented in the United States.

Measure 5.1: Investment in primary care research by the National Institutes of Health (NIH) in dollars spent and percentage of total projects funded.
Potential data source: Sample performance:
 
NIH RePORT database (NIH, 2020) Family medicine received $71 million, 0.22 percent of total funding from NIH (2011–2014) (Cameron et al., 2016)
 
Seven hundred and fifty projects related to primary care, approximately 1 percent of the total, were funded by NIH (fiscal years 2012–2018) (Mendel et al., 2020)

Comments:

As the committee recommends in Chapter 12, using this scorecard will itself be a way to track progress of the implementation of this committee’s five objectives. However, Measure 5.1 above gets to the committee’s recommended research action. While this report has cited numerous examples of best practices and presented an evidence-based vision for implementing high-quality primary care, primary care research is woefully underfunded and underdeveloped. Enhancing the evidence base could propel the field, to the benefit of all Americans.

REFERENCES

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Cameron, B. J., A. W. Bazemore, and C. P. Morley. 2016. Lost in translation: NIH funding for family medicine research remains limited. Journal of the American Board of Family Practice 29(5):528–530.

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Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×

CDC. 2020b. National health interview survey: Interactive summary health statistics for children. https://www.cdc.gov/nchs/nhis/KIDS/www/index.htm (accessed November 23, 2020).

CDC. 2021. National health interview survey. https://www.cdc.gov/nchs/nhis/index.htm (accessed January 13, 2021).

Chen, C., S. Petterson, R. L. Phillips, Jr., F. Mullan, A. Bazemore, and S. D. O’Donnell. 2013. Towards graduate medical education (GME) accountability: Measuring the outcomes of GME institutions. Academic Medicine 88(9):1267–1280.

Chou, S.-C., A. K. Venkatesh, N. S. Trueger, and S. R. Pitts. 2019. Primary care office visits for acute care dropped sharply in 2002–15, while ED visits increased modestly. Health Affairs 38(2):268–275.

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CMS. 2020c. Master beneficiary summary file: Limited data set. https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/LimitedDataSets/MBSF-LDS (accessed Novermber 6, 2020).

Ganguli, I., T. H. Lee, and A. Mehrotra. 2019. Evidence and implications behind a national decline in primary care visits. Journal of General Internal Medicine 34(10):2260–2263.

Ganguli, I., Z. Shi, E. J. Orav, A. Rao, K. N. Ray, and A. Mehrotra. 2020. Declining use of primary care among commercially insured adults in the United States, 2008–2016. Annals of Internal Medicine 172(4):240–247.

HCCI (Health Care Cost Institute). 2020. Commercial data. https://healthcostinstitute.org/data (accessed November 6, 2020).

HHS (U.S. Department of Health and Human Services), HRSA (Health Resources and Services Administration), and NCHWA (National Center for Health Workforce Analysis). 2020. Characteristics of the U.S. nursing workforce with patient care responsibilities: Resources for epidemic and pandemic response. Rockville, MD: Health Resources and Services Administration.

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Jabbarpour, Y., A. Greiner, A. Jetty, M. Coffman, C. Jose, S. Petterson, K. Pivaral, R. Phillips, A. Bazemore, and A. Neumann Kane. 2019. Investing in primary care: A state-level analysis. Washington, DC: Patient-Centered Primary Care Collaborative.

Mendel, P., C. A. Gidengil, A. Tomoaia-Cotisel, S. Mann, A. J. Rose, K. J. Leuschner, N. S. Qureshi, V. Kareddy, J. L. Sousa, and D. Kim. 2020. Health services and primary care research study: Comprehensive report. Santa Monica, CA: RAND Corporation.

Mullan, F., C. Chen, and E. Steinmetz. 2013. The geography of graduate medical education: Imbalances signal need for new distribution policies. Health Affairs 32(11):1914–1921.

Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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.
×

NCCPA (National Commission on Certification of Physician Assistants). 2020a. 2019 statistical profile of certified physician assistants: An annual report of the National Commission on Certification of Physician Assistants. Johns Creek, GA: National Commission on Certification of Physician Assistants.

NCCPA. 2020b. NCCPA research. https://www.nccpa.net/research (accessed November 6, 2020).

NIH (National Institutes of Health). 2020. Research portfolio online reporting tools (report). https://report.nih.gov (accessed January 13, 2021).

Petterson, S., R. McNellis, K. Klink, D. Meyers, and A. Bazemore. 2018. The state of primary care in the United States: A chartbook of facts and statistics. Washington, DC: Robert Graham Center.

Phillips, R. L., Jr., S. Petterson, and A. Bazemore. 2013. Do residents who train in safety net settings return for practice? Academic Medicine 88(12):1934–1940.

Rao, A., Z. Shi, K. N. Ray, A. Mehrotra, and I. Ganguli. 2019. National trends in primary care visit use and practice capabilities, 2008–2015. Annals of Family Medicine 17(6):538–544.

Ray, K. N., Z. Shi, I. Ganguli, A. Rao, E. J. Orav, and A. Mehrotra. 2020. Trends in pediatric primary care visits among commercially insured U.S. children, 2008–2016. JAMA Pediatrics 174(4):350–357.

Reid, R., C. Damberg, and M. W. Friedberg. 2019. Primary care spending in the fee-for-service Medicare population. JAMA Internal Medicine 179(7):977–980.

Reiff, J., N. Brennan, and J. Fuglesten Biniek. 2019. Primary care spending in the commercially insured population. JAMA 322(22):2244–2245.

The Commonwealth Fund. 2020a. Primary care spending as share of total, age 65 and older. https://datacenter.commonwealthfund.org/topics/primary-care-spending-share-total-age-65-and-older (accessed January 13, 2021).

The Commonwealth Fund. 2020b. Primary care spending as share of total, ages 18–64. https://datacenter.commonwealthfund.org/topics/primary-care-spending-share-total-ages-18-64 (accessed January 13, 2021).

Zuvekas, S. H., and J. W. Cohen. 2016. Fee-for-service, while much maligned, remains the dominant payment method for physician visits. Health Affairs 35(3):411–414.

Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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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×
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Suggested Citation:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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:"Appendix E: The Health of Primary Care: A U.S. Scorecard." 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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Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care Get This Book
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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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