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Defining High-Quality Primary Care Today
The report Primary Care: America’s Health in a New Era (IOM, 1996) presented the following definition of primary care:
Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.
This definition advanced several important ideas about primary care that are still relevant today. First, and perhaps most significant to the current committee, is the idea that the relationship (referred to as a “sustained partnership” in the definition) is foundational to primary care. While the definition describes a relationship between patients and clinicians, this committee’s view is that this foundational relationship is sustained through interactions between patients, their families, and any member (or members) of the primary care team (IOM, 1996). While the primary care team will change over time, primary care relationships are important throughout a person’s life, beginning at childhood and into adolescence, adulthood, and old age. Second, primary care is not provided in a vacuum but rather occurs within the context of the patient’s family and community. Third, primary care is best delivered in an integrated and accessible system. While these ideas were widely embraced as ideal (Halfon and Hochstein, 2002; IOM, 2012; Starfield et al., 2005), progress has been markedly limited in making them a reality for most primary care practices (Frey, 2018; Larson et al., 2005; Levene et al., 2018). Other notions, such as comprehensively
addressing a large majority of a person’s health care needs, were not new at the time, but nonetheless highlighted an important core function of primary care that continues today.
AN UPDATED DEFINITION OF PRIMARY CARE
While the committee agreed that the essence of the 1996 Institute of Medicine (IOM) definition was still highly relevant, it felt that the definition did not fully capture certain important shifts in primary care since 1996. Specifically, the committee felt an accurate, contemporary definition should
- shift the emphasis from the provision of health care services to integrated, whole-person health;
- emphasize the foundational sustained relationships at the core of high-quality primary care;
- recognize the importance of communities and their critical roles in the provision of primary care;
- highlight the need for primary care to be equitable;
- recognize the interprofessional care teams that deliver primary care; and
- acknowledge the diversity of settings (and modalities used) in which primary care occurs.
Recognizing these six key shifts,1 this committee offers an updated definition of high-quality primary care, largely based on the 1996 IOM definition but with several meaningful changes that, in its view, more accurately reflects what high-quality means today:
High-quality primary care is the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.
Like the 1996 definition, this updated definition is in many ways aspirational—that is, it describes what high-quality primary care should be. In reality, what most people have access to in the United States today does not fully realize the vision presented in this definition. Additionally, it presents an ideal that will require additional financial investment in many settings (see Chapter 9 for more on paying for primary care). This definition
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1 These topics are discussed in greater detail later in the chapter.
articulates the committee’s vision and represents what this report’s recommendations and implementation strategy broadly seek to achieve.
Figure 2-1 visualizes what high-quality primary care can look like for a family in the United States, showing how it is based on strong relationships between the interprofessional primary care team and the individual,
family, and community and is delivered in a variety of settings. The person receiving care is in orange, physicians are in white, other team members are in blue, and family members are in olive. The top third of the illustration encompasses the many ways in which primary care can mesh with the community, while the bottom third represents connections that primary care should have with secondary and tertiary care. The figure also illustrates the unique roles of different members of the interprofessional primary care team in each of these settings.
If this definition is realized, primary care will better deliver both societal and individual benefits. In that sense, it is like public education—a common good to be assured, not a personal service to be delivered. Primary care’s documented salutary effects for population outcomes and equity (and
contribution to inequity when missing or inadequate) within the United States, and the considerable evidence of its contribution to relative improvement in health outcomes in other developed countries, support this goal of making it a public benefit rather than a health service (Basu et al., 2019; Franks and Fiscella, 1998; Gong et al., 2019; Hansen et al., 2015; Starfield, 2009, 2012; Starfield et al., 2005; WHO and UNICEF, 2018). Doing so creates a public interest in high-quality, accessible primary care and the collective benefit it delivers, both of which are demonstrably greater than exists for other health care and clinical services. Given the challenges facing primary care cited throughout this report, this benefit undergirds the sense of urgency that this committee wishes to convey. (See Box 2-1 for more on primary care as a public good.)
Embracing Integrated, Whole-Person Health
The current U.S. health care system focuses on delivering specific, reimbursable services centered around a disease process; this has resulted in increased health care spending, widening disparities, and inequitable health outcomes (Shi, 2012; Stange, 2009). While treating, diagnosing, and managing acute and chronic conditions are core functions of primary care, providing whole-person care requires a comprehensive person-centered, integrated approach based on relationships that account for mental, physical, emotional, and spiritual health and the social determinants of health in the context of community experiences (Ellner and Phillips, 2017; Feuerstein et al., 2016; Ring and Mahadevan, 2017; Sia et al., 2004). The whole-person approach considers health to be about the well-being of the person, not just the absence of disease (Thomas et al., 2018).
Integrated primary care facilitates care across different professionals, facilities, and support systems and is continuous over time and tailored to individual and family needs, values, and preferences (Singer et al., 2011). This care facilitation should occur within the immediate primary care team and with groups and services outside of that team, including community-based services and the health system overall, as seamlessly as possible. This supports whole health, ensuring that physical health, behavioral health, social needs, and oral health are comprehensively addressed (Ellner and Phillips, 2017) (see Chapter 5 for more on integrated delivery).
The Importance of Sustained, Foundational Relationships
While the 1996 definition does refer to “sustained partnerships,” this committee felt it was important to frame this partnership as a relationship and to emphasize that these relationships are not just between patients and clinicians but between individuals, families, and the interprofessional care team more broadly who work together in achieving personal health care needs and whole-person health.
Fundamentally, primary care supports the health of a person in the context of their life and community. Care should be contextualized to each person’s situation and evolve as needs change over time. To meet a person’s needs most effectively, clinicians, the individual, and other partners (including family members, informal caregivers, and extended interprofessional team members) need to come to shared understandings of the context of the individual’s life. This activity is inherently a relational one, requiring trust and respect between the individual and their care team and others involved in their lives and their communities. A relationship implies that individuals and their families seeking primary care have identified one or more clinicians in the practice who accepts accountability for their care,
health, and wellness and whom they trust and prefer to see. Thus, delivering primary care is a social and local activity in which relationships and interdependencies need to be carefully cultivated and supported (Buckley et al., 2013; Colwill et al., 2016; Ellner and Phillips, 2017; Flieger, 2017; Frey, 2010; Gottlieb, 2013; Green and Puffer, 2016; Kravitz and Feldman, 2017).
The evidence for the important role of relationships, often captured as continuity of care and self-reported outcomes, is some of the strongest for primary care’s beneficial effect (see Chapter 8 for more on primary care measures). Building this relationship and trust to make primary care centered on people, their families, and communities includes ensuring that primary care is accessible, convenient, and desirable, which requires flexibility and variation in the way in which care occurs across and within communities.
Primary care means different things across different age groups, settings, and health statuses. For example, to a healthy 25-year-old, it may be an occasional sick visit at a retail clinic with a nurse practitioner. This type of care is symptom specific and may include very little interaction or relationship building but may be adequate for that person at that moment in their life. An individual with multiple chronic comorbidities or a disability, however, may depend more on a primary care team to coordinate care across multiple specialists and locations, and, more importantly, to help define priorities and health goals that will guide choices across the set of subspecialty services. Similarly, a mother with a healthy infant may depend on her primary care team to help her navigate preventive care and developmental needs and address the family’s social needs that may impact her infant’s health and well-being. For these individuals and all others, regardless of need or complexity, a strong relationship with a care team will help ensure that personal values and needs are honored and met. See Chapter 4 for more on primary care relationships.
The Role of the Community
For decades now, community involvement in delivering primary care has been recognized as critical to help achieve whole-person health goals. Focusing on the community was one of the features of the Declaration of Alma-Ata in 19782 (International Conference on Primary Health Care, 1978), and adding community-oriented primary care to the new conceptualization
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2 The Declaration of Alma-Ata was adopted at the International Conference on Primary Health Care in what was then known as Alma-Ata in the Soviet Socialist Republic (today, it is known as Almaty, Kazakhstan). The conference and declaration called for national and international action to strengthen primary health care throughout the world (International Conference on Primary Health Care, 1978).
addresses the individual’s and family’s culture and social context as they are embedded within a medical and social neighborhood, rather than from a solely delivery-centric model (Braddock et al., 2013; Buchmueller and Carpenter, 2010; Chokshi and Cohen, 2018; Davis et al., 2005; DeVoe et al., 2009; Driscoll et al., 2013; Edgoose and Edgoose, 2017; Enard and Ganelin, 2013; Etz, 2016; Finkelstein et al., 2020; IOM, 1983; Kramer et al., 2018; Landon et al., 2012; McNall et al., 2010; Possemato et al., 2018; Starfield, 2011; Yoon et al., 2018).
In community-oriented care, families and other informal caregivers are integrated with formal care to better support older adults (Miller and Weissert, 2000) or keep children and adults with special needs healthy. Increasing access to community- and school-based health centers and telephone visits would pull the gravitational center of health care toward the individual being treated. Community health workers (CHWs) can also play a particularly important role in this regard. In addition, community-oriented primary care facilitates coordination between public health approaches and primary care delivery, opening the door for primary care to play a central role in improving the health of the community (Eng et al., 1992), particularly those with disadvantaged populations (Cyril et al., 2015; Derose et al., 2019; Shukor et al., 2018). See Chapter 4 for more on the role of the community in primary care.
Primary Care’s Role in Improving Health Equity
Health inequity costs the U.S. health care system billions of dollars per year (LaVeist et al., 2011), and the COVID-19 pandemic has exposed how that system does not serve all Americans equally (Tai et al., 2020; Webb Hooper et al., 2020). Since 1996, there has been increased focus on the critical role that primary care can play in improving equity (Shi, 2012; Starfield, 2009, 2012; Starfield et al., 2005) and in reducing, and ultimately eliminating, disparities in health and its determinants, including social determinants. Health equity involves striving for whole-person care that meets the highest possible standard of health that is available to everyone, which speaks to equal access, but should also aim to improve health outcomes specifically for disadvantaged populations, reduce disparities in clinical care, and address the social determinants of health (Braveman, 2014). Using interprofessional primary care teams that reflect the communities they serve, within an integrated system that supports building and developing relationships with individuals, families, and communities, is integral to achieving health equity.
According to a 2017 report by the Robert Wood Johnson Foundation, achieving health equity “requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness
and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care” (Braveman et al., 2017, p. 2). While primary care alone cannot remove all of these obstacles, this report will examine the role primary care can play in making health care more equitable. Much like the World Health Organization Declaration of Alma-Ata stating that health is not merely the absence of disease but complete physical, mental, and social well-being, health equity is about not merely equal access to care or addressing inequalities but rather justice and fairness in attaining equal opportunities to achieve complete physical, mental, and social well-being (International Conference on Primary Health Care, 1978).
The Role of Interprofessional Teams in Primary Care
An optimal team to deliver high-quality primary care includes a variety of clinical and nonclinical team members who can effectively and efficiently deliver whole-person care that meets the needs of the community or population they serve. This team may look different across settings, communities, and populations and should ideally reflect the diversity of its community. Interprofessional team-based delivery, however, does not abdicate individual accountability, especially for the primary care clinician (or clinicians) on the team—individual team members are responsible for their assigned roles and responsibilities. In many instances, non-clinician team members, such as health coaches and CHWs, can fill a critical role as the main point of contact for primary care and even may be the most effective keepers of the relationship between the individual and the care team, even if they are not accountable for delivering the actual care (Bodenheimer, 2019; Bodenheimer and Smith, 2013; Brownstein et al., 2011; Grumbach et al., 2012; Kangovi et al., 2018; Margolius et al., 2012) (see Chapter 6 for more information about primary care teams).
Furthermore, interprofessional care teams should ideally be highly engaged in promoting population health in the communities in which they are practicing and addressing community needs that impact health. The COVID-19 pandemic has demonstrated that primary care and public health cannot exist in silos and that the primary care and public health workforces need to work together in improving population health (IOM, 2012) and to be accountable for the health of the populations they serve.3 See Chapter 6 for more on interprofessional primary care teams.
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3 This committee adopts the definition of population health as the health outcomes of a group of individuals, including the distribution of those outcomes, from Kindig and Stoddart (2003). Groups are most often determined by geography but may also be employees of the same organization, share an ethnic group, or be cared for within a system (e.g., veterans who seek care through the U.S. Department of Veterans Affairs).
The Wide Variety of Settings and Modalities Providing Primary Care
Compared to 1996, people today obtain primary care in a variety of ways—beyond traditional face-to-face visits in clinician offices—that did not exist at all or were very limited in their application 25 years ago, including retail clinics, virtual encounters via telehealth, community settings, such as schools and workplaces, direct messaging via patient portals and smartphone applications, and other modalities that were inconceivable in 1996. In some settings, primary care is provided through integration into specialty practices (Sandberg et al., 2016). In many ways, an individual chooses a setting to receive primary care based on their health needs at that point in their life. For example, as discussed in Chapter 3, young adults, who are less likely to have complex health needs, are more likely to use retail clinics than older adults. Older adults in nursing homes or assisted living facilities may receive most of their primary care in those settings.
In communities with few physical health care facilities or local clinicians, virtual visits may be the optimal way to make care accessible to those who do not require a face-to-face consultation to receive the majority of their care, via telehealth visits with a clinician, communication on mobile applications or patient portals, or asynchronous consultation with a care team that is not physically present. Ideally, these technologies are used to strengthen, not replace, the relationship between people and the interprofessional care team (Weiner and Biondich, 2006). The COVID-19 pandemic rapidly expanded information technology–enabled care, and both patients and clinicians hope that it will remain a routine option (Bashshur et al., 2020; Hollander and Carr, 2020). Using technology, however, requires ensuring that people have equal access to it. For those that do not or cannot obtain access, or for the many who do require face-to-face consultation, alternate access points need to be made available.
FACILITATORS OF HIGH-QUALITY PRIMARY CARE
The committee identified seven facilitators that can help develop and sustain the updated definition of high-quality primary care and support primary care teams in achieving the vision of accessible high-quality primary care for all. The first five (payment models, accountability and improving quality, digital health care, interprofessional care teams, and research) have dedicated chapters in this report. The others (leadership and policy, laws, and regulations) are considered throughout the chapters that follow. See Box 2-2 for a summary of all the facilitators.
Payment Models
Payment for primary care is currently insufficient relative to the value and amount of care provided. As discussed in Chapter 1, the sector that provides more than one-third of all care, and that can help govern downstream health care costs, receives about 5 percent of total spending (Jabbarpour et al., 2019; Johansen et al., 2016; Martin et al., 2020; Reid et al., 2019). To ensure the United States can implement the committee’s vision, payment models for primary care need to be able to support it. Currently, most primary care (and health care in general) relies on a fee-for-service (FFS) model, which pays clinicians for billable services provided, regardless of the quality of those services or their outcomes. This payment model does not support flexible, interprofessional team-based care that uses a variety of health care professionals to build and maintain lasting meaningful relationships with patients. It also often does not cover less traditional delivery modalities (e.g., telehealth or patient portal communications) that can improve access to care, facilitate relationship building, and make care delivery and workflow more efficient.
In response to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services (CMS) relaxed some payment rules to make most telehealth visits reimbursable at the same rate as in-person visits (CMS, 2020a), and several states’ Medicaid programs and many private insurers did the same (Bodenheimer and Laing, 2020). However, these changes were slow, incomplete, and only some have been made permanent. COVID-19 also showed that FFS payment does not facilitate rapid and flexible changes in delivering primary care to meet communities’ needs and cannot sustain primary care when a crisis significantly reduces visit volume (Scott, 2020; Slavitt and Mostashari, 2020). In addition, current common payment models may not cover care provided by some team members at all (e.g., CHWs or health coaches) (Basu et al., 2016, 2017; Hudak et al., 2017; Kangovi, 2020; Katkin et al., 2017; Smith et al., 2018).4
However, even in a capitated payment model, high-quality primary care remains elusive when payment inadequately covers the expenses necessary to support integrated, team-based care. Current capitated arrangements cannot sustain primary care when individuals and families have medical and social complexity that requires more care services and a wider interprofessional team (Hudak et al., 2017). Health care practices and systems will need financial support to transition toward a more integrated, team-based primary care delivery model (primary care payment is discussed further in Chapter 9).
Accountability and Improving Quality
Since the 1996 IOM report, there has been a movement toward improved health care quality and measurement to hold the health care system accountable to its stated goals (IOM, 2001). The delivery of primary care is distinctly different from specialized care and ideally occurs in integrated settings that are adaptable to the unique needs of individuals and communities. Therefore, many of the quality measures used in other sectors of health care are not directly transferable (Chen et al., 2012; Johnston et al., 2015; Kronenberg et al., 2017). Furthermore, it is critically necessary to be thoughtful about the measures that will identify accountability within primary care and facilitate improvement in settings of care where primary care teams and delivery modalities will differ from each other. Currently, primary care is measured mostly by its parts, relying on hundreds of disease
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4 The Center for Medicare & Medicaid Innovation does allow states to file plans to reimburse for services delivered by CHWs (https://www.cdc.gov/dhdsp/programs/spha/docs/1305_ta_guide_chws.pdf [accessed October 8, 2020]). In addition, the American Medical Association approved new billing codes for health coaches that went into effect in 2020 (https://blog.gethealthie.com/2019/12/11/guide-to-new-health-coach-cpt-codes [accessed February 19, 2021]).
and process measures that present an incomplete assessment of quality and drive care away from patient values, relationships, and effective management of health (Mutter et al., 2018; Shuemaker et al., 2020). As discussed in Chapter 8, better measures of the high-value functions of primary care could better align the intrinsic and extrinsic motivations to improve care, improve population health, and reduce burnout (Etz et al., 2017, 2019; Phillips et al., 2019; Stange et al., 2014).
Digital Health Care
Today, digital technologies touch every aspect of care. In fact, no other aspect of patient care delivery has changed as dramatically since the 1996 IOM report. Digital health care applications and technologies can be used to facilitate the relationship building between the care team and the individual and improve access while sustaining those relationships (Meskó et al., 2017). However, while digital tools, such as patient portals and telehealth, can improve access to care for some (IQVIA Institute, 2017), patient populations have differing levels of access, capacity, and familiarity with them (Estacio et al., 2019), and clinicians need to be flexible and able to use the tools that their patients have access to and can use. Within the care team, digital health tools should enable team members to seamlessly communicate with each other, share patient data, effectively monitor patient populations, and do their jobs more efficiently without contributing to professional burnout.
Digital health data can provide valuable metrics on care delivery and patient outcomes, and digital health technologies have promise for use in changing and shaping health behaviors, helping with patient- and family-level prevention and care management, and incorporating health-related data across sectors outside of health, such as education and community (Nittas et al., 2019; Vassiliou et al., 2020). Ultimately, the information in these data systems needs to be interoperable and accessible to improve care delivery to individuals and communities. Ideally, the transfer of information across systems should be seamless, to enable efficient coordination and reduce administrative burden associated with manual entry of patient data (NASEM, 2019).
Digital health care tools also expand the scope of primary care and may shift diagnostic and therapeutic capacity from subspecialty care back to the primary care setting (Damhorst et al., 2019; Howick et al., 2014; Young and Nesbitt, 2017). Point-of-care ultrasound, for example, has been able to replace X-rays and magnetic resonance imaging in some applications and may enhance the quality of some procedures. Given the rapid and transformative technological and digital changes in health care in the past
two decades, the committee considered the importance of digital advances throughout this report and discusses it in detail in Chapter 7.
Interprofessional Teams
Compared to 1996, primary care today is more of an interprofessional team effort. The breadth of skills that a well-functioning team of diverse clinical and non-clinical professions offers can more comprehensively support the whole-person health goals of primary care than any individual clinician is capable of doing.
Primary care teams today need preparation to function in integrated systems with multiple types of health care workers and others in the community supporting the goals of primary care. Challenges include determining the size of the workforce that is needed; the types of team members needed in different communities; the necessary competencies of team members to function in an integrated, interprofessional manner; the funding and payment needed to ensure an adequate workforce and team composition; and the ways that the workforce can integrate and coordinate care with public health. Most recent evidence suggests that the primary care workforce is eroding generally, but this particularly true in rural areas (Basu et al., 2019) (see Chapter 6 for more on primary care team members).
Research
A better understanding of best practices in the delivery of primary care will also lead to further improvement, new discoveries, and cutting-edge innovation. While research is commonly conducted within primary care settings, it is primarily focused on a disease or condition and seldom designed to examine the science of effective models of providing or organizing primary care itself. The Agency for Healthcare Research and Quality is home to the National Center for Excellence in Primary Care Research, but the center has never had regular funding and currently has none (NIH and NIRSQ, 2020). The National Institutes of Health funds research that occurs in primary care, but it is routinely less than 0.4 percent of its budget (Cameron et al., 2016; Lucan et al., 2008). About 30 percent of the most recent funding from the Patient-Centered Outcomes Research Institute (PCORI) was directed to primary care research (PCR), most of it limited to comparative effectiveness research (Balster et al., 2019). While PCORI has become the mainstay for PCR funding and also funds essential infrastructure, it alone does not sufficiently meet the needs for PCR. Furthermore, this organization could change its focus and move away from primary care topics and/or fail to be reauthorized by Congress and disappear completely.
Primary care is one of the largest sectors of care yet remains unexplored territory for the origins and prevalence of disease, treatment outcomes, and care improvement. A dedicated home for research funding, sustained funding for PCR infrastructure, and funding mechanisms to study how to improve the care delivery are all needed to help inform, guide, and improve primary care learning health systems. Research is needed to improve the quality, experience, and cost of primary care and the experience of the primary care team. Research testing novel approaches, comparing various approaches, and studying the implementation of primary care would all be equally important. Research using primary care–specific metrics could also lead to creating a primary care learning health system.
Leadership
Primary care lacks a focal voice for its own advocacy, which may be the most important reason why the IOM’s 1996 recommendations were not implemented. It lacks organization at local, state, and national levels. Despite several primary care professional societies, each of which is very active in professional and patient advocacy, there is no conjoint mechanism for them to come together on common issues of great import. The very interprofessional nature of primary care demands that the focal voice be able to speak across disciplinary boundaries. Within government, leadership is needed to better coordinate the many primary care activities across agencies. For this report to succeed in launching an effective implementation plan, and with that, increased accountability of primary care for implementing changes, more coordination of primary care’s voice across organizations, disciplines, and government is required. Regardless, primary care will face increased accountabilities without sufficient resources. For example, it spends more time reporting quality measures than any other health care sector (Casalino et al., 2016) and is increasingly held responsible for point-of-care collection of social determinants and management of related issues without sufficient preparation or support (DeVoe et al., 2016; Solberg, 2016). Addressing the powerful combined forces of systemic discrimination and structural racism in education, housing, finance, social services, and the health care system is also likely to fall first to primary care, as it is where most people interact with health care. Collaboration across primary care professional associations will require leaders to embrace the generalist model of high-quality primary care put forth in this report.
Policy, Laws, and Regulations
A patchwork of federal and state policy, laws, and regulations directly and indirectly influence the scope, quality, availability, and accessibility of
health care, including primary care. Law helps determine how primary care is delivered, who is able to deliver it, whether care will be accessible, where and how it is paid for, and the types of technology that can be used in its delivery. Additionally, law can have a large impact on innovation—both as a mechanism that can enable positive change as well as a means of limiting progress. As noted by Shin and colleagues (2010, p. 1):
Law, as embodied in federal or state statutes, regulations, executive orders, administrative agency decisions, and court decisions, plays a profound role in shaping life circumstances, particularly as it relates to access, financing, and quality of individual health care.
The Patient Protection and Affordable Care Act (ACA)5 in 2010 offers an example of how changes in federal law can facilitate improved access to health care generally (e.g., by making health insurance more affordable for millions of previously uninsured Americans) and primary care specifically (e.g., by financing the expansion of the Health Resources and Services Administration–funded health center program).
On the other hand, many current federal and state policies, laws, and regulations may deter or actually serve to undermine the growth of high-quality primary care and prevent primary care from attaining the common good status it deserves. For example, federal Medicare law6 grants the U.S. Department of Health and Human Services (HHS) Secretary broad powers to determine Medicare payment rates and adjust the program’s physician fee schedule to reflect payment for specific types of care. The Medicare fee schedule plays a role far beyond Medicare itself, since it is used as a payment benchmark by private insurers and employer health plans and thus largely determines the range of primary care procedures that will be compensated along with their payment levels, as well as the classes of health professionals who are qualified to directly bill the program and receive payment in their own right (Clemens et al., 2015). As discussed in Chapter 9, the fee schedule is a key driver of the undervaluation of primary care services and activities and this effectively is built into both broader financing schemes such as the capitation payments made by insurers and employer plans to large-scale integrated delivery systems in their networks or the fees insurers and plans pay to individual participating physicians (Trish et al., 2017). Several states, however, have passed laws to help correct this imbalance by requiring private insurers to increase the share of spending that goes to primary care (Delaware DOI, 2020; Jabbarpour et al., 2019;
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5 Patient Protection and Affordable Care Act, Public Law 111-148 (March 23, 2010).
6 42 U.S.C. § 1395w-4.
Koller et al., 2010). See Chapter 9 for a detailed discussion on primary care payment, including the policy, laws, and regulations that shape it.
Federal and state laws also play a significant role in codifying the training and practice requirements and programs that govern the health care workforce. As discussed in Chapter 6, trainees of many primary care professions are ineligible for the largest source of federal funding support, which comes through Medicare’s graduate medical education payment system (IOM, 2014). The funds are also primarily distributed to teaching hospitals, not community-based settings where most primary care is delivered. By amending the ACA, Congress has, however, taken steps to fund training in non-hospital settings through the Teaching Health Center Graduate Medical Education program (HRSA, 2021; Mach and Kinzer, 2018). Similarly, while funding support through Title VII and Title VIII health professions training programs is open to more professions in community settings, actual annual appropriations levels remain low, limiting their impact on strengthening the workforce and improving access for the underserved (Palmer et al., 2008; Phillips and Turner, 2012).
Regarding the underlying scope of practice itself, despite national frameworks for education, training, and paying for health care, states retain the power to determine who may lawfully practice health care, to what extent, and under what conditions. State health professions practice acts, implementing regulations, and a web of legal rulings establish licensure competency requirements and the range of health care services each health profession may provide and under what conditions. This power has the effect of exposing health care practice itself to the political decisions of individual states, rather than ensuring that decisions regarding the regulation of health care practice are based on education and training competencies and evidence (IOM, 2011). See Chapter 3 for more on state-by-state scope of practice variation.
In a nation (and health care system) as varied and complex as the United States, there is no one-size-fits-all solution for the regulation of and payment for primary care. But that does not mean that laws do not evolve. Federal law can encourage innovation by promoting broad standards for coverage and payment of primary care, up to the limits of state-sanctioned licensure standards. As we have seen in recent federal action to broaden the classes of health professionals who may administer vaccines during a public health emergency, law can even preempt narrow state restrictions that impede access to lifesaving treatment (HHS, 2021). States can, of course, learn from one another regarding health professions regulatory innovation and encourage the growth of primary care models that are more person centered, integrated, and community oriented. This can be achieved, in part, through policies, laws, and regulations that allow for local adaptations of care delivery to enable primary care teams the flexibility to meet
the needs of the populations they serve. Altering primary care payment policy is one major change that can help catalyze innovation at the practice level and allow the needed flexibility for practices to deliver primary care that aligns with the committee’s definition. Changes in laws, policies, and regulations can also strengthen incentives for trainees to enter the primary care workforce and eventually work in federally designated shortage areas. Additionally, states can further enable high-quality, team-based care by altering their health professions regulatory standards to allow all health care professionals to work at the top of their license. Making permanent the policy and regulatory changes introduced during the COVID-19 pandemic (as CMS did for some, but not all, of the 2020 Physician Fee Schedule and telehealth expansion changes) will strengthen the delivery of and payment for services such as telehealth (CMS, 2020b; Verma, 2020).
The 2018 Declaration of Astana,7 endorsed by the world’s health ministers and HHS, affirms primary health care within a framework of universal health care and acknowledges that the fruits of effective primary health care can only be realized if everyone has access to it (WHO, 2018). The U.S. delegation had a different perspective on assuring access but nonetheless agreed that it was necessary. Policy solutions that solve the problem of inequity will also require addressing the underlying social, economic, political, justice, educational, and health systems that individually contribute to systemic, structural racism (Hardeman et al., 2020). Fully addressing the policies, laws, and regulations that enable and perpetuate societal inequalities and inequitable health care is beyond the scope of this report; however, legal, regulatory, and policy changes can improve equitable access to high-quality primary care regardless of insurance status, facilitate improvements to the care delivered, and enable the integration of that care with the broader health care system.
The impact of law (including federal and state statutes, policies, and regulations) is a major and overarching consideration for the delivery of and payment for all of health care. Various aspects of the law as they apply specifically to primary care are discussed throughout this report. An extensive examination of the interaction between law and health care delivery, including all of the barrier-creating and barrier-removing elements, is beyond the scope of this report. However, the important broader context of this relationship warrants follow-up examination and discussion as the recommendations within this report are implemented.
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7 In 2018, governments, nongovernmental organizations, professional organizations, and other stakeholder groups met at the Global Conference on Primary Health Care in Astana, Kazakhstan, to endorse a new declaration that reaffirmed a commitment to improving primary health care around the world.
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