Tyler
“The good physician treats the disease, the great physician treats the patient who has the disease” – Sir William Osler
The type of patient care described by Sir William Osler is the holistic approach that every primary care physician (PCP) should embody. PCPs are invaluable as they not only address immediate health concerns, but also build long-term relationships with patients that enhance preventive care, improve health outcomes, and reduce the need for costly interventions. In any high-functioning healthcare system, PCPs act as the first point of contact for patients, providing them with comprehensive care and only referring to specialists when necessary.
Unfortunately, the U.S. healthcare system doesn’t operate this way. According to a 2019 National Ambulatory Medical Care Survey, only 50.3% of physician office visits are to PCPs, with the remaining 49.7% being split between medical (29.0%) and surgical (20.7%) specialists. Although specialists are a necessary part of our healthcare system, they shouldn’t play a substantial role in routine patient care. Specialists often lack PCPs’ comprehensive, long-term understanding of a patient’s overall health, and their focus on specific conditions can lead to narrower treatment approaches. For instance, a surgical specialist may recommend surgery when less invasive treatment options could suffice. U.S. health systems must prioritize investment in primary care to foster a more equitable, efficient, and effective healthcare system centered on holistic patient care.
Background
Since the 1980s, primary care has gained recognition as a cornerstone of a high-quality healthcare system, providing cost-effective care and preventive services that improve long-term patient outcomes. Despite this recognition, primary care in the U.S. has experienced decades of underinvestment and a shortage of providers, which have constrained its accessibility. Primary care accounts for a mere 5-7% of total healthcare expenditure in the U.S., while other high-income countries spend approximately 13%–nearly double the U.S. investment. This underinvestment exacerbates health inequities and contributes to declining health outcomes for patients, particularly in underserved populations with limited resources.
In recent years, there has been a push for greater investment in primary care as a result of evidence-based research and greater policy advocacy, yet primary care continues to lag behind hospitals and specialists in the allocation of U.S. healthcare dollars each year. Although many factors contribute to this imbalance, it is often perpetuated by a traditional fee-for-service reimbursement model that rewards high-cost procedures over preventive care. The establishment of Accountable Care Organizations (ACOs) through the Affordable Care Act (ACA) of 2010, along with broader state-level investments, has generated positive momentum in primary care reform by better aligning reimbursement incentives, but significant work remains to achieve equitable funding.
Why should the U.S. invest in primary care?
Primary care plays a pivotal role in improving health for patient populations through proactive and continuous care. In both developed and developing nations, primary care is linked to enhanced outcomes, reduced hospitalizations, and emergency department visits. Through consistent patient engagement, primary care providers implement preventive measures—such as prescribing preventive medications, offering lifestyle interventions like diet and exercise counseling, and conducting routine screenings—that keep individuals healthy and significantly lower the risk of catastrophic health events.
Countries with greater investment in primary care (10-15% of healthcare expenditure) tend to exhibit better health markers than those who spend less. Despite having the highest per capita healthcare spending of any developed nation, the U.S. has the highest rate of amenable mortality—deaths from diseases that are potentially preventable given timely and effective care—and experienced the smallest reduction in that measure from 2004 to 2014. This gap in amenable mortality shows how other countries’ focus on comprehensive primary care improves health outcomes, while U.S. spending elsewhere generates less meaningful benefit.
(Source: Peterson-KFF Health System Tracker)
Primary care also exists as one of the most efficient entry points into the healthcare system for individuals of all demographics to receive the care they need. Decades of patient-, system-, and population-level studies have underscored primary care’s critical role in advancing health equity.
A 2019 study by the Patient-Centered Primary Care Collaborative found that states with higher levels of investment in primary care, such as Minnesota and Rhode Island where spending exceeds 7% of total healthcare costs, experience a 3-5% reduction in preventable hospitalizations—showing how equitable access to primary care can mitigate health disparities by ensuring consistent preventive care for all populations. However, poorer populations with less resources often underutilize primary care providers and preventive services, instead relying on visits to the emergency department (ED) due to barriers like limited access, transportation issues, and lack of insurance. Infrequent or inconsistent primary care visits can lead to severe comorbidities, driving patients to seek catastrophic care in the ED rather than preventive intervention in medical offices. This patient behavior intensifies inequities and strains healthcare resources.
PCPs wield a unique ability to continuously interact with patients, guiding them toward healthier behaviors through personalized advice and counseling. Spending more time with patients to discuss lifestyle changes—such as improved diet, regular exercise, or smoking cessation—has been shown to foster higher trust among patients, encouraging them to be more candid about their challenges and needs. This trust creates an open dialogue, enabling PCPs to better tailor interventions that delay disease onset, manage chronic conditions, and improve their patient’s well-being. Investing in primary care means cultivating a community of greater trust, where patients have enhanced access to lifestyle management and are more likely to adopt the behavioral changes necessary for long-term health improvements.
Investing in primary care has been shown to significantly lower overall healthcare costs by emphasizing prevention and reducing the need for expensive interventions. A 2021 report by the Purchaser Business Group on Health (PBGH) on advanced primary care provides compelling evidence, demonstrating that U.S. adults with a primary care physician incur 33% lower healthcare costs compared to those primarily seeing specialists. The report also estimates that if every American used primary care as their main source of care, the healthcare system could save $67 billion annually, primarily through reduced hospitalizations and ED visits. This cost efficiency stems from primary care’s focus on early intervention—such as managing chronic conditions like diabetes through regular check-ups and lifestyle counseling—which prevents costly complications that often require acute care settings.
Moreover, primary care investment is crucial for transitioning from the traditional fee-for-service (FFS) model to value-based care, a shift that prioritizes outcome-focused care over the volume-driven approach that has long favored specialists. Historically, the Resource-Based Relative Value Scale (RBRVS), introduced in 1992, has skewed reimbursement toward specialists by assigning higher value to procedural interventions, making their roles more financially rewarding than the cognitive, preventive work of primary care physicians. However, as value-based care models gain traction—evidenced by initiatives like the Affordable Care Act’s Accountable Care Organizations (ACOs) and CMS’s Making Care Primary program launched in 2023—reimbursement structures are evolving to reward coordinated, outcome-driven care, which primary care is uniquely positioned to deliver. By investing in primary care, health systems can align with this shift by supporting comprehensive care that improves patient outcomes while reducing costs rather than perpetuating a system that incentivizes high-cost procedures, over-treatment, and fragmented care without regard for long-term health.
Prioritizing primary care investment not only delivers significant cost savings and improved health outcomes, but also positions health systems to excel in the evolving landscape of value-based care that emphasizes prevention, patient well-being, and strategic spending over excessive volume and disappointing results.
Case study: Oregon PCPCH
The Oregon Patient-Centered Primary Care Home (PCPCH) program, established in 2009, was a state-led initiative to transform primary care delivery by creating a patient-centered model that prioritized accessibility, coordination, and comprehensive care. The goal was to address rising healthcare costs, poor health outcomes, and inequities, particularly for Medicaid populations in Oregon. The PCPCH program was tasked with the following:
The Oregon Health Authority (OHA) established a 15-member advisory committee, consisting of patients, clinicians, and health plan and purchasing representatives to develop the standards to define the care delivered by PCPCH-designated clinics. The committee finalized the initial standards in 2011, which were revised and updated in 2014. Subsequent Standard Advisory Committees were formed, leading to further program and model revisions in 2017 and 2020. The standards were developed to reflect the six core attributes of the Oregon PCPCH program, listed below:
Providers could participate in the program by applying for recognition through a system that awarded credit for actions like implementing telehealth, tracking care coordination, or integrating behavioral health services. The OHA supported practices through the Patient-Centered Primary Care Institute by providing training, webinars, online modules, and practice coaching to help practices achieve recognition.
The program’s methods also included financial incentives to drive adoption: recognized PCPCH practices received per-member-per-month payments from Medicaid and other payers to offset transformation costs and encourage quality improvements. In 2012, the program integrated with Oregon’s Coordinated Care Organizations (CCOs), requiring CCOs to prioritize PCPCHs as the primary care delivery model. By 2019, 82% of Oregon’s primary care practices had achieved PCPCH recognition, reflecting widespread adoption, though rural clinics often faced challenges due to limited staffing, technology, and funding that hindered their ability to meet program standards.
The financial impact of the PCPCH program was evaluated by Portland State University and the OHA, as detailed in this 2023 report. The study utilized de-identified Oregon All Payer All Claims (APAC) data from January 2011 to September 2019, attributing Oregonians with at least one primary care claim in a study year to either PCPCH or non-PCPCH practices. It compared utilization and expenditure trends between PCPCH-recognized practices and non-PCPCH practices, reflecting the experience of 759 practices and 702,417 individuals between October 0211 and September 2018. The outcomes measured included per-person expenditures, likelihood of service use, and expenditures per service user, across overall and specific service types.
Key findings include a 6.3% reduction in total healthcare expenditures per person (approximately $76 per person per quarter), with nearly $12 in savings on services like emergency department and inpatient care for every $1 increase in primary care expenditures tied to the PCPCH program. Over its first eight years, the program generated at least $1.3 billion in savings, growing from $68 million in the first year to $200 million in the eighth, with potential for further increases as the program expands. Expenditure reductions were 1.5 times greater for children and youth (18 and under) compared to adults, though adults contributed the bulk of savings due to higher baseline costs and larger population size. The Oregon Health Plan (OHP) saw 1.5 times higher expenditure reductions than private insurers or Medicare (Advantage), with savings of $717 million for OHP, $365 million for private insurers, and $195 million for Medicare over the eight years.
Oregon’s PCPCH program is a powerful illustration of how investing in primary care can significantly cut healthcare expenditure and utilization, especially for vulnerable populations. The results of this study position the PCPCH program as a compelling blueprint for driving health system efficiency and equity through increased usage of PCPs and value-based care reimbursement methodologies.
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