What is the Issue with Primary Care?

When we think of medicine we often think about certain specialties or subspecialties of the field -- OBGYN, cardiology, surgery, neurology, and orthopedics. However, when was the last time we visited any of these specialized providers? The glue that binds the healthcare system together, especially from the patient perspective, is the primary care provider. Yet the fact that we often think of these specialized providers and not primary care providers (PCPs) reflects our unique US healthcare culture; at the national level, we prioritize specialized physicians over PCPs who serve a much larger patient population admitted for a variety of healthcare needs. In the US, only 87% of adults report having a PCP or a clinic they frequent when accessing healthcare, as compared to 96% in Germany, 97% in the UK, and 99% in the Netherlands. (1) Furthermore, only 43% of adults in the US have a strong relationship with their PCP; this is important to address as PCPs are responsible for coordinating care for patients on managed care plans. (1)

This disparity perhaps can be seen most clearly in annual healthcare funding. In 2021, 4.7% of US healthcare spending was allocated to primary care compared to 14% on average in other comparable countries. (1) So why is primary care so important? Across the world, PCPs are generally the primary point of contact for patients seeking care or when receiving diagnostic or preventative health services; PCPs, especially in managed care plans in the US are responsible for coordinating patient care, connecting patients to specialists and assisting in the receipt of healthcare services. (2, 3)

In the US, roughly 99% of workers in 2022 were enrolled in a managed care insurance plan, with most of these involving a PCP to coordinate patient care. (4) Thus, this underinvestment in primary care and lower emphasis placed on PCP-initiated care results in increased burden amongst a smaller group of providers and has long term consequences for patients.

How does this manifest in the real world? From 2005 to 2015, the number of PCPs fell from 46.6 to 41.4 per 100,000 people in the US. (5) This decrease in the number of PCPs might be due to a multitude of factors all stemming from a culture that values specialists and that undervalues primary care as its own medical field.  

Earnings may play a role in the number of PCPs as well; due to this lack of funding at the national level, PCPs tend to earn less than physicians in other specialties. (5, 6) For example, while specialists made on average $394,000 in 2023, PCPs made $277,000. (6) A similar 2023 study found that neurosurgeons made on average $1 million relative to PCPs who made roughly $230,000. (5)

Given this context, it makes sense that, earlier this year, several companies including Walmart, CVS, and Walgreens closed many of their primary care clinics. (7, 8) In Spring 2024, Walmart closed primary care clinics in Arkansas, Illinois, Florida, Texas, and Georgia while maintaining its existing vision centers and pharmacies across the country. (7) At roughly the same time, Walgreens closed over 140 of its roughly 600 VillageMD clinics across the country (after purchasing VillageMD for over $5 billion) and CVS closed 25 MinuteClinics in LA. (7, 8) Executives at all of these firms cited profitability and low returns on investment as reasons for scaling down their primary care clinics. (7, 8) While these clinics may have struggled for a variety of reasons including the lack of patients without a pre-existing PCP, the extreme overhead costs, and the unconventional retail healthcare setting, this frame adds another dimension to this issue. (7)

Although the US healthcare system has prioritized specialty medical care at the expense of primary care, the importance of PCPs in the US cannot be overstated. (5) Research from 2019 shows that life expectancy in the US increases by roughly 51.5 days for each increase of 10 PCPs per 100,00 people. (5) PCPs are invaluable in the US healthcare process; an early consultation with a PCP may result in detection of disease at its early stages before more complex intervention is required. (5) A 2019 report identified that a health condition, when cared for in the emergency room versus a primary-care setting, may cost 12 times more, placing additional burden on patients and the healthcare system as a whole. (5) Ultimately, the healthcare system in the US is fueled by specialist providers; to improve healthcare outcomes, the Federal Government and hospital administrators must put a spotlight on primary care, increasing investment and supporting primary care physicians who are a part of the existing workforce.