Diagnosing primary care in America: ‘We need to fix it’

Ripley Hollister, MD, has been practicing medicine since the mid-1980s, when Ronald Reagan was president and MTV played music videos all the time.

Hollister loves being a primary care physician, but he says it’s become much harder. When he first began practicing, he had a group of patients with various medical needs, but he says the reimbursements were sufficient. That’s no longer the case, he says.

“There is a systemic under-investment in primary care that makes those kinds of quality caring physician-patient relationships more and more difficult as reimbursements decline,” he says. “I think that things can be done, certainly to improve that, but I think a big understanding needs to take place in funding in healthcare in general.”

The Milbank Memorial Fund and The Physicians Foundation recently released its third annual scorecard on primary care and the report outlines disturbing trends. Fewer doctors are choosing primary care as a career, and there are declines in nurse practitioners and physician assistants as well.

Hollister, a board member of the Physicians Foundation, talked with Chief Healthcare Executive® about the report, the state of primary care, and the urgent need to address the problem.

“We can fix it, and we need to fix it, and we need to make sure it's not getting any worse,” he says. (See part of our conversation in this video. The story continues below.)

‘The spine’

In 2022, primary care accounted for 5% of all U.S. healthcare spending, the report states.

Speaking like the physician that he is, Hollister calls primary care the backbone of health care, and it needs attention.

“Primary care is the spine, which supports the whole skeleton and all the organ systems within our healthcare system,” he says. “Our bone density is rapidly declining, and our healthcare system is developing osteoporosis. A vertebral body fracture is imminent, which could lead to devastating and expensive results. Primary care needs an urgent infusion of nutrients and attention to prevent this needless occurrence.”

The scorecard, developed by researchers at the Robert Graham Center for Policy Studies in Primary Care, outlines some concerning trends.

More than 30% of U.S. adults don’t have a “usual source” of primary care, the highest level in a decade. Conversely, in 2022, less than a quarter (24.4%) of new physicians entered primary care, the lowest level in a decade.

The report also found a troubling drop in nurse practitioners in primary care, falling from 34% in 2021 to 30% in 2022. The number of physician assistants also tumbled, from 34% to 29.7% in that same span.

“So all of these things are happening at once and kind of leading to this lack of recognition about the disinvestment in primary care,” Hollister says.

Physicians have fumed over declining Medicare reimbursements to physicians in recent years. Advocacy groups for physicians have slammed Congress for taking no action to avert Medicare cuts in payments to doctors in 2025. Doctors say the cuts are forcing some practices to stop taking Medicare patients, and some practices are closing their doors.

More doctors are choosing to enter specialty care because of the greater earning potential, the report says. While Hollister laments the lack of physicians entering primary care, he says he understands it.

Specialty care visits generate up to five times as much revenue as a visit to a primary care physician, according to the report.

In addition, primary care physicians can also deal with greater levels of stress in their practice and can work longer hours.

“I think it's quality of life,” Hollister says. “I think it's the demands that are placed in primary care and the under investment.”

“They talk to me about the amount of intellectual issues and the burden of dealing with multiple chronic diseases and the difficulty, and I think that when it comes for them to decide which career path they take … I can't blame them for choosing to enter a different line,” Hollister says.

The report also argues for more robust investments in graduate medical education in community-based settings. Hospital-based graduate medical education receives much more funding, and Hollister cites that as another barrier to new physicians choosing primary care.

“When physicians are trained in sort of highly complex hospital-based environments, they have a tendency to move into more specialized fields,” Hollister says. “When they're trained in where they take care of patients, if you will, and in a community-based environment of training, they tend to stay there.”

Price of lower investments

There are consequences to the lack of investment in primary care, Hollister says.

Those without easy access to a primary care physician don’t get preventive care that can help them avoid more serious health conditions. Often, if patients without a doctor get sick, they end up in urgent care or a hospital emergency room, which adds cost to the system.

Even if that issue gets resolved, those patients without a primary care doctor may not be getting follow-up they need to avoid complications.

Healthcare and hospital leaders have expressed concerns about the possibilities of cuts to Medicaid, which they say would make it harder for Americans to get the care they need. They have also argued that it will lead to higher costs for hospitals and the entire healthcare system, if patients end up going to the emergency room because they have no other options.

“So the paradoxical thing is, spending more on primary care actually reduces healthcare total costs,” Hollister says. “And I think it's clear that that has to do with access. It has to do with people getting in the door to primary care and primary care being able to then, in an inexpensive way, manage the issue.”

Hollister points to his own work as a physician, where he sees patients with multiple chronic diseases. He helps them manage their illnesses and make sure that their medications don’t conflict and cause problems.

“Primary care has to be uplifted, if you will,” he says. “And what this study is showing is that our support of primary care is insufficient, and because of that, the physician pipeline is really crumbling, and we need to do something in a hurry to get this thing on the right rail.”

Hollister says his practice is hampered by staff shortages, inflation and declining Medicare reimbursements. At the same time, he’s seeing more patients with multiple chronic diseases.

“We need to be using healthcare dollars more intelligently and spending them more carefully within primary care,” he says. “And oftentimes that just means paying primary care practices more money so that we can have those effective teams, so that we can provide that access to care.”