Payment Reform to Transform Primary Care: What More Is Needed?

Primary care has been struggling in the USA for over 50 years. By the 1960s, the decline in new entrants to general practice led to the Millis Commission report defining essential attributes of the imperiled primary care role, as well as to the establishment of Family Practice (now Family Medicine) as a new specialty dedicated to primary care. Despite this and other new “generalist” physician pathways to primary care careers (like general internal medicine, general pediatrics, medicine-pediatrics, and geriatrics), medical student interest languished. By the 1990s, US health care cost growth had become a serious concern and policy researchers noted spending appeared to be less in systems with more robust primary care. However, resulting US payment reforms often defined the key role of primary care as “gatekeeping” patient access to specialized care, an image that proved widely unpopular with both consumers and clinicians. By the 2000s, many physicians in titular “primary care” disciplines like family medicine or general internal medicine were shifting into hospitalist or other clinical roles, remaining generalist practices further adapted to new regulations (as well as declining rates) for visit-based payment, and dedicated urgent care practices and retail-based clinics proliferated. In this chaotic environment, payers and policymakers resisted the idea that simply paying higher fees for visits to generalist clinicians would address the problems in primary care. Accordingly, several national professional associations began advocating for payment reform tied to a more formalized “medical home” model of generalist clinical practice, and in March 2007 agreed on “Joint Principles of the Patient-Centered Medical Home (PCMH).”