Systemic underinvestment has limited access to effective primary care across the US, according to a new report.

US adults are among the least likely to have a regular doctor compared to individuals in other developed countries, which has compounded chronic conditions and increased healthcare costs, according to the Commonwealth Fund’s 2019 and 2020 international health policy surveys. The fund polled practicing primary care doctors in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom and the US

The physician fee schedule should be adjusted to incentivize more doctors to practice primary care, policy experts said.

“What always surprises me is the lack of support for the relationship between the patient and provider,” said Munira Gunja, co-author of the report and a senior researcher in the Commonwealth Fund’s international program in health policy and practice innovations. “If people can’t get to a primary-care provider, it’s hard to manage chronic conditions and bigger problems arise in the future.”

The US has the lowest access to home visits or after-hours care, according to the report. Only half of US primary-care physicians said there was adequate care coordination with specialists and hospitals.

The US’ relatively poor performance can be traced to underfunding of key programs and inadequate reimbursement policies, industry observers said.

“While money is poured into a lot of these innovative primary-care models, payment for the provision of primary care itself has remained far below the inflation rate—we have just let them go,” said Jeff Goldsmith, president of the consultancy Health Futures. “I think we pay a price for that.”

The US has the largest wage gap between generalist and specialist physicians and the highest tuition fees among developed countries, according to the report. Narrowing that gap and subsidizing medical school tuition fees to get more medical students into primary-care programs would help stabilize the sector , researchers said.

Family medicine physicians earned an average of $236,000 per year, less than half of plastic surgeon’s $526,000 compensation package, according to Medscape data.

Reimbursement surged for procedure-oriented specialties when Congress shifted pay models from physicians’ historical charges to the “relative values” of services in 1992. High payments for new services under the Medicare physician fee schedulecoupled with substantial increases in the number of expensive diagnostics and interventions, has widened the income gap between primary-care physicians and specialists, causing more students to pursue specialties.

CMS has put limited resources into updating the physician fee schedule, said Paul Ginsburg, health policy professor at the University of Southern California and senior fellow of the USC Schaeffer Center for Health Policy and Economics.

“The Medicare physician fee schedule started out with an effective shift from specialties to primary care, but lost it overtime with a flawed updating process. The fee schedule really needs more attention than it has gotten,” he said, noting that it been in effect for 30 years now. “A lot better data could be used to make payments more accurate and reflect the relative cost of providing different services.”

The Affordable Care Act aimed to shift the focus to more preventative treatment and primary-care visits, with many of the law’s provisions focusing on caring for all of a patient’s needs. But it didn’t carve out long-term financing mechanisms.

Programs like the ACA-established Prevention and Public Health Fund, which allocated $15 billion over 10 years to support primary-care efforts, have been constantly underfunded.

These reimbursement models and investment patterns have exacerbated primary-care shortages, which are poised to get worse, data show.

The US needs nearly 16,000 more primary-care physicians to meet current demand in health professional shortage areas, according to the latest data from HHS’ Health Resources and Services Administration. The shortage could balloon to 48,000 by 2034 as more primary-care physicians switch to specialty care and retire, the Association of American Medical Colleges estimates.

The physician fee schedule is the only Medicare payment system that has a budget neutrality requirement, which has pitted physician specialties against each other. Doctors staunchly oppose any pay cuts, which has deterred Congress, Goldsmith said.

“There’s plenty of evidence that a properly armed primary-care physician can make a difference, but that still hasn’t penetrated the thick skulls in Washington DC,” he said. “Putting resources in the front end of care can save money and lives , but it doesn’t get the advocacy muscle it needs in this political culture. This is a political problem.”