Building a Workforce to Develop and Sustain Interprofessional Primary Care Teams

The National Academies of Sciences, Engineering, and Medicine (the National Academies) 2021 report Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care defines high-quality primary care as

The report also concludes that high-quality primary care, given its distinct benefit to society and individuals, is a common good worthy of public policy support and investment to ensure that it is available to all who seek it. Achieving this level of access to high-quality primary care requires a well-trained and well-supported primary care workforce.

The 2021 report highlights the integral role of the interprofessional team in ensuring access to high-quality primary care for patients, families, and communities. Unfortunately, the promise of accessible, high-quality primary care delivered by interprofessional teams to all is being thwarted by a worsening workforce shortage. People throughout the United States face growing challenges finding a primary care clinician who accepts new patients, or for those individuals fortunate to have an established source of primary care, to be able to schedule appointments in a timely manner with their primary care clinician (Jabbarpour et al., 2024).

The task of this committee, which comprises members of the National Academies’ Standing Committee on Primary Care,¹ was to examine the inputs (including the human and financial resources) and functions needed for interprofessional teams to successfully and sustainably deliver high-quality primary care, as defined by the 2021 Implementing High-Quality Primary Care report. (See Box 1-1 for the full statement of task.) Building on the conclusions of that report, this report reviews the literature around the current condition of primary care and how this context affects the structure and operation of interprofessional primary care teams. The committee met twice in closed session and worked asynchronously to complete the report.

Throughout deliberations, however, and as this report describes in detail, the committee determined that to build and sustain interprofessional primary care teams that are accessible to all and that deliver high-quality primary care, the nation must first address the insufficient way that primary care is paid for in the United States. The committee focused on how more accurate valuation of, and payment for, primary care can enable effective recruitment, training, and the scalable transformation of the primary care workforce. The committee makes nine recommendations for how federal agencies and other actors can better support workforce development and sustainable interprofessional teams to deliver high-quality primary care in the United States.

THE WORK OF PRIMARY CARE

The work of primary care is central to the current U.S. Department of Health and Human Services (HHS) priorities of improving health through preventive care and chronic disease prevention (HHS, 2025). Decades ago, the work of primary care principally consisted of addressing symptomatic medical problems that could be addressed in intermittent office and hospital visits. Today, primary care is responsible for delivering an ever-expanding array of preventive and chronic whole-person care in addition to caring for urgent and emergent medical conditions (NASEM, 2021b). The “whole” of whole-person care has become increasingly comprehensive and complex in scope (NASEM, 2023). For example, the U.S. Preventive Services Task Force recommends dozens of evidence-based primary care preventive services, including breastfeeding support, unhealthy alcohol use, colorectal cancer screening, and osteoporosis screening, among others.

The rise of complex and chronic medical conditions among children and adolescents, as well as an aging population, has resulted in an increase in the prevalence of people living longer with chronic conditions (Maresova et al., 2019; NASEM, 2024a; Perrin et al., 2014), many of whom are

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¹ For committee biographical sketches, see the Appendix.

managed by primary care clinicians who prescribe and administer often complex medication regimens and self-management supports. Moreover, destigmatizing behavioral health conditions, many of which are first seen and often managed in primary care settings (Caspi et al., 2024), has meant primary care is assuming greater responsibility for diagnosing and treating depression, adverse childhood events, substance use disorders, and related conditions (Austin et al., 2024; Jetty et al., 2021).

In addition to expanded scope of what it means to deliver primary care, patient and public expectations, information technology, health system complexity, workforce shortages, and related factors are placing growing demands on practices, making it more and more difficult to deliver the essential functions of accessible, comprehensive, longitudinal, and coordinated high-quality primary care to people across the country (NASEM, 2021b). The advent of patient portals linked with electronic health records, along with changing societal norms about around-the-clock asynchronous digital communication, is overwhelming primary care practices with patient messages and expectations for timely communication (Ferguson et al., 2023; Matthews et al., 2025). The COVID-19 pandemic also led to an increase in the use of telehealth, challenging practices to adopt modalities for virtual

care. Although clinicians in primary care and nonprimary care settings alike experience time burdens from asynchronous communication with patients, research has shown that primary care clinicians bear a disproportionate share of this burden compared to other specialties (Rotenstein et al., 2021).

Similarly, although the movement to systematically document and improve the quality of care includes care delivered in all settings, a disproportionate number of the metrics used by quality-reporting systems (e.g., HEDIS) are preventive and chronic care measures, which largely fall in the domain of primary care (Office of Disease Prevention and Health Promotion, 2025). Therefore, the work of primary care includes extensive efforts (and pressure) to measure and perform well on a range of quality metrics (Casalino et al., 2016; Stange et al., 2023). The overwhelming administrative burdens of the U.S. health care system place additional strains on primary care, including the responsibility for completing time-consuming prior authorizations, managing prescriptions amid constantly shifting formularies, and handling related tasks (Holmgren et al., 2024). While other specialties also experience these burdens, primary care is disproportionately affected (Rao et al., 2017).

The extent to which expectations of primary care exceed capacity is evident in studies that have modeled the time required to provide all the evidence-based services expected in primary care. A recent study estimated that it would take a primary care clinician with a panel of 2,500 patients 26.7 hours per workday to deliver all guideline-recommended preventive, chronic disease, and acute care services, with preventive care constituting about half of that time (Porter et al., 2023). Assessment of—and planning for—an interprofessional primary care workforce to deliver accessible, equitable, comprehensive, high-quality care must account for this growing workload.

THE INTERPROFESSIONAL PRIMARY CARE TEAM

The Implementing High-Quality Primary Care report describes the interprofessional care team as having a relational and functional culture that works with patients and families to provide comprehensive, coordinated, and continuous connection with the aim of improving health (NASEM, 2021b). Guided by the established principle that “form follows function,” the interprofessional primary care team is the form needed for contemporary practices to successfully care for patients with the increasing workload described above (Grumbach, 2009). These teams use the skills and expertise of the individual team members—clinicians and others—to efficiently deliver the expanding definition of high-quality primary care.

Figure 1-1, originally from the Implementing High-Quality Primary Care report, presents a schematic of a potential primary care team structure.

At the center are the patient and family surrounded by three levels of team members:

1. The core team, including primary care clinicians (typically a physician, nurse practitioner, or physician assistant), nurses, medical assistants, and office staff;
2. The extended health care team, including behavioral health specialists, social workers, pharmacists, care managers, community health workers, dentists, and early childhood specialists; and
3. The extended community care team, including school-based support, social services, home health aides, and health behavior support.

With the central presence of the patient and family, the core team delivers more of the traditional visit-based, synchronous care that may be in-person or virtual, and assists with the patient outreach and engagement, self-management, care coordination, and panel management that is necessary between visits and through asynchronous modalities, as well as quality improvement efforts. The core team enables patients and families to be informed, activated partners in health promotion, disease prevention, and chronic condition management (Bodenheimer et al., 2002; NASEM, 2021b).

The extended health care team members may also engage in outreach, self-management support, and care coordination, but they also bring increased specialization of services that align with additional needs of the community. These may include community health workers, peer supports, pharmacists, dentists, social workers, behavioral health specialists, lactation consultants, nutritionists and dieticians, physical and occupational therapists; each extends the capacity and capability of the primary care team to assure coordination and integration of more comprehensive services. In coordinating care for patients, primary care teams function as part of multiteam systems, including collaboration with community-based services (part of the extended community care team) as well as specialty care teams (Fiscella and McDaniel, 2018; Weaver et al., 2018).

It is important to note, as the Implementing High-Quality Primary Care report does, that Figure 1-1 illustrates just one example of what an interprofessional team can look like. The composition of interprofessional primary care teams in different communities with different needs and resources will vary accordingly to those needs and resources. In training and building primary care teams, the roles need to be locally tailored to the needs of the patients, families, and communities that are served (e.g., patient needs based on age, condition, or disease state, or the social needs of the community). The roles also need to be tailored to the local workforce supply. Regional attributes, such as rurality, can shape the types of

professionals available to and working in community primary care settings (Hawes et al., 2024; Lombardi et al., 2019).

Since the release of the report in 2021, further evidence supporting the need for care delivered by interprofessional teams has emerged. For example, primary care patients’ need for behavioral health care has grown with primary care clinicians increasingly diagnosing and treating behavioral health conditions (Caspi et al., 2024; Jetty et al., 2021) Similarly, patients seen in primary care practices can benefit from the expertise and involvement of pharmacists who assist clinicians and patients with medication regimens and their management for diabetes, high blood pressure, high cholesterol, and other chronic conditions (Blood et al., 2025; Joseph et al., 2017; Manolakis and Skelton, 2010). Whether part of the core or extended teams, the Implementing High-Quality Primary Care report comprehensively described the various interprofessional primary care team members, including their roles, disciplines, and training pathways (NASEM, 2021b). When they are part of interprofessional teams, these professionals work together to address different patient needs based on the contributions of their experience and training.

THE PRIMARY CARE WORKFORCE SUPPLY

For interprofessional primary care teams to function, they need an adequate supply of workers to staff core and extended team positions. Primary care clinicians, which are the foundation of the primary care team, are in critical shortage, which is one of the nation’s most pressing health care workforce problems. The growing workload and demand for primary care services exceeds the supply of primary care clinicians. Supply–demand models from the U.S. Health Resources and Services Administration (HRSA) using traditional methods for counting physicians (i.e., counts of active clinicians, self-reported specialty taxonomies) suggest that the United States currently has a deficit of 20,000 to 50,000 primary care physicians, with projected deficits of 40,000 to 87,000 physicians in 2037 (GlobalData Plc, 2024; HRSA, 2024b; Petterson et al., 2012; Primary Care Collaborative, 2023). While demand is increasing, the number of primary care physicians per 100,000 people in the United States decreased from 67.7 in 2012 to 67.1 in 2022 (Jabbarpour et al., 2024; Milbank Memorial Fund, 2025), with the annual number of new entrants lagging behind the pace of retirement and attrition of primary care physicians, resulting in projected deficits of primary care physicians to increase in the coming years.

Although a growth in the supply of nurse practitioners (NPs) and physician assistants (PAs) in past decades temporarily offset the decrease in primary care physicians, primary care NP and PA supply per capita began declining as well in 2022. The recent decrease in the primary care NP and

PA supply per capita is explained not by fewer of the professionals overall in the United States, but by more of these professionals shifting from primary care to other specialty settings for their work. A similar dynamic has affected the physician workforce, particularly for general internists. While the vast majority of family physician residency graduates tend to remain in primary care (Carek et al., 2024), over recent decades the proportion of graduates of internal medicine residency programs entering careers in primary care has decreased from about 50 percent to less than 10 percent. This is attributable to a surge in graduates pursuing careers in hospital medicine along with many entering subspecialty medical fields (Bodenheimer, 2006; Gray et al., 2022; Paralkar et al., 2023).

The actual deficit of primary care clinicians is likely even more dire than that estimated by HRSA. The data typically used to enumerate clinicians for supply–demand models are “head counts” of active clinicians, with categorization into primary care based on self-reported specialty and other taxonomies. There is growing evidence that these enumerations may dramatically overestimate the number of clinicians functioning as primary care clinicians—meaning those delivering comprehensive, relationship-based care in the ambulatory setting for an ongoing patient panel (Jabbarpour et al., 2024). Increasing numbers of primary care clinicians are working part-time, though the extent of this trend is difficult to estimate using currently available data (Goldman and Barnett, 2023).

Studies using health plan claims data to examine practice activity find that the number of physicians providing comprehensive, continuous ambulatory care is far lower than the number based on traditional head counts. For example, an analysis in Virginia using claims data found that the state had far fewer primary care physicians than estimated using traditional methods (Huffstetler et al., 2022; Petterson et al., 2018; United Health Foundation, 2024). An analysis of primary care clinicians in California using similar methods and including NPs and PAs as well as physicians found that traditional head count methods may overestimate the functional supply of primary care clinicians by as much as 40 percent (Rubino and Soni, 2024). Studies of the primary care workforce in Canada are revealing similar discrepancies when claims data are used to measure the primary physicians providing primary care services (Frymire et al., 2024). These analyses using claims data reveal that many of the clinicians identified by specialty taxonomies as being primary care clinicians are actually practicing in nonprimary care roles such as hospitalists, emergency department clinicians, specialty care, or other areas. Replacing the supply estimates used in conventional models with estimates using claims data to measure clinicians who are serving communities in ambulatory care settings could increase these deficits by between 20 and 40 percent owing to the overestimation of the true primary care clinician supply.

In addition to this limitation in supply measurement, supply–demand models have often used unrealistic demand standards for the number of primary care clinicians needed per capita based on historical data suggesting that a full-time primary care physician can care for 2,000 to 2,500 patients. Newer data indicate that the average family physician has a patient panel size of about 1,800, with the mean panel size declining by 25 percent from 2013 to 2022 (Bazemore et al., 2024). This decrease in panel size is not surprising given the vastly increasing work of primary care described above. For example, the Veterans Health Administration (VHA) has adopted a panel size standard of 1,200 patients per full-time primary care clinician in recognition of the high workload of primary care (VA, 2021). Using a panel size standard closer to that established by the VHA for supply–demand models would further widen the gap between existing primary care clinician supply and population need.

The primary care clinician workforce supply–demand mismatch has created a vicious circle. Overwhelming workload contributes to clinician burnout, which disproportionately affects primary care, and acts as a disincentive for choosing primary care as a career (Adler-Milstein et al., 2020; Dai et al., 2020; O’Rourke et al., 2025; Shanafelt et al., 2022; Willard-Grace et al., 2019; Woolhandler and Himmelstein, 2014). Clinicians exit primary care for more focused and often better remunerated work (Faber et al., 2016; Paralkar et al., 2023) or take on smaller panels via concierge or direct primary care practices, and health professionals in training are directly and indirectly discouraged from pursuing careers in primary care. The shortage then worsens, and the workload further increases for clinicians remaining in primary care, patient access deteriorates, and the unmet needs of individuals, families, and communities continue to grow.

Modeling suggests that having a robust interprofessional primary care team with clear delegation of tasks and responsibilities could considerably reduce the work demands of the primary care clinicians on the team (Altschuler et al., 2012), as well as improve efficiency, productivity, access to care, and better meet the needs of patients and their families (Ghorob and Bodenheimer, 2012). For example, the study mentioned earlier that estimated 26.7 hours of work per day for a primary care clinician concluded that a team model might reduce clinician workload to 9.3 hours per day, with nonclinician team members managing most of the preventive services delivered by the practice (Porter et al., 2023). Research has also found that efficient use of teams is associated with lower burnout among clinicians and other primary care workers (Dai et al., 2020; Willard-Grace et al., 2014). Additionally, the whole is more than the sum of the parts, with interprofessional teams including health care workers with diverse and complementary skills that equip a practice to more effectively serve the comprehensive needs of patients and communities.

Given that interprofessional teams have intrinsic merit for more comprehensively meeting patients’ needs, and the added benefit of potentially enhancing clinician work life to help attract and retain more clinicians in primary care, a key question is whether the United States has a sufficient supply of workers to more robustly staff the diverse core and extended team positions to actualize high-performing interprofessional primary care teams in practices across the country. Are primary care clinicians the only personnel input in short supply, or are there shortages of the other health professionals needed to staff primary care teams? HRSA projections of health workforce supply and demand for 2022–2037 indicate that for many professions, such as registered nurses, nurse practitioners, pharmacists, and physician assistants, the supply is approximately adequate to meet demand (HRSA, 2025), although it is important to note, the data do not indicate the specialty areas where these providers practice and the extent to which the supply of professionals is appropriately distributed between urban and rural settings within individual states. Another key issue for these professionals is attracting them to positions in primary care rather than in other sectors such as hospitals and specialty care, which often offer higher wages (AAPA, 2023; Li et al., 2018; Mee, 2006). The high levels of administrative burden, decreased exposure to primary care training environments, and lower wages all serve as deterrents to recruiting all types of health workers into primary care fields (Matthews et al., 2025).

For one of the critical positions on the core primary care team—medical assistants—HRSA does not have national data available to produce supply and demand estimates, although the short period of training required for this occupation (typically less than 12 months) makes it relatively elastic in terms of supply being able to rapidly respond to labor market signals. That said, and while data are limited, the turnover rate for medical assistants is high in part because of low wages and the limited potential for growth without additional training. This is costly for health care organizations to manage and does require a steady supply of new medical assistant trainees entering the workforce (Friedman and Neutze, 2020; Lai et al., 2023).

One group of professionals that does appear to be in short supply is behavioral health workers, with HRSA projecting a growing supply-demand gap from 2022 to 2037. By 2037, HRSA projects the adequacy of supply as only 57 percent for mental health counselors, 55 percent for psychologists, 45 percent for addiction counselors, 65 percent for child and adolescent psychiatrists, and 43 percent for adult psychiatrists. For all of these professions, the supply-demand gap projections widen dramatically between today and 2037. Psychiatric nurse practitioners and psychiatric physician assistants fare better, with adequacy of supply projections equaling 120 percent and 86 percent, respectively (HRSA, 2025). These national projections do not reflect the tremendous variation in health professional

supply across regions and communities. Even when national estimates indicate general alignment between supply and demand, many pockets of health worker shortages exist, particularly in rural and low-income urban communities (HRSA, 2024a). In addition, there is a lack of racial and ethnic diversity in these professional workforces, which can limit cultural and language concordance among professionals and the patients and communities they serve (NASEM, 2021b).

While the dire shortage of primary care clinicians in the United States is well documented, the supply data for other interprofessional primary care team members who are needed to ensure delivery of high-quality primary care are limited. Nevertheless, policies to address the training and labor economic factors that are described below could influence more clinicians to choose to practice in community primary care practice and encourage other professionals on the team to do the same.

DEVELOPING AND SUPPORTING THE WORKFORCE FOR PRIMARY CARE TEAMS: TRAINING PATHWAYS AND LABOR ECONOMICS

Among the necessary conditions for developing and supporting a primary care workforce to meet society’s needs, two are paramount: (1) training programs with sufficient capacity and appropriate curricula to produce the right number of professionals on the primary care team with the right skills, and (2) a labor market that makes primary care careers financially attractive and sustainable.

Health Professions Training

Health professions training programs are administered by a wide array of private and public higher education and health care institutions, financed by fees paid by students and their families, funding from state and federal government, philanthropy, clinical revenues, and other sources. HRSA currently funds a number of health workforce research grants that are focused on workforce planning, preparation, and training across professions (HRSA, 2022). Some states have recently implemented major programs to invest state funds to address training needs in professions experiencing shortages, such as California’s Strategy to Expand Behavioral Health Workforce (California Department of Health Care Access and Information, 2024).

Extensive information has been published on health professions education and its bearing on the primary care workforce, with findings and recommendations that remain applicable today (Council on Graduate Medical Education, 2017; IOM, 2015; NASEM, 2021a,b). Two important findings that are consistently reflected in the literature have clear federal

policy implications. First, the Implementing High-Quality Primary Care report recommended that to help ensure access to high-quality primary care for populations across the country, the federal government should be dedicating a specified and appropriate share of physician training investments to primary care residency programs (NASEM, 2021b). The principal federal investment in health professions education is funding of graduate medical training, with Medicare funding of graduate medical education (GME) amounting to $17.8 billion annually (Congressional Research Service, 2024). Medicare GME funding is limited to accredited residency programs in medicine, osteopathy, dentistry, or podiatry. A 2014 Institute of Medicine (IOM) report criticized he Medicare GME program for delegating considerable discretion to the hospitals receiving these funds in how they choose to allocate funding for residency positions in different specialties, resulting in more than two-thirds of positions being in nonprimary care specialty training (IOM, 2014). Additional issues highlighted in the report include geographic maldistribution of training slots and disbursement of training funds to hospitals rather than sponsoring institutions and community-based ambulatory training facilities.

The IOM report recommended greater accountability for GME funding and better alignment with national workforce goals, such as producing more primary care physicians. The recommendations from this report, which were reinforced by the recommendations in the Implementing High-Quality Primary Care report, have not been implemented and remain relevant next steps for action (Kaufman et al., 2021; NASEM, 2021b). Recent analyses reveal that higher levels of Medicare GME funding are not associated with a stronger primary care workforce; in fact, states receiving the most Medicare GME support tend to produce a lower proportion of physicians entering primary care (Milbank Memorial Fund, 2025).

Although Congress in recent years has enacted some community-based primary care training programs, such as the Teaching Health Centers program administered by HRSA, at current funding levels these measures are insufficient to ensure adequate training opportunities for primary care physicians. GME programs administered by the Centers for Medicare & Medicaid Services (CMS) continue to account for the vast majority of federal residency training dollars and disproportionately support specialist training. In 2021, Medicare contributed $17.8 billion of the approximately $24 billion total spent on GME (Congressional Research Service, 2024; Milbank Memorial Fund, 2025), while the Teaching Health Center Program received only about $126.5 million for that year in comparison (American Association of Teaching Health Centers, 2025).

The second important finding reflected in the Implementing High-Quality Primary Care report, as well as a 2015 IOM report and other literature, is that a new approach to workforce training is needed (Endalamaw

et al., 2024; IOM, 2015; NASEM, 2021b). The Implementing High-Quality Primary Care report recommended that federal GME be modified to support the training of all members of the interprofessional primary care team, including (but not limited to) NPs, pharmacists, PAs, pediatricians, behavioral health specialists, and dental professionals, and that federally funded GME efforts should shift from hospitals to more community-based settings (NASEM, 2021b). Primary care teams need to be trained to function as an interprofessional team above and beyond the mere recognition of typical role-based approaches. Improved training on interprofessional team-based care has been identified as a need for primary care clinician collaboration with pharmacists, mental health professionals, and cross-sectoral collaboration (Rawlinson et al., 2021).

Interprofessional practice has four major established core competencies:

1. values and ethics for interprofessional practice,
2. roles and responsibilities,
3. interprofessional communication, and
4. teams and teamwork. (Schmitt et al., 2011)

Challenges exist in offering interprofessional didactic and experiential learning that align with these competencies in the already crowded medical and health professional educational programs, and in assuring existing workforces have the time to adapt clinical workflows and adjust their work accordingly to accommodate learners. Teams benefit from communication, collaboration, and mutual accountability, and both learners and existing care team members need to continuously reflect on their experiences and adjust their strategies in the already time-sensitive environment of patient care.

Interprofessional team training is needed for health professional education programs as well as for health care professionals already in practice. The National Center for Interprofessional Practice and Education released its Guidance on Developing Quality Interprofessional Education for the Health Professions, which has been endorsed across interprofessional health education accrediting bodies and embedded in health professions curricula across disciplines (Health Professions Accreditors Collaborative, 2019). Nearly all medical schools require interprofessional education for students (Salzman et al., 2025). The Accreditation Council for Graduate Medical Education (ACGME) requirements include interprofessional collaborative practice competencies; however, there is limited literature on interprofessional training in residency programs. In a survey of program directors of family medicine residencies, approximately 62 percent of respondents reported they have formal learning objectives on interprofessional collaborative practice. Team training for those already practicing is a valuable

component of continuous professional development, improving engagement and ensuring members of the team are practicing at the top of their licenses (Smith et al., 2018). Such training not only requires introduction of new diagnostic and treatment modalities as scientific knowledge expands, but also team-based approaches to technology including digital health and artificial intelligence. An interprofessional team needs to optimize workflows to enhance communication and coordination, and training and additional facilitation are necessary supports.

Practice Facilitation

Practice facilitation has the potential to help meet these training needs, assisting primary care practices to improve their work as an interprofessional team. Facilitators are trained to build capacity in primary care practices and provide on-the-job training to interprofessional team members to implement meaningful operational changes (Dogherty et al., 2010; Knox and Brach, 2018; Nagykaldi et al., 2005; Taylor et al., 2013). Facilitators provide support to practices through education and can be paired with teamwork trainers (Cohen et al., 2023; Grumbach and Mold, 2009; Phillips et al., 2019). Facilitators use materials that guide care teams through formalization of policies and procedures for interprofessional team-based care that can improve team performance (National Association of Community Health Centers, 2019). Facilitators also support motivation to change, accountability, and guidance on organizational process. They work with practices—through plan-do-study-act cycles and quality improvement activities—to promote better communication and relationships among clinical team members, train staff, and provide technical advice (AHRQ, 2022; Dogherty et al., 2010; Kilbourne et al., 2023; Sweeney et al., 2022; Taylor et al., 2013).

Facilitators have been used in primary care to good effect (Baskerville et al., 2012; Grumbach et al., 2012; Nutting et al., 2010; Ritchie et al., 2017; Wang et al., 2018). Facilitators are most effective when they work in person and when they have the skills to engage and influence leaders, assist practices with problem solving, cultivate motivation to change, identify and address resistance, and provide structure and accountability. Ongoing training and support promotes facilitator effectiveness (Miake-Lye et al., 2021; Sweeney et al., 2020, 2022), and an external organization, such as a primary care extension program, can provide that organizational infrastructure to facilitators who function as local extension agents, sharing knowledge, creating connections among primary care practices, and facilitating improvements such as adoption of interdisciplinary team-based care models (Balasubramanian et al., 2022; Cohen et al., 2021, 2022). Primary care extension programs have been modeled and tested in the United States

for nearly three decades and was authorized in 2010 (but never funded) by the Patient Protection and Affordable Care Act (ACA).²

Labor Economics: Valuing Primary Care by Paying More and Paying Differently

Since 2024, three National Academies’ study committees (all subgroups of the Standing Committee on Primary Care) have produced reports addressing the misvaluing of primary care services and the need for Medicare physician payment reform to more appropriately value and pay for primary care services (NASEM, 2024b,c, 2025). There is an inextricable link between payment and the primary care workforce challenges the nation faces today.

Health workforce planning in the United States has insufficiently focused on labor economics and the powerful influence of payment policies in shaping career choices and the composition of the workforce. The appropriate valuation of primary care services also has profound implications for providing the adequate resources the entire workforce needs for interprofessional primary care teams (NASEM, 2025).

One major economic factor contributing to the shortage of primary care clinicians is the large disparity in earnings of primary care physicians relative to their specialty counterparts (CompHealth, 2024). For example, a 2024 national survey of U.S. physicians found that the average annual earnings of family physicians and pediatricians was approximately half that of orthopedic surgeons and cardiologists (CompHealth, 2024). The proportion of residency positions in a specialty filled by U.S. medical school graduates is highly correlated with the average income of physicians in that specialty (Faber et al., 2016), with fill rates among the lowest for primary care residency programs. Temporal variation in the likelihood of medical school graduates planning careers in primary care is associated with changes in the relative earnings of primary care physicians and specialists (Council on Graduate Medical Education, 2010).

Growing levels of educational debt among graduates of health professions schools elevates the consideration of future earnings prospects in decisions about specialty choice. Although loan repayment programs such as the National Health Services Corps (NHSC) program administered by

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² Public Law 111–148.

HRSA prioritize providing awards to primary care clinicians working in health professions shortage communities and have proven value for recruiting physicians and other primary care providers to shortage areas, the total amount of loan repayment is dwarfed by the disparity in lifetime career earnings between primary care physicians and those in most specialty fields. While programs such as the NHSC have proved to have important value for mitigating the geographic maldistribution of the health care workforce and staffing community health centers, they are insufficient to reverse the overall labor economic disincentives for students and trainees to choose primary care fields (Davis et al., 2023; Han et al., 2019).

Elena Falcettoni, an economist at the Federal Reserve, during a panel discussion at the May 2025 meeting of the Standing Committee on Primary Care, summarized why misvaluing of primary care services drives workforce imbalances, stating

Not only do lower payments dissuade clinicians from selecting primary care careers, but they are also inadequate to support the interprofessional staffing needed for high-quality primary care. Many primary care practices are operating on tight and decreasing margins that make it challenging for them to hire the personnel needed for extended and community care teams (Leach et al., 2017; Payerchin, 2023). In addition to the undervaluing of primary care services in fee schedules, the very method of fee-for-service payment is poorly designed to support team-based care. Typically, payers only allow physicians, nurse practitioners, and a few other types of licensed health professionals to bill for services, excluding many other members of the team as billable providers (CMS, 2025). Moreover, itemized fee-for-service billing is better suited to discrete encounter- or episode-based units of services than the relationship-based, longitudinal, comprehensive approach characterizing primary care, which include asynchronous communication, time spent in care coordination, and related activities (NASEM, 2021b).

Alternative payment models, such as those implementing hybrid payments, often include a component of payment for performance. There is limited evidence on performance incentives directed toward the team rather than individual clinicians (Aggarwal et al., 2023); case studies highlight the importance of valid, reliable, feasible, and important performance measures that are inclusive of all team members and allow them to feel in control over their performance. Regular reporting of team metrics may motivate

collaboration and performance. Individually targeted pay-for-performance (P4P) has been associated with fostering teamwork and expanding team member skill sets; however, it is also associated with a number of unintended consequences. External motivators (e.g., payment) can complement important internal motivators, which may be fostered through positive organizational culture and team training (Aggarwal et al., 2023).

For these reasons, the Implementing High-Quality Primary Care report recommended that all payers should shift primary payment toward a hybrid model incorporating a prospective payment component in addition to increasing the overall portion of health care spending going to primary care (NASEM, 2021b). CMS’s recently launched Advanced Primary Care Management (APCM) codes are an example of a new hybrid payment that primary care practices can bill for per patient per month. This both pays participating primary care practices more than traditional fee-for-service and enables them to support efforts of the full interprofessional primary care team, including time spent outside of face-to-face visits (CMS, 2024a; NASEM, 2024b, 2025).

While it is too soon to know if APCM payments are sufficient to truly give a meaningful boost to participating practices to finance interprofessional team-based care, and too soon to know how many practices will participate, this committee agrees with recent reports by subgroups of the Standing Committee on Primary Care and supports the APCM approach (NASEM, 2024b, 2025). If successful, APCM could be a model worthy of expansion for other payers.

Federally Qualified Health Centers (FQHCs), which offer comprehensive primary care and other services to underserved populations in rural and urban settings, offer another example of paying practices more and differently than traditional fee-for-service. Half of FQHC patients were covered by Medicaid in 2023, and nearly 18 percent were uninsured (Federman et al., 2024). While many FQHCs face financial pressures due to serving large uninsured populations and stagnant financial support despite an increase in patient volume (Federman et al., 2024), many FQHCs have more robust interprofessional team-based models than is typically found in other settings. This is attributable in large part to the funding structure of FQHCs. The Prospective Payment System for Medicaid patients served by FQHCs is a visit-based payment model, but it bundles all services provided to a patient on a given day under a payment rate typically much higher than usual Medicaid rates for office-based primary care services, enabling FQHCs to tailor the care they provide based on the specific needs of their community with an integrated, interprofessional team-based approach (Carlo and Wardlow, 2025; CMS, 2024b; Coker et al., 2025; MedPAC, 2011; Patel et al., 2024; Sotelo Guerra et al., 2023). FQHCs also receive HRSA grant funding to help pay for services to uninsured patients.

Paying more and differently to achieve the desired outcome of strengthening the primary care workforce and developing and sustaining interprofessional primary care teams, such reforms need to ensure that increased payments are invested directly in primary care practices. The complexity of health care organization in the United States requires attention not just to policies on payments from health plan payers to provider organizations, but to the flow of those revenues within organizations.

When a health plan directly pays a primary care practice (e.g., payments by traditional Medicare to a small, independent primary care practice), the translation of higher health plan payments into more resources for the primary care practice is relatively straightforward. The process is more complicated when health plan payments flow through intermediaries situated between the payer and the primary care practices, such as integrated health systems, large medical groups with employed physicians, independent practice associations, and other entities (Bodenheimer et al., 2023). Primary care payment policies designed to increase support for interprofessional primary care teams must therefore include mechanisms to ensure that the increases in payment make their way to the practice level to increase clinician and staff compensation and fully staff care teams. This helps ensure that policies have their intended effect of strengthening the core and extended primary care teams and enhancing patient access to high-quality primary care delivered by interprofessional teams.

Some state governments and other state regulatory bodies are measuring and increasing the portion of state health care spending committed to primary care and play an important role in developing and implementing payment policies that affect the primary care workforce. There are over 13 states that either have or are developing a method to estimate spending on primary care as a component of policy efforts to strengthen primary care (Cohen et al., 2024). Rhode Island was one of the first states to monitor and mandate an increase in primary care spending, with evidence suggesting that these payment policy changes resulted in lower hospital prices, reduced insurance premiums, and out-of-pocket spending (Baum et al., 2019; Hurwitz et al., 2019).

These policies are necessary as most provider organizations and health systems currently prioritize capital and human resource investments in specialty and procedural services that create higher margins and a faster return on investment (e.g., surgical centers and imaging services). Primary care is a lower margin service and receives less investment in staffing, technology upgrades, and other innovative efforts that would support the existing workforce and improve patient outcomes (Jabbarpour et al., 2019). Even within integrated systems, only 5 to 7 percent of health spending in the United States goes to primary care, and the primary care workforce bears the burden of these respectively low resources while patient needs and

workload continue to increase (Milbank Memorial Fund, 2025; NASEM, 2021b). Examples such as the Stanford Health Care physician-directed reinvestment program is an approach designed to help ensure that the primary care workforce is engaged in the prioritization of effort both at the front line and the health system levels of decision making (Vilendrer et al., 2022). At the state policy level, state regulators could adopt measures to incentivize or require health systems to invest new revenues from enhanced primary care payments in the interprofessional staffing and practice support needed to strengthen primary care operations.

RECOMMENDATIONS

Many factors and policies shape the development and deployment of the workforce and interprofessional teams needed for people in communities across the United States to access comprehensive high-quality primary care. These include the operation and funding of training programs, policies to address geographic maldistribution in rural and other underresourced communities, and the engagement of patients, families, and community members in defining interprofessional team configurations best suited to local needs, among other considerations. This committee concludes, however, that the single biggest current impediment to developing and sustaining the interprofessional primary care teams needed by the U.S. public is inadequate payment.

The disparity in compensation for primary care clinicians relative to specialists is a powerful disincentive for health professionals to select careers as primary care clinicians. The low overall investment in primary care relative to overall health care spending in the United States does not provide sufficient resources for primary care practices to hire and sustain the full complement of core and extended team members needed for high-performing interprofessional primary care (Milbank Memorial Fund, 2025). Developing and sustaining interprofessional primary care teams is not only about having enough money. Flourishing teams require ongoing attention to training and practice facilitation to promote a culture of teamwork, and roles and disciplines on the team must continually adapt to changing patient and community needs. Appropriate levels and methods of payment are absolute necessities to build a culture of teamwork that effectively prepares, recruits, and retains the workforce needed to staff flourishing, agile, and adaptive interprofessional primary care teams. More funding does not always result in the intended production of flourishing teams without mutual guiding principles of primary care as an essential common good for all. Assuming they have the resources to do so, health system leaders can help build a culture of teamwork to actualize this concept and help ensure the communities they serve have access to high-quality primary care. Based

on the evidence summarized in this report and building upon prior work, this committee makes nine recommendations for developing and sustaining interprofessional primary care teams in the United States.

Primary Care Payment

This emphasis on payment is consistent with recent National Academies reports completed by subgroups of the Standing Committee on Primary Care that address reforms to primary care payment and valuation to appropriately support comprehensive, high-quality primary care (NASEM, 2024a, 2024b, 2025). If public and private payers do not reform how they pay for primary care, the nation will not be able to fix pervasive, worsening primary care workforce shortages and adequately staff interprofessional primary care teams. In addition to paying more, alternative payment methods that include prospective payment are needed to ensure access to critical primary care functions, including prevention and population health, chronic disease diagnosis and management, and assisting patients with behavioral and social issues. Examples of hybrid payments include the CMS Innovation Center primary care models (e.g., Comprehensive Primary Care Plus, Making Care Primary) and the CMS APCM payment. While these hybrid payments are a step in the right direction, they still make up a very small proportion of primary care payment overall. Multipayer alignment with these and other hybrid models will help reach a tipping point in practice payment that enables substantive change that can support the development and sustainability of interprofessional teams delivering high-quality primary care.

Accountability for Enhanced Primary Care Payment

For enhanced primary care payments to achieve the goal to support interprofessional primary care teams, mechanisms are required to ensure that health care organizations and practices invest those additional revenues in the workforce and practice infrastructure needed for high-performing primary care.

Payers have the leverage to hold health systems accountable to invest more in primary care services and interprofessional primary care team development. If payment intended for primary care does not actually reach the primary care practices, then the payment increases are moot.

As health care in the United States has evolved into a profit-driven commodity, it is critically important to use policy levers to ensure that the health and well-being of individuals, families, and communities are prioritized (Berwick et al., 2025). The contractual and regulatory requirements in recommendations 2 and 3 are, therefore, crucial and could include transparency in reporting the allocation of funds within a provider organization, as well as documenting measurable improvements in practice infrastructure, such as an increase in staff full-time equivalents (FTEs) in primary care practices that can ensure interprofessional primary care teams are able to deliver high-quality primary care that achieves better outcomes and increased long-term cost savings.

Interprofessional Primary Care Team Training and Facilitation

Primary care extension and practice facilitators can play a vital role in supporting scale and spread of an interdisciplinary team-based approach to primary care. Through tools, training, and coaching, facilitators can help develop a culture, as well as define roles, functions, and processes in primary care practices that support the teamwork that is central to interprofessional, relationship-centered patient care.

In addition to affirming the 2014 IOM recommendations on GME support (IOM, 2014; NASEM, 2021b), recommendations 4, 5, and 6 address the need for comprehensive support for interprofessional care teams beyond the initial preparation of individual roles within the primary care workforce, including a focus on on-the-job training through practice facilitation. Implementation of Recommendation 6 could potentially fall under the auspices of the newly proposed Administration for a Healthy America or the proposed Office of Strategy, both within HHS. While authorized by the ACA, the Primary Care Extension Program was never funded and may require congressional support.

Monitoring, Assessment, and Accountability for Workforce Policy

The need for, and success of, policies to revitalize the primary care workforce to sustainably deliver care in an interprofessional team-based model depends on accurate measurement of the clinicians and practice staff truly functioning as providers of comprehensive, longitudinal primary care,

and accountability among stakeholders for achieving national and regional workforce goals.

A longstanding challenge for workforce assessment and planning is accurate measurement of the primary care workforce. Data from traditional repositories enumerating health professionals, such as state licensing board records and files curated by professional associations such as the American Medical Association, are insufficient for accurately measuring who is providing primary care (and at what level of FTE effort), where they are providing it, and the type of practice they are working in. Initial state-based assessments using claims data suggest an even more dire shortage of primary care clinicians than estimated using traditional taxonomy-based methods. Many states now have all-payer claims databases that may be used for these more sophisticated workforce analyses. A concerted, coordinated effort is needed to compile and curate data from a variety of sources, including claims data and other data that measure roles and activity, to produce a publicly available national primary care workforce compendium, moving beyond just head counts based on clinician taxonomies to more meaningful measures of the clinicians and other workers functioning in primary care roles (Ganguli et al., 2020).

An agency within HHS (such as AHRQ or, per reorganization plans announced by the Trump administration, a new HHS Office of Strategy) could take the lead, in collaboration with state agency representatives, health professional and health care organization stakeholders, health workforce researchers, and other parties, to develop and maintain a primary care

workforce compendium. This compendium could include claims and other data from private and government-administered health plans, including Medicare, Medicare Advantage, and state Medicaid. A more accurate assessment of the functional primary care workforce would inform assessments at the national and state level of the adequacy of the primary care workforce and its responsiveness to policy changes such as a reform of primary care payment, as proposed in the recommendation of the Implementing High-Quality Primary Care report for HHS to establish a national primary care scorecard (NASEM, 2021b). This compendium could also be an invaluable resource for research assessing how workforce supply and team configurations may impact the health of communities and be affected by changes in federal and state policies and the health care marketplace.

More accurate assessment of the primary care workforce across all roles included within the interprofessional care team needs to be linked to an accountability mechanism to ensure data are used to inform needed policy changes. Several accountability mechanisms specific to or inclusive of primary care workforce have been previously proposed. Prior NASEM reports have recommended accountability infrastructure for Medicare GME funds (via a GME Council in the Office of the Secretary of HHS and GME Center within CMS) and for primary care (via a Secretary’s Council on Primary Care). The Affordable Care Act authorized a National Health Care Workforce Commission that would provide recommendations to Congress and the administration, but funds were never appropriated for this purpose.

CONCLUSION

Effective interprofessional teams are a foundational component of high-quality primary care (NASEM, 2021b). However, without changes to how primary care is paid for, health systems and primary care practices will continue to struggle to build and sustain robust interprofessional primary care teams needed to deliver high-quality primary care. These recommendations for the federal government, payers, and health systems—expanding

payment to cover the full functions of the interprofessional primary care team, paying more for these functions and the complex and valuable relational work primary care clinicians and teams do, paying for primary care with more prospective and value-based methods, holding stakeholders accountable for supporting the primary care workforce, promoting a culture of teamwork, altering how we train primary care across professions and facilitate primary care practice, and measuring the needs and progress of this workforce—are urgently needed to ensure all communities in the United States have access to high-quality primary care. This care should be delivered by interprofessional teams that address patient and community needs with relationships sustained over time by a robust and well-supported workforce. Health system leaders also play a significant role in actualizing these recommendations; it is imperative that leaders commit to fostering and promoting a culture of teamwork and strive to build and sustain the interprofessional teams that can effectively deliver high-quality primary care to the communities they serve. If implemented, these recommendations will help ensure that primary care practices can build and sustain interprofessional teams to carry out the demanding and complex work of primary care while fostering work–life balance. Bold actions are urgently needed to maximize recruitment and retention, reverse the burnout and ongoing exodus of the primary care workforce, all with the aim of improving primary care access and health outcomes for everyone in the United States.

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