A team of researchers at Dartmouth’s Geisel School of Medicine, led by co-principal investigators Karen Schifferdecker, PhD, MPH, and Elliott Fisher, MD, MPH, has received a $4 million grant from the National Institute on Aging (NIA) to address disparities in primary care across the U.S.
There is broad consensus that disparities in health within the U.S. are pervasive and, for some populations, widening. Studies conducted at Dartmouth and other leading institutions have also shown that high-quality primary care plays a vital role in the prevention, diagnosis, and management of the many chronic health conditions that contribute to health disparities.
But primary care in the U.S. is threatened—even before COVID-19, the per-capita supply of primary care physicians was falling and varied dramatically by county, putting rural and other less-advantaged communities at risk. In addition, little is known about how access to primary care has been impacted by the pandemic.
“These gaps in understanding have hindered our ability as a country to provide the best primary care consistently across our communities,” says Schifferdecker, an associate professor of the Dartmouth Institute for Health Policy and Clinical Practice and of community and family medicine at Geisel. “So, we wanted to take a deeper dive into the policies, systems, and practices that support primary care to reduce health disparities, and we’re doing that with a particular focus on older adults.”
The five-year project will build on previous work that the team has been engaged in. Utilizing a mixed-methods approach, it will draw on a unique national dataset that includes annual information on the ownership and staffing of all U.S. primary care practices (from 2017 to 2025), linked Medicare claims data, and surveys of nationally representative samples of these practices that were carried out in 2017 and 2022.
“As important as quantitative or data analysis work is in trying to determine what works and what doesn’t in health policy, it can only take you so far. Much depends on people’s judgement and knowledge about what’s going on in the real work of policy or clinical practice—and with the mixed-methods approach you get both,” explains Fisher, a professor of the Dartmouth Institute for Health Policy and Clinical Practice, of medicine, and of community and family medicine at Geisel. “We’re fortunate that some of the top researchers in the country in primary care policy and healthcare disparities have agreed to be collaborators and advisors on the grant.”
This list of experts includes Drs. Robert Phillips, Mark McClellan, and Kurt Strange in an advisory role, as well as Drs. Matt Mackwood, Ellesse Akre, Nancy Morden, Jeah Jung, and James O’Malley as research collaborators.
In their work, the project team will examine U.S. trends in access to primary care for Medicare beneficiaries and determine how these trends vary for less-advantaged populations. They will identify factors associated with better processes and outcomes of care for Medicare beneficiaries, with a focus on those with fewer social and economic advantages. And they will conduct qualitative research, such as in-depth interviews, to identify key policies aimed at supporting primary care to inform further analyses that examine outcomes of these policies.
The team will then sample practices that participated in the 2022 national survey that work with economically less-advantaged and minoritized populations, and conduct in-depth qualitative interviews with their leaders and staff to identify underlying barriers and facilitators to improving primary care for less-advantaged populations.
“As we look ahead, we’d like to be advocating at both the federal and state levels for better attention and support for primary care, and also around health disparities,” says Schifferdecker. “Over the years, various things have been tried to create a stronger foundation of primary care but they’re not working. More needs to be done.”
Fisher agrees. “I think we’re at a place where there’s broad agreement that primary care is in trouble, and there’s a commitment at the federal level and in many states to try to do better,” he says. “Based on our findings, we hope to develop recommendations that can assist practices, health system leaders, and policymakers in improving primary care and reducing health disparities for older adults.”
