The Real Barrier to Better Primary Care: Getting People to Actually Show Up

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Barbara Starfield's framework has shaped primary care for four decades.

The four Cs remain foundational because they work. When primary care delivers on all four dimensions, healthcare costs fall, health outcomes improve, and the gap between who receives excellent care and who doesn't begins to close.

• First contact
• Comprehensiveness
• Coordination
• Continuity

But here's the problem: Starfield's framework assumes the patient shows up.

Her groundbreaking work describes what happens once someone is in the room with a doctor. It measures the strength of the doctor-patient relationship, whether the practice can address the full spectrum of health needs, and how well it coordinates with the rest of the healthcare system. Every metric assumes someone has already walked through the door.

And that's where primary care breaks down for the people who need it most.

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What causes people to not seek care?

All working Americans should have access to great primary care. Yet even when people have access, many don't use it.

• Cost: Copays, surprise bills, unclear pricing
• Inconvenience: Long wait times, distance to travel, time off work
• Bad experiences (or perception of them): Prior negative encounters that teach people to stay away

These barriers teach people to wait. And waiting is how a manageable problem becomes an expensive one.

Meanwhile, hospitals spend heavily advertising their emergency rooms, urgent care centers, and specialists directly to consumers. When people finally need care, these services are top of mind. So they default to the expensive option, the one that's already advertising to them. By then, the problem isn't manageable health. It's crisis management.

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The Cost of Non-Engagement

Here's what this looks like in the data: About 9% of members drive 46% of the next year's spend[2]. The people whose health is about to get expensive are disproportionately the ones who never engaged with primary care in the first place.

You can build a practice with excellent doctors and strong continuity. If the person who needs it most never comes through the door, none of it matters.

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What actually gets someone to use primary care?

This is the question that Starfield's framework doesn't answer, and it's the one that decides whether any of it delivers/

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Cost, Convenience, and Communication.

Cost

Cost is really a barrier to engagement more than a driver of it, which is exactly why it belongs here. A copay, a surprise bill, an unclear sense of what something will cost: each one is a reason to wait, and waiting is how a manageable problem becomes an expensive one.

Take the financial friction out of the front door and people come in earlier and more often. That matters well beyond the individual patient, because earlier engagement with primary care is one of the most direct levers on total cost we have, and most of the savings show up as hospitalizations that never happen.

The One Big Beautiful Bill Act now enables employers to cover Direct Primary Care memberships and virtual care so all plan members can receive high quality care at no cost to the member[3]. That's a structural fix to the cost barrier.

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Convenience

More than eight weeks for an appointment. A drive across town. Time off work that not everyone can afford to take. Every one of these is a reason the people with the least flexibility in their lives fall out of care first.

Starfield called this first contact and framed it partly as gatekeeping: is primary care the required front door to the system? The more honest question today is whether it's the easiest door.

For a lot of people, convenience is what decides whether care they nominally have is care they actually use.

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Communication

Communication is the C that sits closest to Starfield's continuity, and it's worth being precise about the difference. Continuity is the relationship a doctor builds with a patient over time. Communication is what keeps that relationship alive between visits and what reaches the people who don't have one yet: the outreach that finds the member who hasn't come in, the follow-up that closes a loop, the plain explanation that turns a diagnosis into a plan someone can actually follow.

Continuity assumes an ongoing relationship. Communication is often what creates it in the first place.

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Why This Matters Now?

Starfield's four Cs are the foundation, and they earned four decades of authority for a reason. But they were written for a world that assumed access was a given and the hard part was clinical. The hard part now is engagement: reaching the people who need primary care most and are least likely to walk in on their own.

Cost, convenience, and communication get dismissed as patient experience, the soft stuff that sits to the side of real medicine, when they're actually the mechanism that turns good primary care into good population health.

Engagement doesn't come after quality. It's what decides whether quality ever reaches the person who needs it. Get the three Cs right, and Starfield's four finally have someone in the room to serve.

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Sources

1Starfield's Four Cs Framework Starfield, B. (1992). Primary care: Concept, evaluation, and policy. Oxford University Press.

2"9% of members drive 46% of next year's spend" Internal analysis based on employer healthcare spend data. This finding reflects a consistent pattern across self-insured employer populations where a small percentage of high-risk members account for a disproportionate share of future healthcare expenditures.

3One Big Beautiful Bill Act (OBBA) Federal legislation enabling employers to cover Direct Primary Care memberships and virtual care as zero-cost benefits to plan members, expanding access to high-quality primary care without member cost barriers.

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