By Casey Korba, Director of Policy & Caroline Smith, Senior Policy Specialist
The United States underinvests in primary care compared to other high income countries; as a result, we have comparatively worse health outcomes. Over the last decade, advocates have built momentum around identifying tangible solutions to increase primary care investment. One solution is through state legislation setting a minimum investment in primary care for the state and in some cases commercial payers. On November 2, 2022, Aledade hosted its first Multi-State Policy Collaborative with a focus on what states are doing to increase investments in primary care and how physicians and clinicians can build support in their communities for primary care investment solutions.
This virtual event featured a panel of experts who were successful in passing primary care investment legislation in their states. The event kicked off with an overview of the supporting data and research findings on the association between primary care and the use of preventive services, the link between primary care and improved health outcomes, and state-level initiatives to increase primary care investment. Speakers then laid out their vision for required minimum primary care spend, how they garnered bipartisan support from a diverse group of stakeholders in their state, and how these investments impact clinical practice and patient outcomes. Following the presentation and panel discussion, participants broke out into advocacy workshop sessions to learn more about tools they can use to begin their advocacy.
What the research tells us about underinvestment in primary care and state efforts to date
There is compelling data that shows increased access to primary care decreases mortality. Other key takeaways from the research on mandated minimum spend presented by Gabe Manion, a former Aledade intern and current MBA candidate, included:
- There is no one definition of primary care. It is a challenge to measure primary care spend due to the disparity in definitions by scope of specialities, clinician type, and care setting.
- States can learn from each other. States often follow similar pathways towards legislation.
- Major strategies states are pursuing center around three buckets. These include transparency (reporting to government agencies, setting and measuring aspirational targets); contracting (opportunities for preferential contracts and requirements for contract parameters); and regulatory (requiring minimum levels of spend, enforced via licensure requirements or other administrative mechanisms).
Building the case for investing in primary care
Oregon State Senator Elizabeth Steiner Hayward discussed the importance of investing in primary care, and some of the strategies that led to Oregon passing bipartisan legislation on minimum primary care spend. While Rhode Island was the first state to work on strategies to mandate minimum spend, she and other stakeholders looked to model Rhode Island’s strategies. The Senator noted that the “data is crystal clear” that the best way to keep people healthy and help them manage chronic illness is to have an adequate supply of primary care providers and ensure continuity of care.
The legislation that she championed targeted the growing reimbursement disparity between primary care and subspecialties. Oregon’s approach was not to tell managed care organizations what they must spend on primary care, but rather, to look at the total services that patients get in primary care, and target a percent of total spend to improve overall health outcomes. Strategies to accomplish this included increasing patient-centered care through tying the percent of total spend to the medical loss ratio, or to what managed care organizations and coordinated care organizations spend on direct care versus administrative costs.
The Senator noted that the “data is crystal clear” that the best way to keep people healthy and help them manage chronic illness is to have an adequate supply of primary care providers and ensure continuity of care.
One ongoing challenge she noted included identifying and analyzing all the data to get an estimate of how health care costs are attributed. Another complication is how to factor prescription drug spend into total costs, especially as primary care clinicians continue to prescribe increasingly expensive medications.
Senator Steiner Hayward identified that iteration was critical in this process, noting that health care transformation is ultimately rooted in iterating on ideas. Having multiple diverse stakeholders look at the problem and continue to work at it until a series of viable solutions can be put forward was a crucial part of the policy making.
Themes from the expert panel: Strategies to introduce and champion legislation
- Think holistically and center on a vision.
Representative Rachel Prusak represents District 37 in Oregon and is a family nurse practitioner who ran for office after witnessing countless missed opportunities to increase access to primary care in Oregon. She advised states to look holistically at primary care: who provides the care, across what licenses and sub-specialties, and where patients can access care. She suggested forming a primary care collaborative in the state that has a clear vision and engages stakeholders as a critical step to implementing the vision. Representative Prusak also talked about the importance of iterating, starting with easier issues that people can agree on, then moving on to address more challenging intricacies in the policy as trust among stakeholders is built. For example, Oregon started conversations with payers, who agreed to remove copays for some primary care visits. From there, payers agreed to add other components, like reimbursing for telehealth, incentives around team based care, and other value-based payments.
- Engage broadly.
Nancy Fan, MD, the Chair of the Delaware Health Care Commission and a practicing OB/GYN, discussed the road leading up to the passage of legislation requiring primary care spend in Delaware. She noted how important it is to have conveners like the Primary Care Collaborative to pull stakeholders together, combined with strong legislative leadership.
Delaware is a small state, and health systems play a large role in the economy. Having them at the table was essential. When asked what was a helpful strategy to get detractors on board, Dr. Fan pointed to the primary care workforce crisis and the critical need to involve a broad range of clinicians in advocacy efforts, including physician assistants and nurse practitioners, as well as getting specialists involved. It’s not about taking money away from other parts of the system, but a rising tide will lift all boats when it comes to improving quality of care. She said that it also helped that Delaware had data on being in the top 5 costliest states for health care in the country, yet not at the top for health outcomes. There was consensus that something had to be done to change this.
- Educate leaders.
Sarah Mullins, MD, is Aledade’s Regional Medical Director and runs Stoney Batter Family Medicine in Delaware. She shared that her Wilmington practice was in crisis prior to joining Aledade in 2018, with many physicians leaving for a variety of reasons, including retirement, moving out of state, and leaving for concierge medicine. She felt she had no choice but to advocate for her patients and practice. Through Aledade, the Delaware Primary Care Reform Collaborative, and other similarly tasked stakeholders, she began by inviting legislators to her practice, testifying in her state legislature, and attending relevant town halls. When the primary care minimum spend bill was proposed, the boots-on-the-ground approach and coalition-building paid off: the bill passed with strong bipartisan support.
- Primary care sustainability is nonpartisan.
Larry McNeely, Policy Director for the Primary Care Collaborative, noted that primary care is ultimately not a partisan issue, because being better stewards of spending in health care, improving outcomes, and saving money in the system is not partisan, and there is data and messaging that appeals to everyone. More and more states are realizing that, and passing measures accordingly. For example, a bill recently passed in Utah that aims to measure how much the state is investing in primary care spending. Nevada also established a health care cost growth benchmark to measure health care costs, and ensure those costs do not outpace state economic or income growth, with an end-goal to improve affordability, quality, access in health care, and improve transparency in Nevada’s health care system.
Moving forward and next steps
If you want more information on minimum primary care spend and ways you can be involved in advocacy in your state, reach out to [email protected]. You can see the presentation of the collaboration here. We are planning more multi-state policy collaboratives for 2023 to enable robust dialogue with subject matter experts and dedicated time to think through strategies to move forward on a state-by-state basis.