Simply put, 2019 has been a big year for primary care in the United States. Whether you follow federal or state healthcare news or simply follow investor-entrepreneur Mark Cuban on Twitter, it’s likely you’ve seen how the conversation about primary care has been elevated. Federally, the Centers for Medicare & Medicaid Services announced its Primary Cares Initiative, which will invite primary care providers to join one of two value-based payment models: Direct Contracting or Primary Care First. The same week, partnering with the Center for Medicare & Medicaid Innovation (CMMI), Mathematica released a report evaluating the largest primary care transformation effort to date, the Comprehensive Primary Care Plus model. In states like Colorado and Vermont, policymakers have advanced statewide efforts to measure investment in primary care and are starting to explore options to change that investment. The Patient-Centered Primary Care Collaborative (PCPCC) focused its annual evidence report on state-level investment in primary care, advocating for a standard measurement for primary care investment.
Last week, PCPCC brought together a broad group of stakeholders to discuss this report. In light of so many recent developments, there was much to discuss about the state of primary care investment in the United States. Representatives from commercial and public payers, employers, patients, and leaders from states like Colorado and Minnesota spoke about what primary care transformation can look like. The room was full, and stakeholders’ excitement about the opportunity to make progress was palpable. Here are a few takeaways from the discussion about where there is consensus and a few thoughts about what might come next.
- Let’s find a common definition for primary care spend. The PCPCC annual report highlights that there is no standard or accepted way to measure the amount of health care dollars spent on primary care services—primary care spend—and that there are many different opinions on what qualifies as primary care. Why the need for consistency? The report puts it well: “[r]egular measurement of primary care spend at the national and state levels can heighten visibility of how public and private payers value primary care over time and by comparison to their other health care expenditures.” As local and national leaders look for ways to begin and expand investments in primary care, consistent measurement will be a critical tool for evidence-informed decision making.
- The conversation can’t just be about saving money. Health care spending in the United States is far too high, and the entire health care community should be investigating ways to bring those costs down. But only looking at transformation efforts which are sure to bring down costs could mean missing the broader point of delivering value for dollars spent. There’s value in managing chronic diseases effectively, in paying providers for above-and-beyond work, and in creating safe care delivery environments where all can feel comfortable and cared for. Yes, the evidence is mixed on whether increased primary care investment reduces overall health care costs. But rather than focus on reducing costs as a justification for primary care investment, let’s talk about which transformation efforts can help improve outcomes and deliver better value.
- It’s time for a tough conversation about reallocating the way health care dollars are spent in the United States. The PCPCC report states that nationally, we only spend 5 to 7 percent of our health care dollars on primary care spending. A recent study in JAMA Internal Medicine showed that primary care spend, calculated using two different definitions, is about 2.12 to 4.88 percent of total health care spending among Medicare beneficiaries. This evidence of minimal investment naturally spurs the primary care community to discuss ways to increase that percentage. Of course, simply increasing investment in primary care without discussing any tough trade-offs is unlikely to make a dent in addressing the rise in overall health care spending. Any discussion about reallocation of spend to primary care without making “the pie” bigger necessarily means someone gets paid differently. The evidence isn’t clear on what can be done yet, but there’s certainly value in everyone involved taking a critical look at the value physicians deliver and starting to compensate based on that value.
This ongoing conversation builds on years of work that provider organizations, CMMI, and countless others have done to invest in new care models and evaluate them. As we gather more evidence and experience in primary care transformation, we gain momentum, common language, and common understanding to aid tough conversations ahead. The momentum gained thus far in 2019 should be just the beginning. Policymakers, providers, advocacy groups, employers, researchers, and consultants collectively have their work cut out for them to push these national and state efforts forward.
