Primary care is a home run for both sides of the aisle

In 2008, Billy Beane, former Speaker Newt Gingrich (R-Ga.), and former Sen. John Kerry (D-Mass.) argued in the New York Times that health care in the United States was overpriced and underperforming. A bipartisan policy has emerged to address this problem — focus on paying for value not volume, with the Medicare Access and CHIP Reauthorization Act as the latest manifestation of this strategy. But a decade later, as the season of baseball is underway, Billy Beane would likely conclude that we have not yet hit it out of the park.

With respect to enhancing value, primary care is foundational. Studies show that advanced primary care reduces unnecessary specialist referrals, hospitalizations, and emergency room visits with better health outcomes for patients. This evidence has spurred the public and private sectors to encourage Patient-Centered Medical Homes (PCMH), a care delivery model that provides comprehensive, coordinated, patient-focused, team-based care.

{mosads}More than 20 percent of primary care physicians practice in a PCMH or similar advanced primary care model but most payment in these new delivery models is still volume not value-based. Care delivery reform has outpaced payment reform — a situation that is unsustainable. A primary care clinician acts for a patient like a general contractor on a construction project — accountable for meeting the customer’s needs, coordination and ultimately quality and value.

Can this be fixed? Follow the money. The United States only devotes 5-8 cents of each health care dollar to primary care. Higher performing health care systems in other developed countries devote double that amount to primary care — and have much better health outcomes to show for it.

But some states are blazing a different path, leveraging both regulatory and legislative strategies to invest more in primary care that support care delivery and payment reform. Other states should take notice.

In 2008, Rhode Island’s Insurance Commissioner used regulatory authority to boost health plan primary care spending as a percentage of medical spending from approximately 5.5 percent in 2008 to over 11 percent in 2014 — investment directed towards the formation of innovative PCMHs. During this time, total medical expenditures for this commercially insured population dropped by more than $170 million dollars. As a result, between 2015-2017, insurance rate increases in Rhode Island were lower than any other state.

On the other side of the country, Oregon’s legislature established the Patient-Centered Primary Care Home (PCPCH) program in 2009. A 2016 report by Portland State University showed that the PCPCH program saved $240 million dollars for Oregon’s health care system over 3 years (2012-2014) — approximately $13 in savings for every $1 increase in primary care investment.

These amazing results catalyzed Oregon legislators last summer to pass Senate Bill 934, which requires both public and private payers to spend at least 12 percent of total medical expenditures on primary care by 2023.

Co-sponsored by Sen. Elizabeth Steiner-Hayward (D-Ore.) and Rep. Knute Buehler (R-Ore.), the bill passed both the Senate and House unanimously. Under this legislation, the additional investments in primary care must be directed to designing or implementing advanced payment models and providing PCPCH-type services.

California and Colorado are the latest states to step up to the plate due in large part to the American Academy of Family Physician (AAFP) chapters and other health care thought leaders. California recently introduced the Primary Care Spending Transparency Act. This bill would require an insurer or plan that offers a health benefit policy to annually report its total primary care expenditures to the state. Similarly, Colorado introduced bipartisan legislation earlier this month to require the same kind of reporting and is setting up a collaborative effort to further the work.

Such policy strategies coupled with ongoing efforts to reform primary care delivery will result in more value for every dollar spent. Underinvesting in “upstream” primary care leads to higher “downstream” costs including poorer health and more hospitalizations and ED visits — it’s time to flip that equation.

As Beane, Gingrich, and Kerry pointed out in the New York Times, “We should learn from the successful teams that have adopted baseball’s new evidence-based methods. The best way to start improving (health care) quality and lowering costs is to study the stats.” We hope other states follow the lead of Oregon, Rhode Island, Colorado, and California, so that they too can hit it out of the park when it comes to health care value.

Ann Greiner is the CEO and president of the Patient-Centered Primary Care Collaborative. Evan Saulino, MD, PhD, Providence Milwaukie Family Medicine Residency, Center for Outcomes Research and Education and Clinical Advisor for Oregon’s Patient-Centered Primary Care Home Program.