Advanced Primary Care Key to Reducing Health Inequities

Robust, comprehensive primary care – a critical foundation for a more cost-effective, high-functioning health system – is equally important in helping boost health equity, a new report states.

The report, produced by the California Health Care Foundation, underscores the variety of ways in which advanced primary care can advance equity in care access and quality for underserved populations. Yet it also warns of significant barriers that continue to thwart primary care’s potential in California and nationwide.

In the face of these obstacles, employers can take steps today to strengthen primary care and reduce health care inequities. Actions can include expanding primary care locations, pushing insurers to strengthen financial support for primary care and increasing telehealth capabilities.

Unlocking Health Equity through Advanced Primary Care

Long-standing racial and economic discrimination in health and social policy has fostered pervasive health gaps for people of color. These disparities range from greater disease burdens and more mental health problems for racially minoritized populations to increased mortality and shorter life expectancies. Historically marginalized racial and ethnic groups also contend with less insurance coverage and reduced access to care.

The good news is that the key components of advanced primary care are particularly well-suited for reversing systemic health care inequities, according to the California Health Care Foundation report. Primary care’s capabilities and resulting benefits include:

• Improved access: A higher density of primary care physicians has been repeatedly linked to increased preventive services, lower avoidable morbidity and mortality and longer life expectancy among Black populations. Increasing the supply of diverse primary care doctors also helps reduce racial disparities in referral patterns and increases needed hospital care for Black Americans.

• Improved care continuity: Ongoing, individualized care provided by a single primary care clinician or practice is tied to lower mortality rates and fewer disparities in receiving recommended cancer screenings among Black and Latino populations. Interpersonal continuity with a primary care practitioner likewise enhances patient trust, which translates into better adherence to recommended preventive services, treatments and medications.

• Better coordination of care: Continuity across provider types and health care settings is shown to reduce racial and ethnic inequities in many important areas, including preventable emergency department visits and improved blood pressure control. For patients with multiple chronic conditions, coordination also lessens the burden of interacting with a fragmented and disorganized care system.

• Greater comprehensiveness: Integrating behavioral health and primary care services is considered one of the most effective ways to improve mental and physical health outcomes while eliminating inequities in care quality and access for racial and ethnic minority populations.

• Whole-person orientation: Elements of accountable, whole-person care — including clinician knowledge of a person’s overall medical history, social needs, preferences, family and cultural beliefs — improves patient self-management for chronic conditions. This is important for patients from racially and ethnically minoritized groups, who are more likely to suffer from complex comorbidities.

Advanced primary care’s power to mitigate health inequities highlights the wider benefits it can produce. Adults who regularly see a primary care physician have 33% lower health care costs and reduced odds of dying prematurely than those who see only a specialist. Every $1 increase in primary care spending produces $13 in savings.

Despite these critical advantages, primary care remains woefully under-resourced, accounting for 35% of health care visits yet only receiving 5.4% of all spending on health care in the U.S. Reimbursement for Medicaid services for low-income, at-risk populations is significantly less than Medicare and commercial rates. As a result, many young doctors burdened with student debt opt for better-paying specialties, exacerbating an already severe primary care clinician shortage.

Employers Can Take Steps to Bolster Primary Care and Advance Health Equity

Notwithstanding these challenges, employers can take steps today to accelerate advanced primary care to help reverse inequities and improve overall employee health, including:

• Increasing the overall proportion of funds dedicated to primary care. Ask your health plan what percentage of spending currently goes to primary care and work to develop incremental increases over time. To track health plan performance over time and hold plans accountable for performance, more than two dozen members of the Purchaser Business Group on Health have signed onto a first-of-its-kind tool called the Health Value Index, which creates actionable insight into a purchaser’s health plan spending and incentivizes both short- and long-term improvements in care for participating companies’ employees.

• Request data on self-identified race and ethnicity, sexual orientation, gender identity, language preference and disability status: Ask providers and plans to report their REaL (Race, Ethnicity and Language) and SOGI (Sexual Orientation and Gender Identity) data and to identify how they’re working to address health care inequities. With this data you can also begin to identify gaps in equity among your employees and families. Some easy places to start is stratifying primary care spend and use of a primary care clinician by REAL and SOGI data to identify gaps to focus on within plan design. This work is difficult, so it could require engaging with experts to help you develop and apply a shared structural understanding of racial inequities to ensure that your team is generating accurate, helpful and actionable insights from data analysis.

• Ensuring access to telehealth that is coordinated with primary care. Telehealth has emerged as a critical tool for advancing health equity by increasing access for underserved populations. Employers should ensure that telehealth services are available for employees, as well as go one step further by working with vendors to ensure that telehealth services are coordinated with the employee’s primary care physician. When telehealth is a service provided by the primary care clinician, this coordination is already in place, however there are many third-party vendors offering telehealth services and employers should be thoughtful in terms of mitigating the risk of creating a two-tiered system that contributes to fragmentation of care.

• Adopting a holistic approach to employee health benefits. Employers should work with their plans to ensure collection and identification of social risk factors and needs that could be affecting their employee population. This would allow for holistic benefits design that could provide assistance to employees with addressing social needs that can have negative, long-term impacts on employee health.

• Ensuring adequate mental health resources. Ideally, behavioral health capabilities should be integrated with primary care to increase access and whole-person care. Setting this expectation for health plans and providers as a purchaser, as well as increasing investment into primary care to ensure these services can be funded, will help ensure these resources are prioritized and funded.

• Expanding after-hours primary care access. There are multiple models supporting after-hours care, including use of telemedicine or expanding clinic hours. Ultimately, purchasers must champion payment reform that will make these types of services possible. Much like with mental health, employers can support this conversation by also highlighting after-hours primary care access as an expectation that this is a part of critical infrastructure and including it in the purchase and payment of services.

Transforming Health Care Through Primary Care

Given advanced primary care’s unmatched ability to both address inequity and transform our health system, consensus is building around efforts to overcome longstanding financial barriers and dramatically strengthen the nation’s primary care infrastructure.

The California Health Care Foundation report, for example, calls for a new paradigm that includes programs to increase recruiting and training of primary care physicians, increased primary care spending, improved Medicaid reimbursement and expanded primary care hours and locations. Employers can play an essential role in pushing payers to invest in primary care, as well as encourage providers to use the investment to realize and extend the many benefits advanced primary care offers.

Ultimately, it is about increasing equal access to high-quality primary care for all. Having access is equity.

Special thanks to Rishi Manchanda, M.D., co-author of the CHCF report.