Advanced Primary Care Key to Reducing Health Inequities
June 14th, 2023
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.
8 Steps to Implementing Advanced Primary Care
September 29th, 2022
Robust primary care is essential to the ability to transform health care in the U.S. Adults who regularly see a primary care physician have 33% lower health care costs and 19% lower odds of dying prematurely than those who see only a specialist. Additionally, every $1 increase in primary care spending produces $13 in savings, and if everyone used a primary care provider as the principal source of care, the U.S. could save $67 billion annually. As part of its pioneering work to define and promote the adoption of advanced primary care, PBGH’s California Quality Collaborative’s primary care improvement efforts led to almost 50,000 hospital bed days avoided, emergency room utilization sharply reduced and total savings of about $186 million in California.
Despite these outsized benefits, misaligned financial incentives, chronic under-investment, infrastructure barriers and a lack of integration with other elements of care — including behavioral health — continue to severely constrain primary care’s impact on the health of American workers and families.
That’s why PBGH is spearheading the development and implementation of ‘advanced primary care.’ Our approach emphasizes bolstering existing primary care to treat more health needs within the primary care practice and refer to only the highest quality specialists when appropriate, increase patient access, integrate behavioral health screening and management, improve care coordination and expand tools and systems that can support population-based care for patients.
A new report highlights eight key takeaways from a discussion with representatives of large employers and public health care purchasers based on their experiences implementing advanced primary care.
1. Changing payment is crucial
Care delivery change requires payment change. Capitated payment – with some flexible incentives – will enable practices to meet clinical and health goals. A model predominantly based on fee-for-service or volume-based payment is antithetical to the core tenants of advanced primary care. Read about how Washington State Health Care Authority is tackling primary care payment reform.
2. Update operating systems or find new ones
Health plan operations are built to pay fee-for-service and are very challenged to pay differently. Whole Foods took a bold approach by creating its own system rather than relying on health plans. Learn how.
3. Align around standardized measures
Purchasers should align to adopt a set of priority standardized measures by which to assess care and service. Through a multistakeholder consensus process, PBGH has selected a set of evidence-based clinical and outcome measures that collectively signal and reflect the desired outcomes of advanced primary care. See how Covered California is using these measures.
4. Redefine your investment priorities with payers and partners
The cost benefits of advanced primary care must be emphasized in negotiations with payers. But this does not mean paying more overall. The expectation is that total cost remains flat. Read about eBay’s perspective on investment in primary care.
5. Hone your message
Despite studies that have repeatedly shown how strengthening primary care can improve outcomes, reduce costs, enhance the patient and provider experience and improve health equity, those benefits are not always apparent to health plans, organizational leadership or even employees. CalPERS’s experience with mandatory primary care provider selection offers important lessons for other purchasers.
6. Think nationally and act regionally
Employers should take the lead in their communities and regions when it comes to enlisting like-minded purchasers in support of advanced primary care. This can include national employers with even a modest presence in the community. Read about The Boeing Company’s approach to this.
7. Identify a trusted authority that can help foster standardization and adoption
A neutral convener can play an important role in helping achieve consensus around common measures and definitions, and likewise serve as a focal point for payer, purchaser and provider discussions regarding implementation and payment challenges. Washington and California offer examples of how regional multistakeholder groups play a key and needed role in implementing national change.
8. Just do it
There is a tendency in health care to focus for too long on discussion and planning without pursuing or engaging in the practical or implementing change. It’s important to start the process of implementing advanced primary care. Read about steps The Wonderful Company is taking on behalf of its employees.
California Providers and Health Plans Sign Agreement to Expand Investment and Increase Access to Advanced Primary Care
July 26th, 2022
Coalition of Large California Payers Commit to Accelerating Widespread Adoption of Advanced Primary Care with The Goal of Reducing Costs and Improving Quality and Equity
As part of a new multi-stakeholder initiative, six health care organizations serving California have signed a memorandum of understanding (MOU) to increase investment in and access to ‘advanced primary care,’ a model that emphasizes comprehensive, person-focused care, integration of behavioral and physical health services and high-quality outcomes. The agreement outlines a new initiative that strengthens the primary care delivery system throughout the state by enabling primary care practices to transform to a high-performing, value-based care model that reduces costs and improves quality and equity.
Known as the California Advanced Primary Care Initiative, the effort is jointly led by California Quality Collaborative (CQC), a program of the nonprofit coalition Purchaser Business Group on Health (PBGH), and the Integrated Healthcare Association (IHA). CQC and IHA convened the state’s largest payers to collectively adopt a model to transform primary care statewide.
The six organizations committed to the California Advanced Primary Care Initiative include Aetna, Aledade, Blue Shield of California, Health Net, Oscar and UnitedHealthcare. The initiative is a first-of-its kind agreement that represents a voluntary joint effort among payers to standardize the way they finance, support and measure the delivery of Advanced Primary Care.
“This initiative builds upon a long history of stakeholder collaboration to improve the care and health of Californians and moves us from vision to action with aligned priorities to scale high-quality primary care throughout the state,” says Crystal Eubanks, senior director of CQC.
“This initiative reflects our understanding that the impact of any one payer alone is limited,” says Peter Long, executive vice president of Strategy and Health Solutions at Blue Shield of California. “That’s why Blue Shield is committed to partnering with our peer payers and providers to scale delivery of high-quality primary care across the state. Ultimately, we know this is what is best for our members, and we all must work together to make this vision a reality.”
California Advanced Primary Care Initiative stakeholders committed to pursuing the following goals in the MOU:
- Transparency: Report primary care investment and adoption of value-based payment models that support the delivery of advanced primary care and performance on the advanced primary care measure set jointly developed by CQC and IHA, a list of metrics that enable purchasers, health plans and providers to identify primary care practices in a given market that are delivering the best results for patients.
- Payment: Adopt an agreed upon value-based payment model for primary care providers that offers flexibility, supports team-based care delivery and incentivizes the right care at the right time.
- Investment: Collaboratively set increased primary care investment quantitative goals without increasing the total cost of care.
- Practice Transformation: Provide technical assistance to primary care practices to implement clinical and business models for success in value-based payment models, integration of behavioral health and reduction of disparities.
“Primary care is the heart of all health care,” says Jeff Hermosillo, California Market President, Aetna. “This innovative initiative will help ensure accessible, affordable and high-quality primary care to improve the well-being of all Californians. Working together with our peers, providers, plan sponsors and members, we are committed to primary care that makes a difference in people’s lives.”
“Health Net is proud to be part of this groundbreaking collaboration that will support physicians in providing high-quality, coordinated care for millions of Californians. As a practicing primary care doctor, I am especially heartened by the opportunity to better integrate behavioral and physical health, a key strategy for effectively addressing our behavioral health crisis.” says Todd May, M.D., vice president, medical director of Health Net’s commercial business.
CQC and IHA have been collaborating since 2019 to develop shared standards of advanced primary care, including common definitions of practice attributes, a performance measure set, methods to identify quality at the practice level and a value-based primary care payment model.
“I am so inspired to see payers collaborating together in a new way toward this timely, crucial cause that will elevate primary care and improve patient lives in California,” says Dolores Yanagihara, vice president of Strategic Initiatives at IHA.
Strengthening Primary Care: A Pilot with Four Large Purchasers
June 10th, 2022
Extensive research and pilot programs have shown that easily accessible, person-centered and team-based primary care that integrates behavioral health and other supports can significantly improve patient outcomes and experience. It can also increase population health, reduce overall costs and serve to improve equity in our health care system.
It is for these reasons that PBGH’s California Quality Collaborative (CQC) has been working for over a decade to improve primary care. That work has culminated in the development of shared attributes and measures that enable purchasers, health plans and providers to identify primary care practices in a given market that are delivering the kind of care research tells us will bring about the best results for patients.
Together with the Integrated Healthcare Association (IHA), PBGH brought together four large health care purchasers in California to pilot this set of performance measures that emphasize patient experience and outcomes. The PBGH/IHA partnership, known as the Advanced Primary Care Measurement Pilot, began in January 2022, and participating purchasers include Covered California, California Public Employees’ Retirement System (CalPERS), eBay and San Francisco Health Services System.
Partnering to Better Primary Care in California
Our already weak primary care system has been further hampered by the pandemic, and these purchasers recognize that the time to strengthen it is now. The four participating purchasers have aligned by incorporating the same Advanced Primary Care attributes and measures into their health plan contracts. The goal is to identify the primary care practices throughout the state performing at the highest levels and delivering high-quality patient care.
The set of performance measures being tested through the pilot reflect the shared standard of Advanced Primary Care as defined through a multi-stakeholder process led by PBGH’s California Quality Collaborative that included input from purchasers, health plans, providers and patients.
The outcome will be an increase in understanding of where patients are getting the highest quality primary care. The pilot will give purchasers and health plans information to help them make decisions about their provider networks, resource distribution and consumer incentives. This information can be used to better connect patients to practices delivering Advanced Primary Care and incentivize improvement for other providers, increasing the availability of Advanced Primary Care.
How the Pilot Works: Existing Data for a New Purpose
Data already available through IHA is being used, so health plans and providers do not have to report anything new. The existing data will be used for a new purpose – to assess individual practices.
Performance information can be diluted when data from multiple practices is combined. By looking at each individual practice separately, we can gain the best understanding of which practices are delivering the best primary care and which ones need improvement.
The data will also be aggregated across purchasers and health plans for the first time to provide a more complete view of each individual practice’s performance, rather than looking at small segments of patients in a vacuum. This will allow for a better assessment of whether a practice has the systems in place to consistently provide high-quality care for everyone
Currently, ways to account for socio-economic and demographic differences in the performance analysis is being explored. This lens is crucial to ensure decisions made around the pilot promote equity and do not inadvertently increase the challenges vulnerable communities already experience in accessing high-quality care.
The analysis will include data from January through December 2022, and results and findings are expected mid-2023.
Using Primary Care’s Potential to Improve Health Outcomes
October 4th, 2021
For over a decade, revitalizing primary care has been a top priority for the Purchaser Business Group on Health (PBGH). Through successive initiatives and in collaboration with a diverse group of committed stakeholders, PBGH has spearheaded efforts to create a blueprint for “Advanced Primary Care.”
What Is Advanced Primary Care?
Advanced Primary Care places patients at the center of every interaction and prioritizes access to high-quality primary care to prevent higher acuity, costlier care and making for a healthier California.
Building off a statewide practice transformation initiative funded by the Centers for Medicare and Medicaid (CMS), PBGH’s California Quality Collaborative (CQC) began crafting definitions for ‘exemplar’ primary care practices with the goal of identifying, celebrating and learning from high-performing organizations within the program’s network. This led to a definition of “Advanced Primary Care.”
CQC defined Advanced Primary Care by high-performance attributes and a set of results-oriented measures that focus on how the care process is, or should be, experienced from the patient perspective. This set of measures is based on existing outcome measures widely in use by California and national payers that if collectively applied would enable medical practices to deliver Advanced Primary Care.
Why Is Primary Care So Important?
Primary care—long underfunded and woefully underutilized—remains the foundation upon which a high-performance, cost-effective health care system must be built.
Evidence shows that improved primary care translates into healthier, happier patients and lower overall health care costs:
- U.S. adults who regularly see a primary care physician have 33% lower health care costs and 19% lower odds of dying prematurely than those who see only a specialist.
- The U.S. could save $67 billion each year if everyone used a primary care provider as their principal source of care.
- Every $1 increase in primary care spending produces $13 in savings.
It is important to note that the development of the Advanced Primary Care model is as much about streamlining the practice of primary care as it is about improving outcomes, enhancing the patient experience and reducing costs. Simple and consistent definitions of optimized primary care across all payer contracts would reduce, if not eliminate, the bewildering array of sometimes-conflicting value-based requirements contained in multiple payer contracts.
Why Doesn’t Primary Care Work Better?
Funding arguably is the greatest hurdle to more effective primary care. Despite 55% of office visits taking place in primary care clinics, only 4-7% of health care dollars go toward primary care.
But misaligned financial incentives, infrastructure and technology barriers and poor integration with other elements of care all play a role in compromising quality and driving up costs.
Advanced Primary Care in Practice
One initiative that has come out of the primary care groundwork laid by CQC is a measurement pilot with Covered California and CalPERS. Both organizations agreed to pursue a pilot program starting January 2022 to test statewide practice-level measurement using CQC’s 11 Advanced Primary Care measures.
Covered California contracts with 11 health plans to provide coverage for 1.6 million Californians, and CalPERS manages pension and health benefits for more than 1.6 million California public employees, retirees and their families.
The goal of the pilot is to create the basis for extending the Advanced Primary Care criteria across PBGH’s membership and to other payers nationwide.
On September 30, 2021, more than 175 employers, public purchasers, health plans, providers and other stakeholders from across the country came together for a summit to discuss implementation of a common purchasing agreement based on CQC’s definition of Advanced Primary Care. Going forward, CQC plans to continue pursuing solutions to barriers that inhibit broader implementation of Advanced Primary Care.
For more about the journey to Advanced Primary Care, click here.
Primary Care Practices Can Engage Patients in Virtual Care
June 6th, 2020
During the most challenging phases of the COVID-19 pandemic, one opportunity for the health care delivery system has been the rapid adoption of telehealth and virtual care by both primary care practices and patients. The Pacific Business Group on Health’s California Quality Collaborative (CQC) has hosted webinars to support and spread successful practices in virtual care for independent primary care practices and IPAs as they rapidly implemented telehealth technology and workflows.
Nationally, the trends reflect widespread virtual care adoption. By one May 2020 analysis, telehealth visits in the US increased 300-fold in March and April 2020 compared to the same time period in 2019 (Epic Health Research Network). Providers have been pleased with their telehealth experience, and patients have too: 88% of patients new to telehealth said they would like to use it again (PwC Health Research Institute). The health system is eager to build on the implementation gains around virtual care made during the public health emergency, especially its ability to improve access to care and reduce costs.
Patient engagement in virtual care
Yet today, more than ever, it’s essential for health care clinicians and care teams to ensure that virtual care being provided is as patient-centered as possible. This topic was the focus of a May 6 webinar hosted by CQC, which highlighted presentations from a number of experts including Dr. Courtney Lyles, Associate Professor, Center for Vulnerable Populations at UCSF; Libby Hoy, Founder & CEO, PFCC partners; and Dr. Fiona Wilson, former Teladoc provider and current Supervising Clinician Specialist, Workers Compensation Division, Department of Human Resources, City & County of San Francisco.
Dr. Lyles shared examples from decades-long research done around patient portals, telephone visits and tactics that help bridge the “digital divide,” even in regions of strong technology adoption, such as the Bay Area. Her advice was not to make any assumptions about what patients do or do not have access to, and establish ongoing trainings, where patients can be assured to get continuous support for the virtual care they are seeking.
Libby Hoy of PFCC partners shared lessons from her organization’s history building patient advisory capacity. She cautioned that the work, especially at this time, is messy, but reminded care teams and providers that involving patients in the design process of the workflows results in more effective care.
Dr. Wilson shared her experience as a telehealth provider during COVID-19 for Teladoc, an organization that provides virtual care for patients all over the United States. Her advice for clinicians was to be an empathetic and engaged listener to patients when they are sharing their health issues, and make sure to ask about non-medical needs that may be even more present today, such as social isolation and economic hardship.
What providers can do now
Today, primary care practices are regrouping after shelter-in-place restrictions lift, adapting to a hybrid of virtual and in-person care, and working to address any care needs of their patients that were deferred during the height of epidemic. Yet even in this time of transition, CQC’s expert panelists shared the following steps practices can take to focus on patient needs:
- Always ask patients their preferences. Ask what technology they have access to, and what makes them comfortable. Make sure your visit builds on your relationship, addresses what device they are using and that you ask how you can be of help during this process.
- Look to your patients and families as resources to designing your telehealth programs. Outside even the visit, consider implementing patient open-ended surveys, focus groups, telephone calls or advisory programs. Tap into the people with the least experience to help you improve your work.
- Make workflows as simple as you can. Technology can be part of the barrier, but at the same time, almost everyone has a phone. Start with the tools that you and patients have. You don’t need a smart phone to conduct these visits.
Access CQC’s May 29 webinar recording and summary here.