The Pathway to Primary Care Investment Is Bolstered by Accountable Care 

Primary care improves outcomes, reduces costs, and decreases disparities, yet continues to be critically underfunded. The result? Fewer clinicians choosing primary care, particularly independent primary care, declining morale among those who do, and decreased patient access.  

As the federal dollars for health care coverage shrink, it’s more important than ever for state leaders to secure stronger, more sustainable primary care while making health care more affordable by reducing overall health care spending. To effectively sustain primary care and reduce total costs of care, states should pursue primary care investment policies alongside an accountable care model.

State Leaders Are Creating Paths to Increased Spending on Primary Care 

More than 20 states have enacted policy initiatives to measure the proportion of state-level health care spending toward primary care, with some setting targets to increase that share. Beginning as a novel movement more than two decades ago, the concept has now gained momentum, with states across the political spectrum finding success. These states have prioritized preventive medicine, understanding that investing more in primary care can reduce the total cost of care (TCOC) over time by replacing expensive emergency room visits with annual wellness visits. 

Among these, Colorado and North Carolina are expanding the scope of state-facilitated task forces to study primary care spending and enforce spending targets. Washington and Oregon have established spending targets and are incorporating more authority for health agencies to gather needed data. New York is aiming for an ambitious spending target. And in Arkansas, grassroots organizing created a working group to set goals for meaningful investment. These movements are increasingly incorporating alternative payment model adoption as an explicit goal. 

To make these efforts most effective, states should approach primary care investment legislation and alternative payment model adoption solutions simultaneously for increased and more diverse revenue streams. Simply paying primary care physicians more isn’t enough — there must be a link to alternative payment to ensure dollars are flowing toward effective, high-quality care and truly reducing TCOC. A blended approach, where states intentionally increase primary care spending while incentivizing and supporting practices to participate in accountable care, will also help primary care face existential threats like insufficient federal funding and consolidation. 

Accountable Care Provides Some Relief 

Independent primary care practices can thrive when they have the right resources and support to participate in accountable care models. The Medicare Shared Savings Program (MSSP) enables accountable care organizations (ACOs) to earn revenue by incentivizing efficient, high-quality care and sharing in the savings from decreased Medicare spending. MSSP produces real results for patients and clinicians — in the 2024 performance year alone, a record 75% of ACOs earned shared savings revenue and MSSP yielded more than $2.5 billion in net savings. For an increasing number of primary care practices, MSSP is becoming an essential revenue strategy, allowing practices to keep their doors open while saving taxpayer dollars. 

MSSP has now grown to incorporate 10.3 million beneficiaries, and alternative payment models continuously prove to be effective in achieving higher quality and savings. But this reach alone cannot fully address the systemic underfunding and critical needs of primary care, especially in light of the forthcoming Medicaid changes enacted through the federal budget reconciliation. This necessitates a broader, more integrated state-led approach — pairing the success of MSSP with the success of primary care investment policy. 

Centering Accountable Care Supports Primary Care Investment 

Primary-care-centric ACOs fundamentally enhance value-based care by prioritizing high-quality, preventive services that drive better patient outcomes and substantial cost savings. ACOs participating in MSSP with support from Aledade, the nation’s largest network of independent primary care, have seen better results than those without such support. Aledade ACOs achieved gross savings of over $1 billion in performance year 2024, with 93% of these earning shared savings revenue. 

These ACOs thrive because our accountable care model focuses on proactive outreach, preventive screenings and chronic care management, equipping independent and community-based practices for success through actionable data insights, hands-on support, user-friendly workflows and integrated care solutions.  

The Aledade experience demonstrates that the accountable care model not only ensures states are more likely to accomplish spending targets, but ensures the revenue directed toward primary care is aligned with strategies that improve the value of care delivered. 

Our analysis of fee-for-service (FFS) primary care spending under Medicare finds that for the nearly 1.2 million Medicare beneficiaries attributed to and served by the 59 Aledade ACOs in 2024, primary care accounted for 6.1% of total Medicare spending. This is greater than the 3.4% reported for Medicare FFS spending on primary care, but much less than the recommended investment targets of 12-15% among states with spending benchmarks. However, when we include shared savings, that figure rises to 11%. (To conduct the analysis, we used MSSP’s procedure-based definition of primary care used for beneficiary assignment found in Appendix C of the 2024 MSSP Specifications). 

Shared savings, achieved through primary care–oriented accountable care arrangements, make a more sustainable and expeditious financial opportunity for states to support primary care — all while reducing acute care utilization and TCOC.  

When it comes to effective primary care investment policy, it’s not only a matter of how much we spend, but how we spend it. Through the shared savings model, physicians are the drivers of outcomes and additional at-risk revenue, meaning they can guide the future of their practices by directly accessing and directing earned funds as a more sustainable solution. 

A Pathway to Success: States Must Facilitate Change for Increased Investment 

State leaders are uniquely equipped to strengthen primary care. We at the Aledade Policy Institute suggest three recommendations for states to consider when designing policy solutions that create a more conducive landscape for accountable care and increased investment. 

1. Explore opportunities for state-level change by learning what others have done. Milbank and the National Academy of State Health Policy released a policy menu earlier this year — a collection of state policy actions, with examples of implementation, that align with national recommendations for implementing high-quality primary care. By incorporating lessons from existing efforts, state leaders can accomplish effective investment and alternative payment model adoption in a more timely and less burdensome manner. 
2. Partner with clinician champions and aligned stakeholders. Many successful state efforts are rooted in multi-stakeholder collaboration, with the primary care clinician voice at the center. Because clinicians are accountable for the care of their patients, effective partnerships must be based on the clinician perspective to ensure effective design, implementation and promotion of innovative payment solutions. Incorporating the diverse perspectives of clinicians, public and private insurers and legislative champions allows for inclusive, sustainable solutions — legislative work takes time, and partnerships are paramount. 
3. Ensure policy design incorporates alternative payment model initiatives for an approach that generates greater, sustainable revenue. As primary-care-centric, alternative payment model adoption becomes increasingly possible, states must incorporate this lens into effective policy design. Promoting appropriate alignment and incentives across payers, and adopting legislative measures that support both bigger investment and non-claims payments is essential for sustainable revenue. The future of primary care payment is not fee-for-service.  

By pairing effective policy with the demonstrated success of the accountable care model, states have the power to enable sustainable, thriving primary care. 

From Undervalued to Empowered: States Must Act Now 

States hold the key to revitalizing primary care. With a limited federal landscape, demonstrated frameworks for effective state-level policies, and the continued success of the accountable care model, state leaders must act now. Primary care can’t wait.