Payers Can Advance Equity by Strengthening Primary Care

Good evidence shows that investing in high-quality primary care is the foundation for a health care system that results in better health for all and greater equity. The level of investment in primary care in the United States, however, is woefully low compared to comparable OECD countries, and many of our health statistics lag as well. This historic underinvestment has resulted in patient access issues and workforce challenges that have led to worse patient outcomes, greater inequities, and higher cost. COVID-19 has further exposed the fragile state of primary care infrastructure and made all too clear that people of color are hurt hardest by these systemic issues.

Primary care in California, like the rest of the country, is weakening. In the first year of the pandemic, a third of California primary care practices felt at risk of permanent closure because of the financial consequences of the pandemic. This could mean that more than 1 in 3 people will have trouble accessing primary care; this impact will be disproportionately felt in areas with a shortage of primary care, worsening already stark disparities in health outcomes.

It is no longer possible to ignore the harms that result from the de-prioritization of primary care. Reversing these trends will require payer, clinician, and community collaborations and investments. To initiate this critical dialogue in California and respond to the call to action in the recent National Academies of Science, Engineering and Medicine (NASEM) report “Implementing High-Quality Primary Care,” the Milbank Memorial Fund is partnering with Blue Shield of California on a three-part event series on how payer, provider, and government participants can work together to develop population-based payment models that strengthen primary care.

The first event, Scaling Innovation: Supporting Access and Equity in Primary Care Through New Payment Models, on December 7, brought together national and local stakeholders to discuss how California can realize the vision for primary care as a common good. The NASEM report identified three key implementation objectives:

1. Pay for primary care teams to care for people, not doctors to deliver services
2. Ensure that high-quality primary care is available to every individual and family in every community
3. Train primary care teams where people live and work

A summary of takeaways from the first event follows. As home to the fifth biggest economy in the world, California’s actions should reverberate around the country.

– Christopher F. Koller

Five Key Takeaways from Scaling Innovation: Supporting Access and Equity in Primary Care Through New Payment Models:

1. Paying for the primary care team is essential to improving health equity, access, and quality

[Payers need to] realign payment to pay for the entire care team to deliver care and not the provider, as well as get the flexibility to deliver care where care needs to be provided. – Sunita Mutha, Director, Healthforce Center, University of California, San Francisco

Aligned payment is fundamental to achieving high-quality primary care. When payment is tied to clinician services only, it is impossible to provide the entire spectrum of team-based primary care. In addition to increasing the portion of total health care spending that goes to primary care, it is essential to provide risk-adjusted, prospective, population-based payments that enable the entire care team, including social workers, community health workers, and allied professionals, to take care of patients holistically and conduct the necessary outreach required to bring care into the community.

2. It is in a payer’s self-interest to invest in stronger primary care

There is no high-performing effective, efficient, equitable health care system in the world that does not have an extremely strong base of primary care and [one] that is continually invested in, promoted, and prioritized. – Asaf Bitton, Executive Director, Ariadne Labs

Payers that are serious about building payment systems that promote the delivery of more efficient and high-quality care cannot succeed without prioritizing and investing in primary care. Primary care is central to achieving health plans’ strategic goals. Even with the historic underinvestment in primary care, changing the scope of payment to pay for primary care teams to deliver care can be cost neutral within three to give years.

If plans are passive about investing in stronger primary care, the market forces currently reshaping primary care delivery will ultimately and directly impact plans’ financial bottom line. For example, one very real challenge amplified by COVID-19 is the vertical integration resulting from health systems, venture capital, and private equity buying up independent practices. The proportion of primary care physicians practicing in organizations owned by a hospital or health system grew from 28% in 2010 to 44% in 2016. This integration can drastically limit plans’ bargaining power, driving up costs in the short and long term.

3. The fragile primary care system we have will continue to erode if we do nothing

Not having this [population-based approach to payment] creates moral injury – you know what the right thing to do is, you know what the evidence base says, but you are stymied by resources and policies that don’t allow you to practice in the way that patients and communities need care, as opposed to how payment has determined care will be delivered. – Sunita Mutha, Director, Healthforce Center, University of California, San Francisco

As of September 2021, 7 million Californians lived in an area where there is a shortage of primary care. Anecdotal evidence suggests that COVID-19 has led to a 20% turnover at all levels of the primary care team, exacerbating workforce shortages and making access an even greater challenge in already underserved areas. Consequently, as primary care capacity shrinks, an already overworked workforce will continue to burn out and the flywheel of people leaving primary care will go faster. The known solution, providing population-based payments that enable flexibility in how and where care is delivered, will expand the care team and, in turn, diversify the workforce and promote equity.

4. We will get the same inequities if we don’t design care delivery models in partnership with patients

There has to be a conversation about historic and contemporary distrust. Otherwise new models will just be seen as business as usual and patients will not use them as they are designed to be used. – Stella Safa, Founder and Executive Director, Just Equity for Health

Designing models of care that address inequities in access and outcomes must put patients at the center of care redesign. Gathering insights from patients will help health systems remove systemic barriers and address racial bias in care delivery. Such change will make health systems more trustworthy, ensuring that patients get the care they need. Without including patients who are representative of those who suffer the greatest inequities in care redesign, we will not build the level of confidence needed for those patients to engage with needed care.

5. There are successful models within California on how to design care around the whole person and break down barriers to equity and access

The goal [of HIV Centers] was to engage patients to come in, and then invite them to undergo medical testing and evaluation once they were engaged. – Stella Safa, Founder and Executive Director, Just Equity for Health

During the HIV/AIDS crisis, the San Francisco Bay Area developed a robust public-health infrastructure capable of helping people who were at risk. To combat the stigma and general ignorance around HIV, community organizers, as well as politicians, health officials, and doctors, connected the city’s government, universities, and marginalized communities. This infrastructure has proved invaluable during COVID-19 in helping to minimize the surge of infection in some underserved communities. In addition to successfully building trust in the healthy system, HIV Centers, which are part of this essential infrastructure, employ patient-centered approaches that include an expanded team, outreach into the communities, and an emphasis on the upstream issues that affect health like education and housing. Replicating this kind of care delivery model will only be possible, however, with population-based approaches to paying for primary care.

6. Payers have the power to improve health equity by aligning population-based payment models with high-quality primary care

Investment in primary care, more than any other part of the health care delivery system, can help address inequities and improve the health of everyone. Payers have the power to preserve this essential public service by joining together to enable widespread adoption of population-based payments. Through existing forums, such as those led by the Integrated Healthcare Association and California Quality Collaborative, health plan stakeholders in California can accelerate their work on payment for advanced primary care and achieve better and more equitable outcomes for all.