Legislation and Regulation

Several states currently measure primary care spending and use that data as a component in their health care reform strategies.

  • Oregon has legislation from 2015 requiring its Health Care Authority to collect data and report on primary care spending by health plans covering commercial and Medicare Advantage enrollees, the Medicaid coordinated care organizations (CCOs), and plans contracting with the state employee benefit. In 2017, Oregon took the next step and enacted legislation establishing primary care spending requirements for health coverage programs under the state’s jurisdiction. The law requires large health plans and Medicaid CCOs to spend at least 12% of their total medical expenditures on primary care services by 2023. The public employee board is required to meet the same spending threshold through its health benefit plans. Read Oregon’s 2019 primary care spend report to the legislature.
  • In 2017, Rhode Island, through the Office of the Health Insurance Commissioner, began to measure how much commercial health plans spend on primary care and, over time, has increased its required investments in primary care infrastructure as a condition of rate approval.
  • A 2018 Colorado bill would establish a primary care payment reform collaborative in the primary care office in the Department of Public Health and Environment. The administrator of the all-payer health claims database reports data on primary care spending by private health insurers, insurers providing state employee health benefit plans, and the department of health care policy and financing for Medicaid and the children’s health insurance program.
  • A 2018 bill in California would establish a primary care payment reform collaborative in the Department of Managed Health Care and Department of Insurance.  Health plans are required to report the percentage of expenses allocated to primary care compared to overall expenditures, as well as the methods used by plans to financially support the delivery of primary care services.  Aggregate data about primary care spending would be published based on these reports.
  • A 2018 bill in Delaware would create a primary care reform collaborative within the Delaware Health Care Commission and establish a statewide health care claims database.  Health insurers would be required to pay primary care providers at Medicare rates of reimbursement.