Milbank-Supported Report

Investing in Primary Care: A State-Level Analysis

July 19, 2019 | Yalda Jabbarpour, MD, Ann Greiner, MCP,, Anuradha Jetty, MPH, Megan Coffman, MS,, Charles Jose, MD, Stephen Petterson, PhD, Karen Pivaral, Robert Phillips, MD, MSPH, Andrew Bazemore, MD, MPH, Alyssa Neumann Kane

Program:  Primary Care Investment

Read more about the process for developing standard measure for primary care investment in a August 6, 2019 Health Affairs blog by Hoangmai Pham, MD, MPH, vice president of provider alignment solutions for Anthem, and Ann Greiner, president and CEO of PCPCC and in a July 27, 2019 Lancet editorial.

Top Findings

Relative to its international counterparts, the United States underinvests in primary care, as reflected in spending by both public and private payers. On average, the United States spends 5%–7% on primary care as a percentage of total health care spending. By comparison, Organisation for Economic Co-operation and Development (OECD) countries average 14% spending on primary care.

This underinvestment represents a major disconnect given the robust evidence base showing that health systems with a primary care orientation have superior patient outcomes, fewer inequities, and lower costs. On these key attributes, performance of the U.S. health system pales in comparison to systems in other industrialized nations.

In a first-of-its-kind study, the 2019 Patient-Centered Primary Care Collaborative (PCPCC) Evidence Report examines states’ primary care spending patterns, including spending across payer types, and considers the implications of these results for select patient outcomes.

More specifically, the 2019 PCPCC Evidence Report finds:

  • There is a lack of agreement about how to measure primary care investment. Consequently, this report includes two leading approaches that reflect a narrow definition and a broad definition of primary care spend.
  • Between 2011 and 2016, spending on primary care as a percentage of overall health care expenditures was low. It varied considerably across states, across payer types, and across age groups.
  • The national average for primary care spend across public and private payers was 5.6% using a narrow definition, as compared to 10.2% using a broad definition.
  • An association was found between increased primary care spend and fewer emergency department visits, total hospitalizations, and hospitalizations for ambulatory care-sensitive conditions. Given the limitations of our data set, we cannot conclude that this is causal, but it is a relationship replicated in the research literature.
  • Minnesota had the highest percentage of primary care investment using both narrow and broad definitions, and performed well with respect to patient outcomes. Connecticut had the lowest primary care spend using the narrow definition. Using the broad definition, New Jersey’s primary care spend was lowest. No pattern was observed for primary care spend by region.

State leaders have a growing interest in using their legislative and regulatory authority to measure and report on primary care spend and, in some cases, to set targets for increasing investment in primary care over the coming years within their jurisdictions. This report provides a high-level description of such efforts in 10 states, seven of which initiated their efforts in 2019. This focus on primary care spend and primary care investment suggests policymakers have some momentum to shift the U.S. delivery system back to its primary care foundation, so that it can better address diverse patient needs across different age and sociodemographic groups.

Read the report.