Focusing on State-Level Primary Care Initiatives: From a Small State With a Great Need


The need for primary care investment has never been greater. Nationally, primary care is in high demand and yet many factors make it difficult to increase the number of practicing primary health care professionals, including salaries, educational debt, and practice redesign. These primary care workforce challenges are particularly acute in Delaware, which is the second-smallest state by area, the sixth-smallest by population, the third-highest in per capita total health expenditures, and the 31st in health outcomes (eg, oral health, infant mortality, obesity rates).1 As a family physician serving as Cabinet Secretary for the Department of Health and Social Services, I faced a challenging fiscal environment my first year in office in which health care costs contributed to a budget shortfall. While state revenues have increased since then, easing the immediate budget pressure, Democratic Governor John Carney, who was elected in 2016, still faces a fiscal landscape in which health care costs consume 30% of the state budget and are growing faster than other components of state spending. Starting in 2017, we had difficult conversations about health care costs and quality, but all of the solutions required a foundation of enhanced primary care and a new direction away from acute and emergent care toward prevention and wellness.2

After my appointment as Cabinet Secretary in February 2017, the state legislature passed and the Governor signed House Joint Resolution 7, which directed the Cabinet Secretary to develop a strategy to reduce health care cost growth and improve health outcomes. I knew that our state’s Road to Value2 needed a greater focus on the essential components of a workforce ready to address the shared principles of primary care: person- and family-centered; continuous, comprehensive and equitable; team-based and collaborative; coordinated and integrated; and accessible and high-value. This discussion led us to become the first state to set a health care spending growth target and track a complement of quality and health measures.

From September through December 2017, the Department of Health and Social Services convened stakeholders to discuss health care costs and quality.3 We heard loud and clear that the fee-for-service world no longer supported patients’ needs, that investments in value-based population health were needed, that a statewide IT infrastructure that included cost was needed, and that independent physician practices were going out of business because their negotiating power with payers was diffuse and diluted.

In February 2018, the Governor’s Executive Order 19 convened stakeholders to discuss a health care spending benchmark (a transparency measure that would target annual per capita health care spending growth), and in November 2018, Executive Order 25 established Delaware’s health care cost and quality benchmarks that included primary care spending and indicators of primary care adequacy (eg, avoidable emergency department utilization and health outcomes in primary care settings).

In the spring of 2018, Delaware physicians collectively led an effort to pass Senate Bill 227, calling for increased data collection on primary care spending and increased commercial reimbursement up to Medicare payment levels, and to establish a Primary Care Collaborative to enable additional conversations. The Primary Care Collaborative met throughout 2018 and included legislators, policymakers, payers, and health care professionals. A January 2019 report recommended focusing on monitoring primary care spending, investing in primary care, creating new authority to meet these goals, and implementing value-based payment models.4

Primary care spending in Delaware is approximately 3-4% based on initial estimates but, without a common methodology or clear definitions on spending, this may be an underestimate. The Primary Care Collaborative is just starting its work, but has found that definitions and methodology are critical to its efforts.

In addition, the Delaware Health Care Commission will report on health status–adjusted total health care costs by line of business (commercial, Medicaid, Medi-gap) for accountable entities that meet the following criteria: a minimum of 5,000 Medicare lives with an individual payer for one or more lines of business and a minimum of 10,000 Medicaid or commercial lives with an individual payer for one or more lines of business. An accountable entity could be a large practice or a health system. In order to report on primary care providers, payers will submit data on members attributed to each insurer’s 10 largest contracts and will report on accountable entities if they meet the above thresholds.

Recently, Senate Bill 116 has established a regulatory framework for primary care spending and investments. Delaware will follow Rhode Island, Oregon, and others that want to measure and discuss primary care investments. We hope that the focus on overall population health, total costs of care, and primary care will change the conversation among all stakeholders. From 1991 to 2014, health care spending in Delaware increased by an average of 5.7% annually, regularly exceeding economic growth.1 Setting measurement targets, clear definitions of spending categories, and a regulatory framework will help us achieve greater value-based care, more lower-cost preventive care, and a primary care focus in health care transformation. Currently, it is not politically feasible to specify how to get to 12% spending, as in Rhode Island’s affordability standards, and to keep total cost at a sustainable growth rate. Nor is it feasible to impose penalties or regulatory levers to ensure that we meet the health care benchmark targets.

We will continue to engage the public and solicit broad feedback on primary care workforce strategy. Primary care providers have been engaged in these discussions as never before, likely due to elevated concerns about health care costs and other time and cost pressures. Through global payment arrangements and risk-based contracts, we hope to transform our health care landscape and achieve improved investment in prevention and wellness. Consumers should benefit, and our state health and social services department will better orient care toward improved population health outcomes.We will use social media and video campaigns to engage all Delawareans in this dialogue. A Medicaid Accountable Care Organization request for information (RFI) and other value-based payment strategies will encourage practices to transition to value-based payments.5

Through better data, focused investments, and transparent engagement, with a strong communications plan and measured optimism, Delaware will seek a multipronged strategy to manage its small population of high-risk patients and to collaborate with communities to improve primary prevention. The hope is that this will work, just as setting targets in Massachusetts has lowered the Commonwealth’s overall cost growth and as Rhode Island’s affordability standards have increased primary care spending and improved outcomes and workforce stability. However, unlike Massachusetts and Rhode Island, Delaware now will simultaneously implement its health care spending targets along with paired targets to monitor primary care spending. Realistically, change can be slow, and Delaware may continue to be an expensive place for health care, owing to its market size and limited competition. Although politics has created barriers to additional regulatory levers, we will continue to consider strategies that reduce unnecessary costs and waste. Prevention and chronic disease management will remain at the center of improving quality and cost. Primary care cannot be left behind.


  1. Lassman D, Sisko AM, Catlin A, Barron, et al. Health spending by state 1991-2014: measuring per capita spending by payers and programs. Health Aff. 2017;36(7):1318-1327.
  2. Delaware Department of Health and Social Services.Delaware’s road to value. Published December 2017. Accessed March 25, 2019.
  3. Delaware Department of Health and Social Services. Delaware health care delivery and cost advisory group summary. Published June 25, 2018. Accessed April 16, 2019.
  4. Delaware General Assembly, State of Delaware. Primary Care Collaborative Report 2019. Accessed July 25, 2019.
  5. State of Delaware. Medicaid accountable care organization request for information no. HSS 19–035. Published February 1, 2019. Accessed March 25, 2019.


Published in 2019
DOI: 10.1111/1468-0009.12424

About the Author

Kara Odom Walker was sworn in as Secretary of the Delaware Department of Health and Social Services on February 6, 2017. As Secretary, Dr. Walker chairs the Health Fund Advisory Council, and is a member of the Delaware Health Care Commission and the Delaware Center for Health Innovation Board. Secretary Walker previously worked as the deputy chief science officer at the Patient-Centered Outcomes Research Institute. Dr. Walker is a board-certified practicing family physician and is a fellow of the American Academy of Family Physicians. Prior to joining PCORI, she was a faculty member of Family and Community Medicine at the University of California, San Francisco. Dr. Walker completed her family medicine residency at the University of California San Francisco, graduated with a Masters of Public Health from Johns Hopkins School of Public Health and Masters of Health Services Research from the University of California, Los Angeles, School of Public Health, where she also completed her fellowship in the Robert Wood Johnson Clinical Scholars program.

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