Authors:
Citation:
Walker L, Watkins LD, Koller C. Defining the State Role in Primary Care Reform. The Milbank Memorial Fund. May 2024.Policy Points
- Six activities can help states optimize their authority to improve primary care.
- Providing data transparency on the health of primary care at the state and local level is a first responsibility, followed closely by building a coalition
Introduction
States play a key role in shaping the local environment for primary care, through both action and inaction. Whether investing in the state’s primary care infrastructure and workforce, mandating or incentivizing alternative payment approaches, or promoting administrative alignment across payers, states have multiple levers to influence the sustainability and quality of primary care. At the same time, it’s challenging for states to define their role and prioritize activities. To help states with this process, the Virginia Center for Health Innovation, in partnership with Milbank Memorial Fund, has developed a Primary Care State–Federal Alignment Tool outlining federal primary care initiatives and offering a template for systematically evaluating a state’s alignment with each policy. In conjunction with the tool, states should consider the following six key activities to prioritize resources and use their authority most effectively.
Six Ways to Leverage State Authority
1. Define the current state of primary care at the state and local level. Providing data transparency is a state’s first responsibility. Understanding current gaps, strengths, and geographic variation across a state’s counties and municipalities is critical to identifying policy options. Although the type of data collected and publicly reported may vary by state and the maturity of its data infrastructure, providing some level of baseline data on workforce, utilization, expenditures, outcomes, and models of care enables the state and industry partners to better prioritize their resources. Given their capacity to understand both local contexts and the overall state outlook, states are in a unique position to set baselines and track trends over time. County- or municipality-level maps can help increase the actionability of data by providing within-state benchmarks and identifying areas to target for intervention or further research. Some states, such as Virginia,1 New York,2 and Massachusetts,3 have developed state-specific Primary Care Scorecards to complement the Health of US Primary Care: 2024 Scorecard Data Dashboard,4 which provides state-level information on the health of primary care.
2. Build a coalition. To better identify and generate support for the most appropriate primary care policies for a given environment, states must convene stakeholders across health sectors. Stakeholders have on-the-ground experience that can help surface barriers to high-quality care, identify successful initiatives that may be expanded or standardized, and provide insight on implementation. With no single association or discipline responsible for primary care, states must bring together physician organizations, advanced practice practitioner associations, health systems, frontline providers, payers, patient advocates, employers, life sciences leaders, and legislative and executive representatives to support alignment across industries and government. (See an example of coalition building and resulting activities in the box Case Study: Virginia Task Force on Primary Care.)
3. Identify policy options. With the many challenges facing primary care come many policy options. A first step for states aiming to select the right policies is building familiarity with the various federal programs and policies that may be relevant to their efforts. The Primary Care State–Federal Alignment Tool, based on the federal initiatives enacted as of March 2024, can help states kick off this policy assessment. The initiatives are drawn from the November 2023 US Department of Health and Human Services primary care issue brief,5 which was in turn informed by the 2021 National Academies of Sciences, Engineering, and Medicine Report Implementing High-Quality Primary Care.6 Such an assessment can help state primary care coalitions begin to inventory their own initiatives, find remaining gaps, identify programs that may be expanded or modified, and draft legislation or statutes that may be necessary. It’s likewise important to review other states’ initiatives and coalition recommendations.
4. Establish consensus priorities. Once its landscape and policy reviews have been conducted, the state primary care coalition should offer consensus recommendations for policy initiatives. These recommendations consider the greatest areas of concern identified and the feasibility of policy execution and implementation. Setting consensus recommendations across industries leverages the authority of each individual group to support the advancement of primary care. Additionally, it encourages participating industries to prioritize any internal adjustments to their practices and workflows needed to align with the recommendations.
5. Identify policy champions. Implementation of any given recommendation will require a policy champion. To identify the most appropriate champion, states must first distinguish between an initiative that requires legislative action versus executive action versus action that industry can take without state involvement. The tool to support alignment of state and federal primary care policy includes a column to define these roles. Additionally, state-level reports on the health of primary care (as described earlier) can be used to identify potential champions based on the identified geographic or population-based disparities. A policy champion may be, for example, a legislator in a district particularly impacted by the recommended solution.
6. Provide an accountability structure. Accountability is key to the successful implementation of priority policy initiatives. States can create mechanisms of accountability through their individual policy champions and by monitoring initiatives’ progress; states can publish annual reports that track data trends and outcomes associated with coalition-recommended policies and report on the status of consensus recommendations. By establishing a structure for monitoring policy and program implementation, states can promote an expectation that primary care initiatives are implemented across health care sectors in a purposeful, informed manner.
States Can Lead
States are uniquely situated to decipher both local challenges plaguing individual primary care markets and overarching barriers to high-quality, accessible care. This position allows states to be a powerful driver in advancing policies that promote sustainable high-quality primary care. By investing in data transparency and coalition building, and then setting strategic policy priorities and holding individuals and entities accountable for progress, states can lead primary care reform. While several states, such as Virginia,7 New York,8 and Rhode Island9 have already established a state coalition in primary care, most have yet to adopt this approach—leading to increasing disparities in primary care across the country. Empowering states to advance policies that meet the needs of their communities will be critical to getting primary care on track for a successful future.
Case Study: Virginia Task Force on Primary Care
The Virginia Task Force on Primary Care (VTFPC) is a multistakeholder coalition launched by the Virginia Center for Health Innovation at the onset of the COVID-19 pandemic. The VTFPC was initially established to address the immediate crises facing primary care: financial distress associated with declines in patient volumes and loss of billable services as well as lack of personal protective equipment (PPE). However, it became apparent that the sustainability challenges facing primary care required long-term investment. The VTFPC now receives ongoing funding from the state to address the various challenges facing primary care.
Who is in the Virginia Task Force on Primary Care?
The VTFPC is composed of 32 leaders across health care industries. Additional individuals with particular expertise support committees focused on clinician retention and well-being, data analytics, education and advocacy, and various pilot initiatives through the payment and practice innovation committee. Committees vary by year depending on the needs of the task force. Each year, the task force puts forward consensus recommendations on policies and initiatives for the following year. VTFPC members include representatives from:
- Frontline providers across primary care disciplines
- State provider associations
- Health plans (commercial, Medicare Advantage, Medicaid, and state employee health plan)
- State personnel from the health department, Medicaid agency, and secretary of health
- Health systems, clinically integrated networks, and independent practices
- State legislators
- Patient advocates
- Employers
What type of activities does the Virginia Task Force on Primary Care do?
Activities of the VTFPC have evolved in response to the immediate and long-term needs of primary care. Examples of initiatives include the following:
- Coordinated with the state and primary care practices at the onset of the pandemic to distribute 750,000 pieces of PPE and 500,000 rapid antigen tests to Virginia’s primary care practices, free clinics, and federally qualified health centers (FQHCs)
- Successfully advocated for $151 million to increase Medicaid primary care rates to 80% of Medicare
- Developed baseline and trend reports, including primary care spend and total cost of care
- Developed a Primary Care Scorecard and county-level dashboard to assess the health and well-being of primary care in Virginia
- Established the Primary Care Innovation Hub to share best practices, recent news, and updates on state policy actions and VTFPC initiatives
- Created state legislative trackers to enable primary care stakeholders to follow legislative proposals
- Piloting Smarter Care Virginia—Improving Vaccination Rates, which provides panel-level vaccine data to practices to support outreach and population health efforts
- Piloting a multipayer alternative payment model to support integration of primary care and behavioral health for children and adolescents
- The full list of consensus recommendations and key activities are published in the annual Comprehensive Report.
Notes
- Virginia Task Force on Primary Care. Virginia primary care scorecard. Virginia Center for Health Care Innovation. https://www.vahealthinnovation.org/wp-content/uploads/2023/07/Virginia-Primary-Care-Scorecard-June-2023.pdf. Published June 2023. Access April 24, 2024.
- New York State primary care scorecard. Primary Care Development Corporation. https://www.pcdc.org/resource/new-york-state-primary-care-scorecard/. Published April 23, 2024. Accessed April 24, 2024.
- Massachusetts primary care dashboard. Center for Health Information and Analysis and Massachusetts Health Quality Partners. https://www.chiamass.gov/massachusetts-primary-care-dashboard. Published February 9, 2023. Accessed April 24, 2024.
- Robert Graham Center. Health of US primary care: 2023 scorecard data dashboard. Milbank Memorial Fund. https://www.milbank.org/primary-care-scorecard/. Published February 28, 2024. Accessed April 24, 2024.
- US Department of Health and Human Services. HHS is taking action to strength primary care. https://www.hhs.gov/sites/default/files/primary-care-issue-brief.pdf. Published November 7, 2024. Accessed April 24, 2024.
- The National Academies of Sciences, Engineering, and Medicine. Implementing high-quality primary care: rebuilding the foundation of health care. https://www.nationalacademies.org/our-work/implementing-high-quality-primary-care. Published 2021. Accessed April 24, 2024.
- Virginia Task Force on Primary Care. https://www.vahealthinnovation.org/virginia-task-force-on-primary-care/. Accessed April 24, 2024.
- Primary Care Development Corporation. New York State Primary Care Scorecard. https://www.pcdc.org/resource/new-york-state-primary-care-scorecard/. April 23, 2024. Accessed April 24, 2024.
- Care Transformation Collaborative: Rhode Island. https://ctc-ri.org/. Accessed April 24, 2024
