States Advancing Policies to Increase Primary Care Investment

Three new state reports—from Colorado, Vermont, and Maine—offer recommendations on how to measure and increase statewide investments in primary care. All three reports were developed as a result of state laws passed in 2019. This growing body of state work focused on primary care investment demonstrates strong interest from policy leaders and reflects public processes that successfully led to consensus among stakeholders about how to define primary care. The movement toward increased investment is important because evidence has shown that primary care can improve quality and reduce total health care spending.

While these reports show that it is feasible to measure primary care investment using existing data sources such as health care claims data that captures information about diagnoses or procedures, for example, the reports also indicate that these measures will not be complete unless non-claims payments, such as insurer reimbursement for an electronic medical record system, are also included. Yet most states do not routinely collect this data today. The Milbank Memorial Fund has commissioned new research on collecting non-claims data to help states capture this information.

The reports also note that there is currently no national standard for how to measure and report on primary care spending. The New England States Consortium Services Organization recently published a Request for Proposals (RFP) to create a single report on primary care investment for the New England states, and we will publish updates about that project once the RFP is awarded.

In the meantime, pioneering states continue to press forward.  Here’s a brief overview of these recent state activities.

 Colorado: Colorado has a history of support for improving primary care but didn’t have a standardized way to track spending. After two years of legislative and stakeholder discussion, in 2019 the state enacted legislation directing the Colorado Division of Insurance to convene a primary care payment reform collaborative that would recommend how to measure and increase primary care investment. This initiative was conceived as part of broader set of policies designed to improve health care affordability.

After several months of multi-stakeholder discussion, the collaborative issued its report with the following recommendations:

• Develop a broad inclusive definition of primary care in terms of health professional specialties;
• Establish a target for primary care investment for commercial insurers to increase by 1% in 2021 and again in 2022, and further evaluate thereafter;
• Work with Colorado’s data organization, the Center for Improving Value in Health Care, to improve the data available to measure primary care investment;
• Determine how to track outcome measures that evaluate the benefit of increasing primary care investment;
• Ensure primary care investment policies support advanced care delivery models;
• Use a combination of payments for practice care management infrastructure and alternative payment models;
• Issue an annual report to the Insurance Commissioner on increasing primary care investment staring in 2020.

Vermont:  Vermont also has a history of support for primary care, including the innovative Blueprint for Health that funds community supports for primary care like teams that link patients with local social services. Vermont is also at the forefront of alternative payment approaches, having launched a demonstration of an all-payer accountable health care payment model that will use the same payment structure for most health providers in the state. Last year, Vermont passed legislation directing the Green Mountain Care Board (GMCB) and Department of Vermont Health Access (DVHA) to measure primary care spending and make recommendations how to increase primary care investment.

The GMCB/DVHA report was developed with input from key stakeholders using an existing state definition of primary care that also includes some specific billing codes for primary care services offered within obstetrics-gynecology and mental health/substance use treatment. The calculation of primary care spending relied on data captured from the state’s all-payer claims database and some non-claims data. The report estimates the percentage of total health care spending going to primary care ranges from 8.9% (claims payments only) to 10.2% (claims and non-claims payments). However, some spending was not captured. For example, a significant amount of capitation (per person) payments were not included because these payments could not be specifically attributed to primary care; additional analyses of this data are planned. In addition, it is expected that the Vermont All-Payer Accountable Care Organization will increasingly use alternative payment models that will bump up the non-claims portion of state primary care spending.

The report finds that Vermont is already using regulatory and value-based payment approaches that will increase primary care investment, but the authors say that the state could explore additional measures relating to insurance rate review and provider rate-setting measures.

Maine: Last year, the state adopted legislation directing the Maine Quality Forum to publish an annual report on primary care spending using claims data and non-claims information tied to alternative payment methods used by payers. Using the legislative language defining primary care as a starting point, the Forum considered information gathered through public input and an insurer survey as it developed its primary care measures. Following a model originally published by the Milbank Memorial Fund, the report presents its results using a narrow (5.5%) and broad (8.8%) definition of primary care broken down by major categories of insurance coverage. The report also identifies several methodological issues the Forum will address in future analyses.