Increasing Primary Care Investment: States Are Leading the Way Rachel Block, Program Officer Presentation for Academy Health Research Meeting June 2, 2019
Milbank Memorial Fund • Mission: Improve the health of populations by connecting leaders and decision makers with the best available evidence and experience • Activities: 1. Build state health policy leadership 2. Source of evidence and experience on selected issues (like primary care) • Evidence through research support • Collect examples of state policy activities • Disseminate this information through: • Reports • Convening states • Collaborating with national organizations 3. Communications (Milbank Quarterly, Publications)
Why focus on primary care investment? • International evidence • Organizing tool • Easily understood • Politically unassailable • Gateway topic for discussing misaligned delivery system priorities • High leverage (at 5% spend, one percentage point = 20%)
Evidence and research Recent Milbank funded activities advance evidence and research about primary care investment
Milbank study on commercial primary care spending measurement Published July 2017 • Work conducted under • contract with Bailit Health Purchasing and subcontract with Rand https://www.milbank.org/p • ublications/standardizing- measurement-commercial- health-plan-primary-care- spending/
Primary Care Spend in Medicare FFS
“The Evidence Report” 2018 focused on primary care and ACO performance
State policy activities Milbank monitors and provides technical assistance about primary care spending measurement and increased primary care investment
Primary Care Investment: Can We Get There from Here? A primary care–oriented U.S. delivery system Increased investment in primary care in U.S. Increased investment in primary care in particular states Regulatory and statutory Employer benefit/insurance Value-based payments actions to increase primary changes (e.g., exempt from I will care spending deductible) mainly focus on these Public and private efforts to establish baseline, conduct ongoing measurement of primary care spend, disseminate evidence
State Primary Care Spend Legislative Activity (as of 5/2019) For updates please visit https://www.pcpcc.org/pri mary-care-investment
Does State Policy Make a Difference? Vermont: 9.69% (Medicare, Medicaid, & Commercial, 2016) Massachusetts 6.6% (Commercial Payers, 2015) Rhode Island: 11.5% (All Commercial Payers, 2016) Connecticut: 4.7% (State Employees, 2017) Source: NESCSO Primary Care Workgroup Presentation, 18 October 2018
Making Primary Care a Priority for the State’s Health Care System: Rhode Island Experience with Commercial Insurers Primary Care Spending as Percent of Total Medical Spending Insurer (2008–2017) Primary care 14.0% spending by BCBSRI 12.0% commercial insurers increased UHC 10.0% from $47 Tufts 8.0% million/year to $73/year over this 6.0% period. 4.0% 2.0% 0.0% 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 Source: Office of the Health Insurance Commissioner, State of Rhode Island
Rhode Island State Policy Levers Controlled Health Care Cost Growth Risk Adjusted Commercial Insurance Spending per Enrollees in Rhode Island vs. Match Control Source: Landon et al, Academy Health Annual Research Meeting, 2018
Oregon: Measuring Primary Care Spending and Setting Primary Care Investment Goals Across Major Payers How did this happen - Legislation (Senate Bill 231) developed by Administration Primary care definition not directly comparable to others: Included OB and Psychiatry Source: https://www.oregon.gov/oha/HPA/dsi-pcpch/Documents/SB-231-Report-2018-FINAL.PDF
Oregon Report Documents Baseline and Variation by Major Payers Note differences in percent of total spend and per capita
Non-claims payments is an important component in PC investment and accounts for large portion of PC spend
Components of Primary Care Spending Claims-Based Payments Non Claims-Based Payments Primary care services Performed by Capitation payments and provider salaries • specialists • Risk-based payments • Payments for primary care medical home or patient centered medical home recognition • Payments for achievement of quality/cost-savings goals Services provided Payments to develop capacity to improve care for • by primary care Primary care a defined population of patients, such as patients with chronic conditions providers services • Payments to help providers adopt health information technology, such as electronic health records Payments or expenses for supplemental staff • such as practice coaches, patient educators, patient navigators or nurse care managers Non-primary care services performed The sum of spending for selected CPT codes and non claims-based payments to by primary care primary care providers becomes the “numerator” in the spending calculation. providers
State Policy Leadership for PC Spend Measurement, PC Investment • Who has the lead varies by state • R.I. Health Insurance Commissioner • Ore. Health Authority • Wash. Health Care Authority • Vt. Green Mountain Care Board • Conn. Office of Health Strategy • Colo. Insurance Commissioner
Key Design Considerations • How to define primary care? • Does the data source include non-claims spending? • Specialties • Services/codes • Claims data mostly sufficient but… • What is the unit of analysis? • You also need data sources for specialty, possibly PCP flags • Primary care/total cost • Payments not made through claims (e.g., (numerator/denominator) capitation, HIT/HIE, shared care management) • Statewide aggregate • What is the state’s authority? • Plans • Statute • ACO • Regulation • What are the data sources? • Contracts • APCD, plan reporting • Monitoring and evaluation • All payer measure is ideal, but need to • How are stakeholders involved address gap in self-insured data in the process?
Broad Messages • It is important to measure primary care investment • Primary care spending is an important measure of “delivery system orientation” – for states and for accountable entities. • Consistent with evidence and good politics • Good issue for organizing and educating • It is feasible to develop and use primary care spending measures • Resources are required, need to plan for it – insurer/plan side, state side • Important to have a process that is transparent and data that is trusted • Manage expectations – part of a broader delivery system reform strategy
Coming soon… • PCPCC – Robert Graham Center evidence report (July) • Presenting new MEPS analysis 30+ states • Medicare FFS analysis • Next publication – compares spending based on health systems affiliation (spoiler alert – it’s lower in health systems) • State level data on Medicare spending • Data specifications for non-claims spending • Research what states have already done • Convene expert panel, states to get feedback • Publish draft specifications for public input • More state legislation!
References • Milbank resources • https://www.milbank.org/programs/primary-care-spend/ • Oregon legislation: setting standards for primary care spending levels • https://olis.leg.state.or.us/liz/2017R1/Downloads/MeasureDocument/SB934 • Oregon primary care spending report • https://www.oregon.gov/oha/HPA/dsi-pcpch/Documents/SB-231-Report-2018- FINAL.PDF • Rhode Island insurance standards • http://www.ohic.ri.gov/documents/2019-Care-Transformation-Plan.pdf
Additional information rblock@milbank.org www.milbank.org @MilbankFund
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