Primary Care Collaborative: Medicaid is key lever to improving physician pay, patient outcomes, health equity

The Primary Care Collaborative (PCC), founded in 2006, has spent years gathering partner members and organizations dedicated to the “Quintuple Aim”: better care, better health, lower costs, greater joy for clinicians and staff, and greater health equity.

In late August, PCC published the new report, “Access & Equity in Medicaid: Robust Primary Care is a Must.” It is a guiding document identifying eight strategies that could help physicians get paid more, and differently, to do what they love: helping more patients get better outcomes.

Given the size of Medicaid, that program must become part of achieving that goal.

In late August, PCC published the new report, “Access & Equity in Medicaid: Robust Primary Care is a Must.” It is a guiding document identifying eight strategies that could help physicians get paid more, and differently, to do what they love: helping more patients get better outcomes.

It states: “Primary care is an essential, and today largely undervalued, foundation of the U.S. health care system.” Especially dealing with Medicaid, whose beneficiaries need primary care, but are underserved. PCC President and CEO Ann Greiner, MCP, spoke to Medical Economics about how new strategies in Medicaid could help doctors and patients.

The strategies are:

1. Report and increase the share of Medicaid spending going to primary care.
2. Increase payment to primary care clinicians.
3. Support behavioral health and primary care integration.
4. Pursue population-based payment models.
5. Stratify data and incorporate health equity quality incentives into payment models.
6. Increase federal funding for community health centers and create new access points.
7. Pay for community health workers.
8. Encourage Patient-Centered Medical Home (PCMH) attributes, including care coordination.

This interview was edited for length and clarity.

Medical Economics: Recently, the Primary Care Collaborative published the report, “Access and Equity in Medicaid: Robust Primary Care is a Must.” How did that report come about? And how would you introduce it?

Ann Greiner, MCP
_{Primary Care Collaborative}

Ann Greiner, MCP: It's actually a really important component of what we're trying to achieve when we're talking about improving patient health. We see Medicaid as a key lever to addressing health equity. But let me back up a moment and explain that it's part of a larger campaign that the Primary Care Collaborative launched in March of 2022. The name of that campaign is Better Health NOW. I'm sure that none of the (readers) can argue with the premise that we need to improve the nation's health. We're now three years behind the Europeans in life expectancy, we took a dramatic dive during COVID, and there's lots of reasons for that. But one of the reasons is that we went into the pandemic with a less than healthy population. When COVID hit, it caused more problems and more deaths than in other high-income countries. This campaign was launched, coming out of COVID, recognizing that the health of the nation was not good, and we can illuminate and talk about many of those problems.

We were so pleased that around the same time we were thinking about how to respond to the health crisis, and what I would call some real challenges in primary care, that the National Academy of Sciences, Engineering and Medicine report was issued in May 2021. We saw that report as critical to bringing the primary care community together around a set of policies. Our focus as an organization is really on changing how we pay and how much we pay, which has a huge effect on how care is delivered, to improve population health outcomes, enhance equity, and provide more access to the front door of our health care system. This Medicaid report represents one of our three Better Health NOW policy planks focused on equity. And briefly, the other two planks are a Medicare plank so we can scale payment and delivery, payment changes, and the third is behavioral health integration.

Medical Economics: How would you describe the interconnections among primary care, health care equity, and Medicaid?

Ann Greiner, MCP: That is a million-dollar question. First, I'd like to say that primary care is essential to addressing equity across any kind of payer. It is our front door, and when the front door’s closed and people can't get access to care, their health is going to deteriorate. It becomes even more problematic for people who don't have access to a lot of resources to then address care when it's more costly, and more problematic and taking them out of the workforce. We have a report that we did with Morehouse that focuses on the critical role of primary care in addressing health equity. In particular, we see Medicaid as a very important lever, because of the size of the program. Secondly, the population that it serves tends to be folks of lower socio-economic means, and also more Black and Brown folks. So, 60% of Medicaid recipients self-report that they are black, Hispanic, Asian-American, and other people of color. So, we see it as a critical lever.

Medical Economics: The first strategy is, report and increase the share of Medicaid spending going to primary care. Given state control and administration of Medicaid programs, will this issue require 50 different policies or solutions?

Ann Greiner, MCP: Oh, my gosh, that'd be a headache. The program really is a partnership between states and feds. The federal government provides most of the dollars but, yes, the specific arrangements are negotiated at the state level, so the level of expenditures devoted to primary care really is at that level. Having said that, we've been involved as a backbone organization since 2018, in helping state leaders pivot towards more primary-care-oriented systems in their state. And they start by first asking the question, what are we spending on primary care? And when we began this effort in 2018, there were two states that required reporting at the health plan level across all payers except for ERISA on expenditures related to primary care. Now, 21 states require that kind of reporting. There's a growing role of state leaders saying, we really need to get a handle on what we're spending. What's driving that question? I think they all want a healthier population in their state. Think about what question that will then raise: Do our expenditures help to support this outcome that we're trying to achieve? And when they look at the differences, and they could be anywhere from 3% of a health plan’s expenditures going to primary care, up to 17%. There's a real variability and in their role providing oversight of these health plans, one, they are able, if they get the legislation or regulatory authority, to request these reports. Then a little over a handful of states have then decided that they're going to require the health plans to increase expenditures towards primary care, without growing total cost of care. Medicaid fits in to those conversations because it's not just one payer. We do think there's a role for states. The federal government also can, as part of their waiver authority, require states to enhance their expenditures on primary care within Medicaid and we've seen some states do that. We think first we need to get the data out there so we understand what our expenditures are. Just in case your audience may not know, our expenditures in primary care as a percentage of total cost of care have actually been falling over the last decade, even though there's so much conversation these days about primary care and its importance. The latest data shows that we spend 4.6%, less than five cents on the dollar, on primary care, across all payer types. Our European counterparts spend at least twice that. Is it any wonder that our population is less healthy?

Medical Economics: The fourth strategy is, pursue population-based payment models. Are those being used right now? And if so, what are the results?

Ann Greiner, MCP: There are some efforts to use population-based payment models. Massachusetts is a great example, Oregon is a really good example of their efforts to pay more and pay differently in the Medicaid arena, and the kind of outcomes that they're achieving. There are some examples and we need many more. We advocate for hybrid, so maintaining some services in fee-for-service. But the bulk in some kind of prospective payment really frees up the primary care physician to practice much more creatively because they're not on this hamster wheel of every patient gets the 10- or 15-minute visit, regardless of what their needs are, which I think is really frustrating for the primary care doc. They would prefer, I believe, to be able to expand or contract the amount of time they're spending depending upon patient need. We really see these models as freeing the primary care doc up to be much more patient-centered. I also believe that they're going to be able to deliver the kind of care that patients really are looking for. Patients don't like to feel like they're on a clock and they're just kind of like on a machine, or that so much time is being spent recording the visit, as opposed to actually interacting with them. And so for lots of reasons the encounters are less satisfying to primary care doctors and less satisfying to primary care patients. We've got to change this. And we need to change this quickly, with some bold policy changes, not waiting another decade until potentially primary care truly collapses. So I really call on policymakers, both in the public and private sectors, to join with us and to get serious about the policy changes we need to really rebuild and reimagine primary care.

Medical Economics: Our main audience is primary care physicians. What would you like to say to them? Or what would you like them to know, especially about this report?

Ann Greiner, MCP: First off, I want to thank you for the decision you made, whenever you made, it to become a primary care physician. You really are the backbone of our nation's health care system, even if at times you don't feel that you are recognized for the important work that you do. It is such critical work. I know that it's been really challenging to be a primary care physician in recent years. We want to help you do the job that you love and remove the impediments to doing the job you love. We want to help you become better resourced, with a full-fledged team, so you really can provide that comprehensive set of services that your patients are seeking. So, I guess what I'd say is, thank you for what you do and join us as we work with policymakers to make the bold changes that are going to strengthen the foundation of our health care system and pry open our health system’s front door.