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States move to prioritize primary care


When it comes to promoting investment in primary care, Oregon might very well be the country’s current champion innovator.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The series continues with this blog by Glen Stream, MD, FAAFP, MBI, a family physician practicing in La Quinta, California, who is also past president of the American Academy of Family Physicians. He serves as the president and board chair of Family Medicine for America’s Health. The views expressed in these blogs are those of their respective contributors and do not represent the views of Medical Economics or UBM Medica.


When it comes to promoting investment in primary care, Oregon might very well be the country’s current champion innovator.

Over the past eight years, the state has put a priority on primary care, putting in place a series of policies that recognize the central role primary care plays in achieving the triple aim of improving patient health and quality of care while lowering costs. 


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The latest example: legislation that Oregon Gov. Kate Brown recently signed into law that will require all commercial insurers in the state to invest a minimum of 12% of their total medical expenditures in primary care by the year 2023. In urging support for the legislation, its backers pointed to evidence showing that increased spending on primary care infrastructure “results in better health outcomes for patients and savings in the form of reduced specialist referrals, unnecessary emergency room visits and hospitalizations.”

Dr. Stream

That’s not just wishful thinking. An initiative that’s been in place for several years-Oregon’s Patient-Centered Primary Care Home program-has already saved the state millions of dollars, roughly $13 in savings for every $1 increase in primary care spending.

Oregon is not alone. 

In Michigan, Blue Cross Blue Shield leads one of the oldest-and largest-patient-centered medical home programs. Its 4,534 primary care doctors at 1,638 practices have led a transformation of care that has resulted in a 15% decrease in adult visits to emergency departments and a 21% decrease in ambulatory care-sensitive inpatient stays, according to a recent report.

The report by the Patient-Centered Primary Care Collaborative and the Robert Graham Center notes that it’s become “widely accepted that primary care practice transformation and delivery are essential to achieving the nation’s quadruple aim – improving patient and provider experience and the health of the population while decreasing cost.”


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Another program, Covered California, the state’s official health insurance exchange, is working with 11 health plans to promote and enhance primary care for the 1.4 million individuals currently enrolled through the exchange and another 600,000 covered by plans off the exchange. The initiative also has the potential to reach another 21 million people the plans cover beyond the individual market.

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achieve its goals, Covered California this year began requiring all enrollees to be matched with a primary care physician, nurse practitioner or another primary care clinician as a patient advocate and first point of contact. 

Enhanced primary care is also having an impact in Rhode Island where Medicaid accounts for about one-third of the state’s budget. The state saw a significant drop in total medical spending after its health insurance commissioner required all commercial plans to increase spending on primary care by 1% of total spending per year over a five-year period. Between 2008 and 2012, Rhode Island’s three largest commercial insurers increased spending on primary care by 37% while total medical spending fell 14%.


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Also in Rhode Island, a pilot primary care project sent nurse practitioners and graduate students to the homes of financially disadvantaged patients with chronic health issues, resulting in decreases of more than 60% in both hospitalization rates and emergency department visits over a six-month period in 2016.

Despite the proven potential of primary care to deliver higher-quality and lower-cost care, a number of obstacles stand in the way of delivering on that promise. Current spending on primary care represents just 6% of total health care spending, half the 12% minimum amount the American Academy of Family Physicians says is needed. 

There’s also a shortage of primary care specialists, a situation that’s projected to worsen over the next several years even as the demand for primary care services increases. 

It’s not hyperbole to assert that these are life-and-death issues. Increasing the number of physicians specializing in primary care could save the lives of more than 100,000 Americans deaths a year.

For that, and many other reasons, the primary care initiatives in Oregon and the other states represent important leadership that others can follow. We need to do a lot more to support and promote primary care to ensure it realizes its full potential as the underpinning of the nation’s health care system.


Glen R. Stream is a family physician in La Quinta, California, and president of Family Medicine for America’s Health, which sponsors the Health is Primary campaign.

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