State Primary Care Spend Targets Comparison
The comparison of state definitions of primary care spend targets highlights the importance of setting such targets to enhance patient outcomes, reduce costs, and improve care experiences. Various states have different approaches to measuring and regulating primary care spending, emphasizing the need for standardized methods. This analysis explores the reasons behind establishing primary care spend targets and the varying strategies adopted by states like Connecticut, Rhode Island, Oregon, and others.
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State Primary Care Spend Targets A Comparison of State Definitions November 2020 1
Why Set a Primary Care Spend Target? (1 of 2) The U.S. health care system is largely specialist-oriented. Research has demonstrated that greater relative investment in primary care leads to better patient outcomes, lower costs, and improved patient experience of care. CMS, states and private payers have elected to utilize primary care to strengthen their health care system performance by: supporting improved primary care delivery (e.g., expanding the primary care team, supporting advanced primary care model adoption) increasing the percentage of total spending that is allocated towards primary care. 2
Why Set a Primary Care Spend Target? (2 of 2) Assessing primary care spending as a percentage of total health care spending is a relatively new approach to measuring health system orientation toward and investment in primary care. There are many use cases for such measurement, including to: Meaningfully quantify current and future health system investment in primary care Objectively compare primary care spend geographically and across payers and health care systems Facilitate analysis of primary care spend relative to total health care costs and to other services (e.g., specialty and institutional) Promote transparency in primary care spend and overall investment in primary care Inform public policy decisions about investment in primary care 3
State Approaches to Primary Care Spend Measurement (1 of 2) States have begun utilizing various (and inconsistent) approaches to measurement. Rhode Island and then Oregon established regulatory primary care spend requirements. Connecticut and Pennsylvania are in the process of setting voluntary primary care spend targets. Other states have focused on measuring primary care spend, e.g., Colorado, Delaware, Washington, and the remaining New England states (Maine, Massachusetts, New Hampshire, Vermont). 4
State Approaches to Primary Care Spend Measurement (1 of 2) The following slides compare the definitions of primary care spend targets in use by Connecticut, Rhode Island, Oregon and the New England States Consortium Systems Organization (NESCSO), specifically: which data source(s) they use to obtain data, the services included under primary care, the eligible primary care providers, the composition of service-based payments, the categories of non-service-based payments, the spending categories included in total spending (the target denominator) and what population(s) are included in target. 5
Data Source Data Source APCD Connecticut* Yes (Medicare only) Yes Rhode Island No Oregon Yes NESCSO** Yes Direct payer reporting Yes (Excel template) Yes (Excel template) Yes (Excel template) *Connecticut adopted two definitions of primary care a narrow definition for the purposes of measuring spending against a statewide target established in an Executive Order and a broad definition for assessing spend more comprehensively. The narrow definition is described throughout this document. **NESCSO adopted four definitions of primary care with different definitions of a primary care provider and services. NESCSO s core definition is described throughout this document.. 6
Primary Care Services (1 of 2) The following tables summarize categories of codes that are included in various definitions of primary care. There may be code-level differences within the categories that are not highlighted here. Service Type Office or home visits General medical exams Routine adult medical and child health exams Preventive medicine evaluation or counseling Telehealth visits Administration and interpretation of health risk assessments Connecticut Yes Yes Yes Rhode Island No service restriction (except lab, x-ray and imaging) Oregon Yes Yes Yes NESCSO Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes 7
Primary Care Services (2 of 2) Service Type Routine obstetric care (excluding delivery and routine gynecological care) Behavioral health risk assessments, screening and counseling Minor outpatient procedures Immunizations (e.g., vaccines and vaccine administration) Inpatient care ED care (e.g., suture removal, splinting) Nursing facility care Hospice care Practice-administered pharmacy Connecticut Yes (if done by PCP) Rhode Island No service restriction (except lab, x- ray and imaging) uses primary care provider definition only Oregon Yes NESCSO No Yes (if done by PCP) No Yes Yes Yes No Yes (vaccine and admin.) No No No Yes (admin. only) No No No No No Yes No No No No No Yes No 8
Primary Care Providers (1 of 2) Provider Type Primary care MD specialties Connecticut Yes family medicine, internal medicine when practicing primary care, pediatric and adolescent medicine Yes when practicing primary care Yes when practicing primary care No Rhode Island Yes family practice, internal medicine, pediatrics, geriatrics Yes Oregon Yes family medicine, general medicine, pediatrics, preventive medicine NESCSO Yes family medicine, general practice, internal medicine, pediatrics Yes NPs and PAs Yes Geriatrics/ gerontology Behavioral health Yes Yes Yes Yes, but only if accepting the role and fees of a PCP See behavioral health No Yes psychiatry and general psychiatry No OB/GYN and/or midwifery Naturopathic health care providers No Yes OB/GYN No No Yes No 9
Primary Care Providers (2 of 2) Practice Type Primary care clinics Federally qualified health centers (FQHCs) and rural health centers (RHCs) School-based health clinics Connecticut Yes Rhode Island No* Oregon Yes NESCSO Yes Yes No* Yes Yes Yes No* No Yes *Rhode Island does not explicitly include or exclude these practice types. It provides a definition of a primary care practice as a practice of a physician, medical practice, or other medical provider considered by the insured subscriber or dependent to be his or her usual source of care. 10
Service-based Payments Connecticut: payments based on allowed medical claims Rationale: captures total spending on services Rhode Island: payments based on paid medical claims Rationale: health plans have the ability to only control paid amounts Note: Rhode Island modeled historical trends for allowed and paid claims and found that while allowed claims were higher than paid claims, there were no differences in overall trend. Oregon: payments based on paid medical claims Rationale: legislators and advocates were focused on plan investments in primary care NESCSO: payments based on allowed medical claims Rationale: New England states expressed a preference for allowed amounts Note: Allowed amounts include the amount the payer paid to a provider for a health care service, plus any member cost sharing for a claim. Paid amounts include only the amount the payer paid to a provider. 11
Non-service-based Payments (1 of 2) Payment Type Care management PCMH infrastructure Pay-for-performance Shared savings distributions Capitation Connecticut Yes Yes Yes Yes Rhode Island Yes Yes Yes Yes Oregon Yes Yes Yes Yes NESCSO Yes Yes Yes Yes Yes (including provider salaries)* Yes Yes Yes (including provider salaries)* Yes Yes (including provider salaries)* Yes Episode-based payment EHR/HIT infrastructure Yes Yes Yes Yes Yes *Closed health systems (e.g., Kaiser Permanente) contribute to provider salaries in addition to capitation in Oregon. 12
Non-service-based Payments (2 of 2) Payment Type COVID-19 support payments Other Connecticut Yes (if feasible) Rhode Island TBD Oregon TBD NESCSO TBD Yes (supplemental workforce payments, including practice coaches, patient educators, patient navigators or nurse care managers; loan forgiveness for training providers; flu clinics) Yes (e.g., behavioral health screens in primary care settings, programs aimed to increase the number of primary care physicians) Yes (supplemental workforce payments, including practice coaches, patient educators, patient navigators or nurse care managers) Yes (supplemental workforce payments, including practice coaches, patient educators, patient navigators or nurse care managers; loan forgiveness for training providers; flu clinics) 13
Total Spending Spending Category Prescription drugs Connecticut Rhode Island Oregon NESCSO Yes (incl. pharmacy rebates) Yes Yes (pharmacy rebates TBD)* No Yes (pharmacy rebates TBD)** Lab and imaging services Dental services Vision services Long-term care Yes Yes Yes No No No No No No No No No No No No (except Skilled Nursing Facility) *Rhode Island plans to refine its primary care spending target definition in 2021. It will finalize whether to include pharmacy rebates at that time. **NESCSO aims to include pharmacy rebates in its definition of total spending, but will finalize its definition after it assesses state submissions. 14
Population Resident/ Provider Location In-state Resident Out-of-state Resident Connecticut Rhode Island Oregon NESCSO Yes No Yes Yes Yes Yes (only for public employees and educators) Yes Yes (only a few select border areas in WA and ID) Yes No In-state Provider Out-of-state Provider Yes Yes Yes No Yes Yes 15
