States Build on Primary Care Models to Expand Access

Washington, D.C. – As federal lawmakers consider the best way to extend health care to the uninsured, they might find lessons in states that make primary care the foundation for increasing access to care.  

Experts discussed the strategies used by some successful state health care initiatives in presentations during the Patient-Centered Primary Care Collaborative Fall Conference(pcpccevents.com) held here Oct. 11-12.

Peter Lee, J.D., executive director of Covered California, discussed how this state insurance exchange maintains a balance between affordable plans for consumers and a market that insurers want to be in.

In all its contracts with insurers, Covered California requires participating plans to address four priorities:

• promotion of primary care,
• health disparities,
• coordinated care and
• a move away from strict fee-for-service payment.

Putting primary care at the center of health care helps solve a problem that Lee pointed out: the fact that expanding coverage through public spending initially leads to increased ER visits, which critics point to as evidence that expansion does not control costs. But he said that's because the ER is the normal point of care for people who were recently uninsured.

"We have to change the culture by moving their normal point of care," Lee said.

As an important step toward this goal, in 2017, Covered California assigned every enrollee to a primary care clinic within 60 days.

"We told patients, 'If you don't know where to go, start here,'" Lee said.

Another strategy to emphasize primary care has been to exempt primary care office visits from deductibles for patients who obtain coverage through Covered California. Lee pointed out that low-income patients are unlikely to schedule primary care visits if they face a high deductible.

"There is no continuity of care if you are thinking about a $3,000 deductible between you and the doctor," Lee said.

The design of the California marketplace attracts a high volume of healthy individuals, which allows insurers to lower costs and keep premiums down. It also keeps the state from facing the problem of insurers pulling out of the market and leaving scant competition. Eleven insurers participate in Covered California, the same number as when the program began.

On average, enrollees stay with Covered California plans for 26 months, and 40 percent leave each year. Eighty-five percent of those who leave Covered California sign on with another plan, compared to only about 50 percent of those who leave the federal exchanges. Lee explained that many young individuals decide they are healthy enough to leave their plans without an alternative after they have insurance for a year.

California is not the only state reporting success with increased access. In 2009, Oregon wanted to transform primary care by moving 75 percent of all residents into a patient-centered medical home (PCMH) model. The transition was completed in 2012; now there are 630 PCMH practices statewide, and 80 percent of residents obtain care in one of these practices.

Although the transformation is a success in terms of access, the state is still working to make it financially sustainable for practices to make changes such as integrating the services of behavioral health specialists and pharmacists, said Evan Saulino, M.D., Ph.D., a family physician who serves as clinical adviser for Oregon's Patient-Centered Primary Care Home program.

Oregon officials looked nationally for programs that illustrated sufficient investment. They modeled their system on a Rhode Island program that devotes 12 percent of health care spending to primary care. As a comparison, Medicaid also spends about 12 percent on primary care, but for commercial insurers, that average falls to just 6.5 percent.

"There were huge differences in investment without any explanation," Saulino said.

To back up the state's requirement, Oregon asked insurers to report their annual expenditures on primary care. The state's medical home model saved $240 million in health costs in its first three years, Saulino noted.

Such outcomes suggest the possibility of more widespread change.

"There are some things that both parties can agree upon across the political spectrum, and primary care transformation is one of them," Saulino said.