At a fall 2023 meeting, 30 experts developed a set of recommendations to enhance the quality of primary care in California. Among the ideas that emerged were a task force on primary care and health equity; a state scorecard on primary care and health equity; and an office for primary care within the state government.
The meeting was hosted by the California Health Care Foundation and Mathematica. The summit was an all-day event held in person in Oakland. Summit participants included 30 policy thought leaders, including experts in primary care and health equity from California, such as state officials, consumer advocates, community leaders, providers, and patient representatives.
The attendees heard about progress being made in other parts of the country. In 2021, the National Academies of Sciences, Engineering, and Medicine (NASEM) published a consensus study report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” which the report says provides a blueprint for increasing primary care policy leadership, action, and accountability at the federal level.
The Milbank Memorial Fund has begun publishing a national Primary Care Scorecard to track progress. Individual states such as Massachusetts and Virginia have followed suit with state scorecards to monitor the health of their primary care infrastructure. Meanwhile, 17 states have adopted legislation to track, report, and ultimately increase investments in primary care.
Building on these efforts, the California Health Care Foundation sponsored Mathematica to host a Summit on Primary Care Policy to Advance Health Equity, with the goal of reaching consensus on primary care policy priorities for California.
Participants reached broad consensus on three foundational policies required to strengthen primary care and advance health equity and 10 priority policy recommendations specific to five primary care topics: community engagement, workforce development, access to care, data standards and sharing, and payment.
They also agreed on a three-part approach to increase leadership and accountability to ensure progress.
A report summarizing the findings of the summit notes that while some recommendations “are already underway, supported by historic investments from state government. However, as of the writing of this report, California is experiencing a budget deficit and there are proposals to reduce spending in many of these areas.”
The first foundational policy is to sustainably increase Medi-Cal primary care provider payments to remove financial disincentives to serving Californians with low incomes. Medi-Cal fee-for-service physician reimbursement for primary care had historically been low, at approximately 76% of Medicare rates. Lower rates plus a heavy administrative burden cause many practices to decline to accept Medi-Cal patients, because payment does not cover the practice’s cost to provide high-quality care. Effective January 1, 2024, the California Department of Health Care Services (DHCS) and the Centers for Medicare & Medicaid Services (CMS) increased payment to 87.5% of Medicare, an important shift in the right direction, the report said.
The second foundational policy agreed upon is to increase the proportion of healthcare spending directed toward primary care to enable sustained, systemwide investment in primary care services and supports; and establish transparent and enforceable time-bound spending targets for public and private payers, to ensure resources are sufficient for the provision of high-quality, equitable primary care for all Californians.
In 2024, the state Office of Health Care Affordability (OCHA) will establish a statewide definition of primary care services and providers, identify mechanisms to measure the percentage of total healthcare expenditures allocated to primary care, and set spending benchmarks that consider current and historic underfunding of primary care services; develop benchmarks with the intent to build and sustain infrastructure and capacity and shift greater healthcare resources and investments toward supporting and facilitating innovation and care improvement in primary care; and promote improved equitable, high-quality outcomes for primary care.
OHCA has proposed a statewide absolute benchmark of 15% of total medical expense allocated to primary care across all payers, lines of business (commercial, Medicare Advantage, and Medi-Cal), and populations by 2034. A final rule is expected late in 2024 for implementation in 2025.
The third foundational policy is to create meaningful engagement of people with lived experiences of discrimination in all California state primary care policymaking and governance bodies to identify impediments to health equity and generate solutions.
Three-Part Approach to Accountability
Drawing on the NASEM recommendations and the experiences of HHS and the Commonwealth of Virginia, the following approach to increasing leadership and accountability in California garnered wide support among summit participants: (1) a task force on primary care and health equity, (2) a California state scorecard on primary care and health equity, and (3) an office for primary care within the state government.
With regard to creating an office for primary care, the report notes that although much is happening across state government (such as increasing primary care investment, bolstering the primary care workforce, and transforming the Medi-Cal primary care delivery system), “increased coordination among these efforts could improve their impact. This could be aided by the appointment of an individual primary care leader, supported with adequate resources and provided authority to coordinate across government departments and to develop a statewide strategy to strengthen primary care with health equity as the goal.”
