Increasing Primary Care Investment: States Are Leading the Way - - PowerPoint PPT Presentation

Increasing Primary Care Investment: States Are Leading the Way

Rachel Block, Program Officer Presentation for Academy Health Research Meeting June 2, 2019

Milbank Memorial Fund

• Mission: Improve the health of populations by connecting leaders and

decision makers with the best available evidence and experience

• Activities:
• 1. Build state health policy leadership
• 2. Source of evidence and experience on selected issues (like primary care)
• Evidence through research support
• Collect examples of state policy activities
• Disseminate this information through:
• Reports
• Convening states
• Collaborating with national organizations
• 3. Communications (Milbank Quarterly, Publications)

Why focus on primary care investment?

• International evidence
• Organizing tool
• Easily understood
• Politically unassailable
• Gateway topic for discussing misaligned delivery system priorities
• High leverage (at 5% spend, one percentage point = 20%)

Evidence and research

Recent Milbank funded activities advance evidence and research about primary care investment

Milbank study on commercial primary care spending measurement

• Published July 2017
• Work conducted under

contract with Bailit Health Purchasing and subcontract with Rand

• https://www.milbank.org/p

ublications/standardizing- measurement-commercial- health-plan-primary-care- spending/

Primary Care Spend in Medicare FFS

“The Evidence Report” 2018 focused on primary care and ACO performance

State policy activities

Milbank monitors and provides technical assistance about primary care spending measurement and increased primary care investment

Primary Care Investment: Can We Get There from Here?

Public and private efforts to establish baseline, conduct ongoing measurement of primary care spend, disseminate evidence Regulatory and statutory actions to increase primary care spending Employer benefit/insurance changes (e.g., exempt from deductible) Value-based payments Increased investment in primary care in particular states A primary care–oriented U.S. delivery system Increased investment in primary care in U.S.

I will mainly focus

• n

these

State Primary Care Spend Legislative Activity (as of 5/2019)

For updates please visit https://www.pcpcc.org/pri mary-care-investment

Does State Policy Make a Difference?

Vermont: 9.69% (Medicare, Medicaid, & Commercial, 2016) Massachusetts 6.6% (Commercial Payers, 2015) Rhode Island: 11.5% (All Commercial Payers, 2016) Connecticut: 4.7% (State Employees, 2017)

Source: NESCSO Primary Care Workgroup Presentation, 18 October 2018

Making Primary Care a Priority for the State’s Health Care System: Rhode Island Experience with Commercial Insurers

0.0% 2.0% 4.0% 6.0% 8.0% 10.0% 12.0% 14.0% 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 BCBSRI UHC Tufts

Primary Care Spending as Percent of Total Medical Spending Insurer (2008–2017)

Primary care spending by commercial insurers increased from $47 million/year to $73/year over this period.

Source: Office of the Health Insurance Commissioner, State of Rhode Island

Rhode Island State Policy Levers Controlled Health Care Cost Growth

Source: Landon et al, Academy Health Annual Research Meeting, 2018

Risk Adjusted Commercial Insurance Spending per Enrollees in Rhode Island vs. Match Control

Source: https://www.oregon.gov/oha/HPA/dsi-pcpch/Documents/SB-231-Report-2018-FINAL.PDF

Primary care definition not directly comparable to others: Included OB and Psychiatry How did this happen

• Legislation (Senate

Bill 231) developed by Administration

Oregon: Measuring Primary Care Spending and Setting Primary Care Investment Goals Across Major Payers

Oregon Report Documents Baseline and Variation by Major Payers

Note differences in percent of total spend and per capita

Non-claims payments is an important component in PC investment and accounts for large portion

• f PC spend

Components of Primary Care Spending

Services provided by primary care providers Primary care services

The sum of spending for selected CPT codes and non claims-based payments to primary care providers becomes the “numerator” in the spending calculation. Claims-Based Payments Non Claims-Based Payments

• Capitation payments and provider salaries
• Risk-based payments
• Payments for primary care medical home or

patient centered medical home recognition

• Payments for achievement of quality/cost-savings goals
• Payments to develop capacity to improve care for

a defined population of patients, such as patients with chronic conditions

• Payments to help providers adopt health information

technology, such as electronic health records

• Payments or expenses for supplemental staff

such as practice coaches, patient educators, patient navigators or nurse care managers Non-primary care services performed by primary care providers Primary care services Performed by specialists

State Policy Leadership for PC Spend Measurement, PC Investment

• Who has the lead varies by state
• R.I. Health Insurance Commissioner
• Ore. Health Authority
• Wash. Health Care Authority
• Vt. Green Mountain Care Board
• Conn. Office of Health Strategy
• Colo. Insurance Commissioner

Key Design Considerations

• How to define primary care?
• Specialties
• Services/codes
• What is the unit of analysis?
• Primary care/total cost

(numerator/denominator)

• Statewide aggregate
• Plans
• ACO
• What are the data sources?
• APCD, plan reporting
• All payer measure is ideal, but need to

address gap in self-insured data

• Does the data source include

non-claims spending?

• Claims data mostly sufficient but…
• You also need data sources for specialty,

possibly PCP flags

• Payments not made through claims (e.g.,

capitation, HIT/HIE, shared care management)

• What is the state’s authority?
• Statute
• Regulation
• Contracts
• Monitoring and evaluation
• How are stakeholders involved

in the process?

Broad Messages

• It is important to measure primary care investment
• Primary care spending is an important measure of “delivery system orientation” –

for states and for accountable entities.

• Consistent with evidence and good politics
• Good issue for organizing and educating
• It is feasible to develop and use primary care spending measures
• Resources are required, need to plan for it – insurer/plan side, state side
• Important to have a process that is transparent and data that is trusted
• Manage expectations – part of a broader delivery system reform strategy

Coming soon…

• PCPCC – Robert Graham Center evidence report (July)
• Presenting new MEPS analysis 30+ states
• Medicare FFS analysis
• Next publication – compares spending based on health systems affiliation (spoiler

alert – it’s lower in health systems)

• State level data on Medicare spending
• Data specifications for non-claims spending
• Research what states have already done
• Convene expert panel, states to get feedback
• Publish draft specifications for public input
• More state legislation!

References

• Milbank resources
• https://www.milbank.org/programs/primary-care-spend/
• Oregon legislation: setting standards for primary care spending levels
• https://olis.leg.state.or.us/liz/2017R1/Downloads/MeasureDocument/SB934
• Oregon primary care spending report
• https://www.oregon.gov/oha/HPA/dsi-pcpch/Documents/SB-231-Report-2018-

FINAL.PDF

• Rhode Island insurance standards
• http://www.ohic.ri.gov/documents/2019-Care-Transformation-Plan.pdf

Additional information

rblock@milbank.org www.milbank.org @MilbankFund