Federal and state governments play a significant role in strengthening the delivery of primary care; current efforts, however, have disproportionally been focused on large or multispecialty practices. This report examines the roles states are playing to reorganize the delivery of primary and chronic care to produce more efficient and effective care for patients and providers, particularly in small practices. Through short case studies developed via interviews with state officials and physicians in Colorado, Michigan, North Carolina, Oklahoma, Pennsylvania, and Vermont, the authors highlight several state-based initiatives that seek to create high-performing health systems by targeting local and regional strengths. Additionally, the authors identify five themes critical to enacting strategic delivery system reforms: leadership and the convening of stakeholders, payment incentives, support for infrastructure, information feedback and monitoring, and certification and recognition.
Although most of the debate preceding the passage of the Affordable Care Act in March 2010 was focused on improving access to care, it is widely agreed that without equal attention to reforms that address cost and quality, the United States is destined to continue its path of uncontrolled, spiraling costs and poor overall performance. The issues are complex, and there is no silver bullet or panacea to solve the problems. This paper examines the roles states are playing to reorganize the delivery of primary and chronic care to produce more efficient and effective care for patients and providers, with an emphasis on small practices. The paper includes short case studies highlighting the diversity of work in Colorado, Michigan, North Carolina, Oklahoma, Pennsylvania, and Vermont, as evidence of effective policies and strategies being used to transform and link practices to improve primary and chronic care.
Federal and state governments have important roles to play in facilitating or establishing the primary care foundation, which is the backbone of an organized delivery system. There have been a number of recent initiatives to strengthen the delivery of primary care, but activity has disproportionately been focused on larger, multispecialty practices. Spreading change to smaller practices remains a challenge.
The state policy levers and actions highlighted in this study emphasize the following five strategic themes that will be crucial in affecting change. These are:
Leaders in the case study states recognized that primary care practice behavior would not change unless payment changed. Findings also indicated that states pursued changes to emphasize more coordinated care across a range of chronic conditions rather than single conditions. The state-based initiatives highlighted in this report are evidence that states are working to create high-performing health systems using approaches and policy strategies that play to local and regional strengths and differences. The states vary greatly in their economic, social, and geographic environments. Highlights of the key features used by states include:
Moving forward, both federal and state policies will play a significant role in strengthening the delivery of primary care. Several provisions in the Affordable Care Act create noteworthy opportunities for primary care in the development of workforce, payment, and practice innovation. Many states will have expanded opportunities to continue experimenting with alternative payment and delivery structures to strengthen primary care and develop the needed infrastructure and workforce. These efforts may benefit from the growing knowledge base developed by the innovative demonstrations and broad-based initiatives under way in the leading states. Finally, the promise of
Medicare’s participation looms as a potential significant accelerator in the next few years. For example, Medicare’s participation in multipayer medical home payment schemes would greatly enhance states’ ability to spread innovations, and its participation would also encourage private carriers to participate.
States can have a significant impact on strengthening primary and chronic care delivery through numerous actions to transform and link small practices. This report illustrates that states can lead the way in delivery system reform and share lessons among each other and with the rest of the nation.