8 Steps to Implementing Advanced Primary Care

September 29th, 2022
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Robust primary care is essential to the ability to transform health care in the U.S. Adults who regularly see a primary care physician have 33% lower health care costs and 19% lower odds of dying prematurely than those who see only a specialist. Additionally, every $1 increase in primary care spending produces $13 in savings, and if everyone used a primary care provider as the principal source of care, the U.S. could save $67 billion annually. As part of its pioneering work to define and promote the adoption of advanced primary care, PBGH’s California Quality Collaborative’s primary care improvement efforts led to almost 50,000 hospital bed days avoided, emergency room utilization sharply reduced and total savings of about $186 million in California.

Despite these outsized benefits, misaligned financial incentives, chronic under-investment, infrastructure barriers and a lack of integration with other elements of care — including behavioral health — continue to severely constrain primary care’s impact on the health of American workers and families.

That’s why PBGH is spearheading the development and implementation of ‘advanced primary care.’ Our approach emphasizes bolstering existing primary care to treat more health needs within the primary care practice and refer to only the highest quality specialists when appropriate, increase patient access, integrate behavioral health screening and management, improve care coordination and expand tools and systems that can support population-based care for patients.

A new report highlights eight key takeaways from a discussion with representatives of large employers and public health care purchasers based on their experiences implementing advanced primary care.

1. Changing payment is crucial

Care delivery change requires payment change. Capitated payment – with some flexible incentives – will enable practices to meet clinical and health goals. A model predominantly based on fee-for-service or volume-based payment is antithetical to the core tenants of advanced primary care. Read about how Washington State Health Care Authority is tackling primary care payment reform.

2. Update operating systems or find new ones

Health plan operations are built to pay fee-for-service and are very challenged to pay differently. Whole Foods took a bold approach by creating its own system rather than relying on health plans. Learn how.

3. Align around standardized measures

Purchasers should align to adopt a set of priority standardized measures by which to assess care and service. Through a multistakeholder consensus process, PBGH has selected a set of evidence-based clinical and outcome measures that collectively signal and reflect the desired outcomes of advanced primary care. See how Covered California is using these measures.

4. Redefine your investment priorities with payers and partners

The cost benefits of advanced primary care must be emphasized in negotiations with payers. But this does not mean paying more overall. The expectation is that total cost remains flat. Read about eBay’s perspective on investment in primary care.

5. Hone your message

Despite studies that have repeatedly shown how strengthening primary care can improve outcomes, reduce costs, enhance the patient and provider experience and improve health equity, those benefits are not always apparent to health plans, organizational leadership or even employees. CalPERS’s experience with mandatory primary care provider selection offers important lessons for other purchasers.

6. Think nationally and act regionally

Employers should take the lead in their communities and regions when it comes to enlisting like-minded purchasers in support of advanced primary care. This can include national employers with even a modest presence in the community. Read about The Boeing Company’s approach to this.

7. Identify a trusted authority that can help foster standardization and adoption

A neutral convener can play an important role in helping achieve consensus around common measures and definitions, and likewise serve as a focal point for payer, purchaser and provider discussions regarding implementation and payment challenges. Washington and California offer examples of how regional multistakeholder groups play a key and needed role in implementing national change.

8. Just do it

There is a tendency in health care to focus for too long on discussion and planning without pursuing or engaging in the practical or implementing change. It’s important to start the process of implementing advanced primary care. Read about steps The Wonderful Company is taking on behalf of its employees.

California Providers and Health Plans Sign Agreement to Expand Investment and Increase Access to Advanced Primary Care

July 26th, 2022
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Coalition of Large California Payers Commit to Accelerating Widespread Adoption of Advanced Primary Care with The Goal of Reducing Costs and Improving Quality and Equity

As part of a new multi-stakeholder initiative, six health care organizations serving California have signed a memorandum of understanding (MOU) to increase investment in and access to ‘advanced primary care,’ a model that emphasizes comprehensive, person-focused care, integration of behavioral and physical health services and high-quality outcomes. The agreement outlines a new initiative that strengthens the primary care delivery system throughout the state by enabling primary care practices to transform to a high-performing, value-based care model that reduces costs and improves quality and equity.

Known as the California Advanced Primary Care Initiative, the effort is jointly led by California Quality Collaborative (CQC), a program of the nonprofit coalition Purchaser Business Group on Health (PBGH), and the Integrated Healthcare Association (IHA). CQC and IHA convened the state’s largest payers to collectively adopt a model to transform primary care statewide.

The six organizations committed to the California Advanced Primary Care Initiative include Aetna, Aledade, Blue Shield of California, Health Net, Oscar and UnitedHealthcare. The initiative is a first-of-its kind agreement that represents a voluntary joint effort among payers to standardize the way they finance, support and measure the delivery of Advanced Primary Care.

“This initiative builds upon a long history of stakeholder collaboration to improve the care and health of Californians and moves us from vision to action with aligned priorities to scale high-quality primary care throughout the state,” says Crystal Eubanks, senior director of CQC.

“This initiative reflects our understanding that the impact of any one payer alone is limited,” says Peter Long, executive vice president of Strategy and Health Solutions at Blue Shield of California. “That’s why Blue Shield is committed to partnering with our peer payers and providers to scale delivery of high-quality primary care across the state. Ultimately, we know this is what is best for our members, and we all must work together to make this vision a reality.”

California Advanced Primary Care Initiative stakeholders committed to pursuing the following goals in the MOU:

  1. Transparency: Report primary care investment and adoption of value-based payment models that support the delivery of advanced primary care and performance on the advanced primary care measure set jointly developed by CQC and IHA, a list of metrics that enable purchasers, health plans and providers to identify primary care practices in a given market that are delivering the best results for patients.
  2. Payment: Adopt an agreed upon value-based payment model for primary care providers that offers flexibility, supports team-based care delivery and incentivizes the right care at the right time.
  3. Investment: Collaboratively set increased primary care investment quantitative goals without increasing the total cost of care.
  4. Practice Transformation: Provide technical assistance to primary care practices to implement clinical and business models for success in value-based payment models, integration of behavioral health and reduction of disparities.

“Primary care is the heart of all health care,” says Jeff Hermosillo, California Market President, Aetna. “This innovative initiative will help ensure accessible, affordable and high-quality primary care to improve the well-being of all Californians. Working together with our peers, providers, plan sponsors and members, we are committed to primary care that makes a difference in people’s lives.”

“Health Net is proud to be part of this groundbreaking collaboration that will support physicians in providing high-quality, coordinated care for millions of Californians. As a practicing primary care doctor, I am especially heartened by the opportunity to better integrate behavioral and physical health, a key strategy for effectively addressing our behavioral health crisis.” says Todd May, M.D., vice president, medical director of Health Net’s commercial business.

CQC and IHA have been collaborating since 2019 to develop shared standards of advanced primary care, including common definitions of practice attributes, a performance measure set, methods to identify quality at the practice level and a value-based primary care payment model.

“I am so inspired to see payers collaborating together in a new way toward this timely, crucial cause that will elevate primary care and improve patient lives in California,” says Dolores Yanagihara, vice president of Strategic Initiatives at IHA.

Strengthening Primary Care: A Pilot with Four Large Purchasers

June 10th, 2022
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Extensive research and pilot programs have shown that easily accessible, person-centered and team-based primary care that integrates behavioral health and other supports can significantly improve patient outcomes and experience. It can also increase population health, reduce overall costs and serve to improve equity in our health care system.

It is for these reasons that PBGH’s California Quality Collaborative (CQC) has been working for over a decade to improve primary care. That work has culminated in the development of shared attributes and measures that enable purchasers, health plans and providers to identify primary care practices in a given market that are delivering the kind of care research tells us will bring about the best results for patients.

Together with the Integrated Healthcare Association (IHA), PBGH brought together four large health care purchasers in California to pilot this set of performance measures that emphasize patient experience and outcomes. The PBGH/IHA partnership, known as the Advanced Primary Care Measurement Pilot, began in January 2022, and participating purchasers include Covered California, California Public Employees’ Retirement System (CalPERS), eBay and San Francisco Health Services System.

Partnering to Better Primary Care in California

Our already weak primary care system has been further hampered by the pandemic, and these purchasers recognize that the time to strengthen it is now. The four participating purchasers have aligned by incorporating the same Advanced Primary Care attributes and measures into their health plan contracts. The goal is to identify the primary care practices throughout the state performing at the highest levels and delivering high-quality patient care.

The set of performance measures being tested through the pilot reflect the shared standard of Advanced Primary Care as defined through a multi-stakeholder process led by PBGH’s California Quality Collaborative that included input from purchasers, health plans, providers and patients.

The outcome will be an increase in understanding of where patients are getting the highest quality primary care. The pilot will give purchasers and health plans information to help them make decisions about their provider networks, resource distribution and consumer incentives. This information can be used to better connect patients to practices delivering Advanced Primary Care and incentivize improvement for other providers, increasing the availability of Advanced Primary Care.

How the Pilot Works: Existing Data for a New Purpose

Data already available through IHA is being used, so health plans and providers do not have to report anything new. The existing data will be used for a new purpose – to assess individual practices.

Performance information can be diluted when data from multiple practices is combined. By looking at each individual practice separately, we can gain the best understanding of which practices are delivering the best primary care and which ones need improvement.

The data will also be aggregated across purchasers and health plans for the first time to provide a more complete view of each individual practice’s performance, rather than looking at small segments of patients in a vacuum. This will allow for a better assessment of whether a practice has the systems in place to consistently provide high-quality care for everyone

Currently, ways to account for socio-economic and demographic differences in the performance analysis is being explored. This lens is crucial to ensure decisions made around the pilot promote equity and do not inadvertently increase the challenges vulnerable communities already experience in accessing high-quality care.

The analysis will include data from January through December 2022, and results and findings are expected mid-2023.

Employers Are Driving Innovations in Primary Care

February 24th, 2022
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Employers know that primary care is essential for a healthy workforce and employees’ access to a high-value health care system. Evidence shows that improved primary care translates into healthier, happier patients and lower overall health care costs:

Large employers are increasingly working with existing direct contracting partners and new vendors to enhance primary care, which includes the integration of behavioral health care among other things.

Four approaches reflect the ways large employers are currently working to improve primary care for their employees:

1. Developing a common set of advanced primary care standards to enable employers to speak with one voice. The development of the advanced primary care model is as much about streamlining the practice of primary care as it is about improving outcomes, enhancing the patient experience and reducing costs. Simple and consistent definitions of optimized primary care across all payer contracts would reduce, if not eliminate, the bewildering array of sometimes-conflicting value-based requirements contained in multiple payer contracts. That fact could mitigate clinician burnout by easing the administrative burden while allowing more time for the actual provision of care.

It is, therefore, essential that employers send a common signal to the market. For that reason, PBGH worked last year with members through an employer-led initiative to create a Common Purchasing Agreement. This enables employers to communicate their priorities and engage payers and providers to make changes to care delivery and payment that meet their priorities.

2. Integrating behavioral health into primary care. Behavioral health integration is an integral part of advanced primary care and a key feature of the Common Purchasing Agreement mentioned above. Nearly seven in 10 patients in need of behavioral health treatment seek care via primary care practices. Evidence shows that integrating behavioral health services into primary care can enhance mental health care access and coordination, improve outcomes and reduce costs. Behavioral health integration, a feature of advanced primary care, allows patients to access mental health care screening, services and treatments through their primary care provider, just like any other specialty care. Employers are highly focused on these efforts, which address an issue that has reached crisis level in this country.

3. Requiring members to choose a primary care provider. Patients benefit from an ongoing primary care relationship with improved care access, greater care continuity and better health outcomes. This in turn reduces employee absenteeism, enhances productivity and lowers overall health care spending for employers. That’s why some employers are taking additional steps to ensure their members are connected to a primary care practice. Methods to do so include mandating that members select a primary care physician and/or team, using benefit design incentives to support the use of primary care over specialty care (when appropriate) and increase education about the importance of having a primary care provider.

4. Helping employees identify and use only the highest quality primary care providers. Using quality measures, such as the PBGH advanced primary care measure set, purchasers and health plans can identify high-performing provider practices. Once those practices have been identified, employers can drive plan members to providers able to demonstrate that they provide high-value care, or the providers identified can be rewarded for their superior performance.

Employers understand better than anyone that the quality of health care their employees can access has a profound impact on their work, lives and productivity. The last few years working through the unprecedented challenges brought about by the pandemic have only reinforced the importance of continuing to strive to reduce disparities in health care and increase access to high-quality and more affordable services.

The same principles of aligning payment incentives and employer voices in primary care provides a model for other care verticals, including maternity care, oncology and musculoskeletal disorders, to name a few. Employers will increasingly work with organizations able to help design and implement the standards necessary to ensure they’re buying the best health care services available for the millions of employees, consumers and families throughout the nation who rely on their employers for health benefits.

A Little Less Conversation, A Little More Action

November 18th, 2021
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“We’ve talked long enough. It’s long past time to take action. Our goal is to foster meaningful, widespread change in health care within three years.” – Elizabeth Mitchell, CEO of PBGH


Large employers and health care purchasers have increasingly begun to take actionable steps to strengthen primary care, the critical precursor to a high-quality, cost-effective health care system.

Extensive research and pilot programs over multiple decades have repeatedly shown that a robust, integrated and accountable approach to primary care—characteristics collectively defined as advanced primary care—can significantly reduce overall health care costs while improving patient outcomes and experience.

Efforts by the nation’s largest employers to transform health care reached a major inflection point this fall when nearly 200 employers gathered with their health plans and health care provider partners from across the country at the PBGH Primary Care Payment Reform Summit. The event created a platform during which employers collectively conveyed their readiness to implement tools designed to induce payers and providers to deliver the same levels of value and quality they routinely expect from other vendors, and their commitment to investing in advanced primary care with integrated behavioral health and a commitment to equity.

Here are 5 key takeaways from the summit about what large employers and purchasers want from their health care vendors:

1. Employers have long accepted poor value for their health care dollars in ways they never would for any other product or service.

Employer-sponsored health plans routinely pay 200-600% times the rates charged to Medicare and effectively provide most of the profit margin for both health plans and providers without visibility into the quality of care their employees receive. Years of provider and insurer consolidation means even the largest employers tend to lack enough employees in any market to exercise adequate leverage to compel greater transparency and accountability.

2. Purchasers feel they’ve given health care stakeholders ample opportunity to reform the care payment and delivery system.

Industry efforts to transform health care have largely failed due to a lack of shared alignment and goals, a fragmented care system, the continued reliance on fee-for-service and the industry’s resistance to change. Now purchasers are collectively taking action to improve value and quality. Read more about what purchasers are doing right now in the full report.

3. Point solutions are making fragmentation worse and threaten to further increase costs.

To better serve members and reduce costs, many employers are turning to third-party vendors for singular, or point, solutions that address specific care functions or services. While many of these new, often digital capabilities are useful in isolation, they’re collectively making worse the already substantial problem of fragmentation and complexity across the care continuum. Many are also backed by venture capital firms seeking maximum profit potential and hence have little incentive to reduce the overall cost of care.

4. Integrating behavioral health into primary care is vital.

Mental health has been a top priority for employers for many years, and the urgency has only increased during the pandemic. Mental health care is hard to access and of variable quality, but mental health care is primary care and needs to be part of advanced primary care practice. Evidence shows that integrating behavioral health services into primary care can enhance mental health care access and coordination, improve outcomes and reduce overall costs.

5. Achieving lasting change will require that purchasers pull together to achieve critical mass.

Employers today have an opportunity to leverage their immense buying power to promote fundamental change in how health care is accessed, purchased and delivered. But even the biggest purchasers in the country lack leverage in most markets. Change on this scale cannot occur unless purchasers work in concert in every region in the country. Only by collectively setting high standards and demanding change can employers hope to overcome the existing system’s enormous inertia.

The Time to Act is Now

Employers want to buy the best health care benefits on behalf of their employees. But they understand better than most how costly and dysfunctional our health care system has become. They provide the critical lifeline of health insurance to about half of Americans, and they grapple every day with ways to keep coverage affordable.

Read the full report A Little Less Conversation, A Little More Action: 5 Takeaways from the PBGH Primary Care Payment Reform Summit here.

See more about the PBGH Primary Care Payment Reform Summit here.

Using Primary Care’s Potential to Improve Health Outcomes

October 4th, 2021
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For over a decade, revitalizing primary care has been a top priority for the Purchaser Business Group on Health (PBGH). Through successive initiatives and in collaboration with a diverse group of committed stakeholders, PBGH has spearheaded efforts to create a blueprint for “Advanced Primary Care.”

What Is Advanced Primary Care?

Advanced Primary Care places patients at the center of every interaction and prioritizes access to high-quality primary care to prevent higher acuity, costlier care and making for a healthier California.

Building off a statewide practice transformation initiative funded by the Centers for Medicare and Medicaid (CMS), PBGH’s California Quality Collaborative (CQC) began crafting definitions for ‘exemplar’ primary care practices with the goal of identifying, celebrating and learning from high-performing organizations within the program’s network. This led to a definition of “Advanced Primary Care.”

CQC defined Advanced Primary Care by high-performance attributes and a set of results-oriented measures that focus on how the care process is, or should be, experienced from the patient perspective. This set of measures is based on existing outcome measures widely in use by California and national payers that if collectively applied would enable medical practices to deliver Advanced Primary Care.

Why Is Primary Care So Important?

Primary care—long underfunded and woefully underutilized—remains the foundation upon which a high-performance, cost-effective health care system must be built.

Evidence shows that improved primary care translates into healthier, happier patients and lower overall health care costs:

It is important to note that the development of the Advanced Primary Care model is as much about streamlining the practice of primary care as it is about improving outcomes, enhancing the patient experience and reducing costs. Simple and consistent definitions of optimized primary care across all payer contracts would reduce, if not eliminate, the bewildering array of sometimes-conflicting value-based requirements contained in multiple payer contracts.

Why Doesn’t Primary Care Work Better?

Funding arguably is the greatest hurdle to more effective primary care. Despite 55% of office visits taking place in primary care clinics, only 4-7% of health care dollars go toward primary care.

But misaligned financial incentives, infrastructure and technology barriers and poor integration with other elements of care all play a role in compromising quality and driving up costs.

Advanced Primary Care in Practice

One initiative that has come out of the primary care groundwork laid by CQC is a measurement pilot with Covered California and CalPERS. Both organizations agreed to pursue a pilot program starting January 2022 to test statewide practice-level measurement using CQC’s 11 Advanced Primary Care measures.

Covered California contracts with 11 health plans to provide coverage for 1.6 million Californians, and CalPERS manages pension and health benefits for more than 1.6 million California public employees, retirees and their families.

The goal of the pilot is to create the basis for extending the Advanced Primary Care criteria across PBGH’s membership and to other payers nationwide.

On September 30, 2021, more than 175 employers, public purchasers, health plans, providers and other stakeholders from across the country came together for a summit to discuss implementation of a common purchasing agreement based on CQC’s definition of Advanced Primary Care. Going forward, CQC plans to continue pursuing solutions to barriers that inhibit broader implementation of Advanced Primary Care.

For more about the journey to Advanced Primary Care, click here.