Strengthening Primary Care: A Pilot with Four Large Purchasers

June 10th, 2022
Tags: , , , ,

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
Tags: , , ,

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
Tags: , , , ,

“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
Tags: ,

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.

5 Pandemic Takeaways: Large Employers See COVID-19 as Catalyst for Systemic Health Care Change

July 8th, 2020
Tags: , , ,

COVID-19’s long-term impact on U.S. health care remains unclear, but amid the ongoing turmoil and uncertainty, large employers see opportunities for much-needed reforms.

Elizabeth Mitchell, president and CEO of Pacific Business Group on Health (PBGH) and Lisa Woods, PBGH chair and senior director, U.S. Healthcare for Walmart, recently outlined five key takeaways from the pandemic during an online summit on the future of health care in a post-COVID world.

PBGH works with some of the nation’s largest employers in addressing health care purchasing challenges. Member organizations include 40 public and private entities that collectively spend $100 billion annually purchasing health care services on behalf of more than 15 million Americans.

Among the repercussions of COVID-19 from an employer perspective, according to PBGH’s Mitchell and Woods:

1. Telehealth is the future. Telehealth will continue to gain traction as a means of delivering appropriate care from a distance. Close to half of physicians are using telehealth in the wake of the pandemic, up from less than 20% two years ago. Analysts expect virtual physician visits will rise by 64% in 2020.

“We’re looking at ways to ensure that our associates can get the care they need in their home communities if they don’t feel comfortable traveling,” Woods said.

“We have been very focused on telehealth [at Walmart] and feel like it is the future,” Woods said.

2. Primary care needs more investment. With many primary care physician groups struggling due to fewer office visits triggered by concerns about COVID-19 exposure, fears are rising that provider consolidation will continue to accelerate, leading to ever-higher health care costs.

PBGH recently joined 35 other employer-focused organizations in urging Congress to impose a 12-month ban on mergers and acquisitions for health care organizations that received federal bailout relief. PBGH also is calling for immediate federal assistance for vulnerable primary care practices and the elimination of all or part of cost-sharing requirements for primary care visits.

Employers additionally want to see a greater emphasis placed on mental health and public health within the context of primary care and are looking for ways to positively impact social determinants of health (education, finances, food and housing insecurity, transportation).

“We haven’t been paying for the right things,” Mitchell said. “We’ve been focused on expensive tertiary care and elective procedures, and we need to focus on primary care. That’s how we keep people healthy and out of hospitals.”

3. Employers are hyper-focused on quality. “We know there are huge opportunities to identify how to get better outcomes, and we think purchasers are going to lead that charge,” Mitchell said.

Woods pointed to PBGH’s Employers Centers for Excellence as an example of the kinds of solutions employers will increasingly turn to in the pandemic’s wake. Through a rigorous evaluation and qualification process, PBGH has identified regional care centers that deliver high-quality elective surgical care for PBGH member-employees.

The centers were pioneered by Walmart and have been instrumental in helping PBGH members improve quality and reduce costs.

4. Employers want more control over contracting. Employers continue to be deeply concerned about health care costs that have been rising irrationally for years and worry the pandemic will fuel even higher prices.

Mitchell said financial pressure from COVID-19 has only exacerbated those concerns and will likely accelerate employer efforts to gain greater control of the health care purchasing process through direct contracting and other quality improvement and cost reduction efforts.

Direct contracting between employers and providers represents a promising solution, she said, because it creates an opportunity to “cut out the noise in the middle” to produce better and more cost-effective outcomes through collaboration between employers and providers.

5. The pandemic is forcing innovation. “[Employers] are going to be forced to innovate much more rapidly than they might have anticipated, because you can’t sustain a bloated, inefficient [health care] system in this environment,” Mitchell said. “The health care system didn’t fix itself, so employers are going to step in and fill that gap.”

In addition to boosting quality, Woods said eliminating unnecessary care—estimated to account for about one-third of all care provided—represents a key objective for employers. She noted that as providers ramp up from the pandemic-driven shutdown of recent months, it will be important to find ways to prevent unnecessary care from creeping back into the system.

The June 22-25 virtual summit during which Mitchell and Woods spoke was produced by Global Health Care, LLC, and included a wide range of presenters, from health plan and hospital executives to clinicians, educators and former policymakers. Their discussion can be viewed online here.

Primary Care Practices Can Engage Patients in Virtual Care

June 6th, 2020
Tags: , ,

During the most challenging phases of the COVID-19 pandemic, one opportunity for the health care delivery system has been the rapid adoption of telehealth and virtual care by both primary care practices and patients. The Pacific Business Group on Health’s California Quality Collaborative (CQC) has hosted webinars to support and spread successful practices in virtual care for independent primary care practices and IPAs as they rapidly implemented telehealth technology and workflows.

Nationally, the trends reflect widespread virtual care adoption.  By one May 2020 analysis, telehealth visits in the US increased 300-fold in March and April 2020 compared to the same time period in 2019 (Epic Health Research Network).  Providers have been pleased with their telehealth experience, and patients have too: 88% of patients new to telehealth said they would like to use it again (PwC Health Research Institute).  The health system is eager to build on the implementation gains around virtual care made during the public health emergency, especially its ability to improve access to care and reduce costs.

Patient engagement in virtual care

Yet today, more than ever, it’s essential for health care clinicians and care teams to ensure that virtual care being provided is as patient-centered as possible. This topic was the focus of a May 6 webinar hosted by CQC, which highlighted presentations from a number of experts including Dr. Courtney Lyles, Associate Professor, Center for Vulnerable Populations at UCSF; Libby Hoy, Founder & CEO, PFCC partners; and Dr. Fiona Wilson, former Teladoc provider and current Supervising Clinician Specialist, Workers Compensation Division, Department of Human Resources, City & County of San Francisco.

Dr. Lyles shared examples from decades-long research done around patient portals, telephone visits and tactics that help bridge the “digital divide,” even in regions of strong technology adoption, such as the Bay Area. Her advice was not to make any assumptions about what patients do or do not have access to, and establish ongoing trainings, where patients can be assured to get continuous support for the virtual care they are seeking.

Libby Hoy of PFCC partners shared lessons from her organization’s history building patient advisory capacity. She cautioned that the work, especially at this time, is messy, but reminded care teams and providers that involving patients in the design process of the workflows results in more effective care.

Dr. Wilson shared her experience as a telehealth provider during COVID-19 for Teladoc, an organization that provides virtual care for patients all over the United States. Her advice for clinicians was to be an empathetic and engaged listener to patients when they are sharing their health issues, and make sure to ask about non-medical needs that may be even more present today, such as social isolation and economic hardship.

What providers can do now

Today, primary care practices are regrouping after shelter-in-place restrictions lift, adapting to a hybrid of virtual and in-person care, and working to address any care needs of their patients that were deferred during the height of epidemic. Yet even in this time of transition, CQC’s expert panelists shared the following steps practices can take to focus on patient needs:

Access CQC’s May 29 webinar recording and summary here.

The Stakes for Primary Care – Impact of COVID-19 and the Urgent Need for Action

May 1st, 2020
Tags: ,

The COVID-19 pandemic has infected nearly 1 million people in the United States, killed tens of thousands, and is having an unprecedented negative effect on the country’s economy. It has also strained primary care providers to near the breaking point. Nearly half of independent primary care practices report that they are in danger of closing in the coming months due to a collapse in revenue. Primary care practice closures threaten patients’ access to health care during this pandemic and afterward.

On April 30, PBGH teamed up with the American Academy of Family Physicians (AAFP) and the Partnership to Empower Physician Led Care (PEPC) to host a virtual Capitol Hill briefing attended by more than 100 congressional staff and interested stakeholders. The briefing was opened by the co-chairs of the bipartisan Congressional Primary Care Caucus, Reps. Joe Courtney (D-CT) and David Rouzer (R-NC), and featured expert speakers, including PBGH’s President and CEO, Elizabeth Mitchell, and the AAFP’s incoming CEO, Shawn Martin.

Primary Care Doctors Share Their Story

The highlight of the event was a panel discussion featuring three front line primary care clinicians, who discussed their own personal challenges in delivering care and keeping the doors open in the era of COVID-19.

These physicians all described the financial hole they find themselves in as office visits abruptly fell off, and the frightening prospect of going out of business and leaving their patients with nowhere else to turn. They talked about the 20-hour workdays for themselves and their staff as they work to manage the concerns and health conditions of thousands of people who entrust them with their medical needs — all while abruptly shifting to deliver care via phone or video chat.

The move to telehealth has been both welcomed and challenging. Through a fuzzy online connection, one doctor talked about the poor broadband access in her small, rural town, and how the financial strain of COVID-19 on her practice required her to choose between upgrading her 15-year old audio visual equipment to improve visibility for online patient visits, or to provide her staff with needed personal protective equipment (PPE).

Another physician described his frustration with insurers who have largely failed to step forward to provide primary care doctors with the support needed to stay afloat and available to millions of patients nationwide.

“We’ve saved our country and insurance companies millions of dollars, and I’m sitting here dying,” he told participants of the briefing. He was recently forced to furlough 75 members of his staff and shared that he and his fellow physicians were now working unpaid.

Taking Action — NOW

As the panel demonstrated, absent an aggressive federal response, the country’s primary care delivery system is on the verge of collapse. PBGH, AAFP, and PEPC delivered clear recommendations to Congress for immediate legislative action in five major policy areas:

The event’s slide deck, including detailed policy recommendations, and a full recording of the briefing are available online.