It’s Called “Primary” Care for a Reason

Primary care providers are the first line of defense in helping Medicaid and Medicare Advantage members detect and manage chronic conditions—and stay healthier.

Primary care is one of the most powerful tools in the medical field and has long been a cornerstone of the healthcare industry. Just the simple act of getting a check-up can help someone catch emerging health issues that could lead to a chronic condition—and help them manage existing chronic conditions before they become emergencies.  

Research has shown that access to primary care can improve health outcomes. That’s because of several factors: People who see a primary care provider (PCP) are more likely to take preventative health measures. Being seen by a care provider regularly, especially one with whom you’ve developed a relationship over time, also means that health concerns can be caught earlier, even if you’re not yet experiencing symptoms.  

U.S. states with higher per-capita ratios of primary care physicians have lower rates of smoking and obesity and higher rates of flu vaccinations and seatbelt use. Better access to family physicians has also been associated with earlier detection of breast cancer, colon cancer, cervical cancer, and melanoma. Another study found that primary care facilities that moved to extend appointments into the evenings and weekends experienced a 26% drop in emergency department visits. Primary care keeps people healthier.  

Barriers and Bridges to Primary Care

A range of social drivers can affect whether someone has access to adequate primary care, including insurance coverage, transportation, disability, access to childcare, lack of employment flexibility, and the availability of doctors. Barriers to health become barriers to health equity, making it harder for some groups of people to be as healthy as they could be, which is why the Centers for Medicare and Medicaid Services is starting to require healthcare providers to screen for certain social determinants of health (SDoH), also known as health-related social needs.  

The healthcare industry continues to evolve and develop creative solutions to help people get the care they need, which usually starts with their PCP:  

  • Virtual Care: The Covid-19 pandemic took a devastating toll on communities and families, but it also sparked an expansion of virtual health and in-home solutions, giving people alternative options for seeing their primary care provider if in-person visits aren’t realistic. A national survey conducted in 2022 found that nearly 23% of adults or their children had used either audio or video telehealth, with the highest rates of telehealth visits among those covered by Medicaid (28.3%) and Medicare (26.8%).  
  • Value-Based Care (VBC): Unlike fee-for-service arrangements, VBC models link payments to outcomes rather than each individual service and appointment. VBC is increasingly being integrated into health plans across the healthcare ecosystem to improve health outcomes and lower costs. The move to collaborative, person-based care seems to be having early success, though research is just emerging. One study found that PCPs participating in value-based models were more likely to screen patients for SDoH and to participate in accountable care organizations or patient-centered medical homes, both of which have shown success in achieving the broader goals of VBC.
  • MA Supplemental Benefits: MA health plans can offer a variety of supplemental benefits to enable, extend, and enhance the care offered by PCPs. Transportation benefits, for example, ensure that people have a way to get to PCP appointments safely and on time if they don’t have another source of transportation. This year, SafeRide Health is on track to deliver 7 million rides to MA and Medicaid health plan members. Nutrition counseling, vision benefits, remote patient monitoring, and dental benefits are a handful of the additional supplemental benefits that can improve outcomes.  

Primary Care Access and Medicaid

Complicating the primary care picture for Medicaid is the fact that Medicaid reimbursement for primary care services in most states is still a fraction of what it is for Medicare patients. Nationally, the Medicaid to Medicare fee index is 0.67.  

To bolster access to primary care for Medicaid beneficiaries and encourage primary care providers to stay in or enter the field, the Affordable Care Act issued a two-year mandatory increase in primary care service fees. In states with the largest fee bumps, there were some noticeable increases in the availability of primary care appointments, which suggested that the move was paying off. Since then, states have widely varying Medicaid payment rates.  

In states with low Medicaid service fees, some independent, office-based practices—where about 75% of nonelderly Medicaid members receive their primary care—don’t accept Medicaid. In fact, from 2014-2019, about a third of office-based primary care providers accounted for 90% of Medicaid office visits. That has led to questions about the quality of care those practices are able to provide.

While there is plenty of discouraging news when it comes to primary care access, there is also a growing recognition that primary care can and does improve health outcomes, lower healthcare costs, and advance health equity. Anything that improves access—easier transportation; higher Medicaid fee reimbursements; more value-based care plans; a range of in-person, at-home, and virtual options—can improve health for all.

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