California Health Care Foundation

Research Context

Primary care is the foundation of all high-performing health care systems. Decades of research show that robust, accessible primary care helps to keep populations healthier, longer. Unfortunately, the US, on average, spends only about five cents of every health care dollar on primary care, or about one-third of what other high-income countries spend.¹ Not coincidentally, our peers boast longer life expectancy and lower rates of chronic disease — all with lower rates of health care spending.²

In many parts of California — especially in the Inland Empire, Northern/Sierra, and San Joaquin Valley regions — the state faces a shortage of health care workers.³ Primary care providers are aging out, many are leaving the field because of burnout, and fewer are entering the field because of financial pressures. Over the next decade, California is projected to face a shortage of over 4,000 primary care providers.⁴

As California considers ways to promote primary care investment, there is much to learn from other states. Recognizing the urgent need to strengthen primary care, more than one-third of US states (17) and several of the nation’s largest public and private purchasers have prioritized shifting more of the health care dollar to primary care. This report (available for download below) provides a detailed review of their primary care investment, payment innovation, and care delivery transformation strategies.

Key Findings

The authors found that states working to shift more resources to primary care typically use three types of mechanisms and a range of specific tools, often in combination, to achieve this goal:

• Transparency — measurement and reporting
• Contracting — shaping formal agreements
• Regulatory — statutes and regulations

The authors conclude California is well positioned to strengthen primary care and should consider these key lessons from other states.

1. Establish a shared vision. To bridge efforts already occurring, convene stakeholders to create a shared vision for primary care. Even without reaching full alignment, a common vision can serve as a useful guidepost.
2. Conduct annual measurement and reporting across markets based on a common definition of primary care investment. Engage in a multistakeholder effort to arrive at a common definition of primary care investment that can be applied across market segments to support annual measurement and reporting.
3. Set investment targets and encourage (or require) all purchasers to commit to them contractually. An investment target provides a clear and transparent achievement goal. It should reflect the true cost of achieving the vision for improved care delivery, including expenses related to additional staff, new technology, and ongoing training and technical assistance.

For More Information

• Press Release 4/19/2022

1. Linda McCauley et al., eds., Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, National Academies Press, 2021, 3.
2. Roosa Tikkanen and Melinda K. Abrams, “U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?,” Commonwealth Fund, January 30, 2020.
3. California Physicians, 2021 — Quick Reference Guide (PDF), California Health Care Foundation, March 2021.
4. Joanne Spetz, Janet Coffman, and Igor Geyn, California’s Primary Care Workforce: Forecasted Supply, Demand, and Pipeline of Trainees, 2016-2030, Healthforce Center at UCSF, August 15, 2017.