Primary Care Collaborative Report 2019

Executive Summary:

Delaware is facing a crisis in its primary health care system. Currently there is inadequate primary care capacity in Delaware to meet the needs of the population. Approximately one in four residents live in a primary care shortage area. This inadequacy is expected to wrose as the average age of the population increases and there continues to be an increasing deficit between new primary care providers coming into practice compared to the rapid increase in providers leaving or downsizing their practices.

One of the root causes of providers leaving or downsizing their practices is insufficient health care dollars being directed towards primary care. Anecdotally, it is estimated that Delaware spending on primary care is at the lower end of the national US average of 4 to 8% of total health care. Inadequacy in primary care access is reflected in the fact that Delaware has the 4th highest health care spending in the country but also has below-average health outcomes. Recognizing the need to alleviate the current crisis and forge the sustainability of primary care, SB 277 convened the Primary Care Reform Collaborative (the "Collaborative"). Members of the Collaborative are the chairperson of the Delaware Health Care Commission (currently Dr. Nancy Fan), the Chair of the Senate Health, Children & Social Services Committee (currently Sen. Bryan Townsend), and the Chair of the House Heath & Human Development Center (currently Rep. David Bentz). The Collaborative was tasked with developing annual recommendations to strengthen primary care in Delaware, including in the following areas:

1) Payment reform

2) Value-based care

3) Workforce development and recruitment

4) Directing resources to support and expand primary care access

5) Increasing integrated care, including for women's and behavioral health

6) Evaluation of system-wide investments into primary care, using claims data obtained from the Delaware Health Care Claims Database

As per the legislative mandate, the Collaborative is to meet and collect input from stakeholders representing the health care and patient community. For this first year, the Collaborative convened six public meetings between September 2018 and December 2018 to discuss the current crisis in primary care and how to proceed with recommendations for the sustainability of primary care.

Specifically, the Collaborative had several meetings with primary care providers practicing across Delaware in small independent practices, health centers (FQHCs), accountable care organizations, large health systems, and multispecialty practices. These providers included physicians and nurse practitioners. Other meetings included representatives from health systems, payors, and consumers, as well as input from other model states that have enacted legislation to strengthen primary care through greater investment.

At these meetings the Collaborative heard extensively about the challenges and problems facing the primary care system in Delaware and stakeholders' recommendations to address these challenges through enhances investments in primary care, There was a wide variety of viewpoints from the invited stakeholder attendees and from public comment as reflected in the meeting minutes found in the appendix. The Collaborative took these comments into consideration along with other evidence in formulating a framework and in making the below recommendations. The minutes from the public Collaborative meetings can be found in the appendix.

The common framework, identified by the Collaborative and shared across stakeholders, consists of the following tenants: (1) ready access to quality primary care is essential for the health of the community and is the foundation for an effective health delivery system; (2) Delaware faces a crisis in primary care access across much of the state; (3) lack of access to primary care contributes to the high total cost of health care. Although the reasons contributing to the high total cost of care are multi-factorial, the Collaborative recognizes that inadequate access to primary care can shift care to higher acuity and more expensive settings, which may result in delayed detection and inadequate management of medical conditions, worse health outcomes, and higher total cost of care. The Collaborative developed the following recommendations to address these concerns through increased investment by the health care system to improve quality and access to primary care across Delaware. While there currently is some system-wide level of investment, the investment is fragmented and clearly insufficient to have prevented the primary care access crisis facing Delaware.

Recommendations:

1. The State should mandaye payers to progressively increase primary care spending to reach percentage milestones that eventually account for 12% of total health care spending, Primary care spending should constitute an investment of these funds to effectively meet the medical, behavioral, and social determinants of health of Delaware's diverse population of patients.

2. The increase in primary care spending should not be strictly an increase in fee-for-service rates. It should include an upfront investment of resources to build and sustain infrastructure and capacity, including use of health information technology, as well as suport needed for a team-based model of primary care across the range of Delaware's primary care settings. It also should include value-based incentive payments that reward for high-quality, cost-effective care.

3. It is recognized that increasing investment in primary care does not call for an increase in total cost of health care within Delaware and should be compatible with the State benchmarking process of promoting only sustainable increases in total cost of care. This may result in the need for ocnstraints on increases in other aspects of health care costs.

4. Enforcement of this mandate will occur through legislative statute or a regulatory enforcament authority, whether as a new agency or within an existing agency.

5. The Collaborative will continue to work with stakeholders regarding enhancing participation in value-based payment models, initiatives to increase and sustain primary care workforce, and integratinf Women's Health and Behavioral Health within a primary care team model.