Concordance Recommendations for Primary Care Payment and Investment

Part of Better Health — Now: A Campaign of the Primary Care Collaborative

As part of PCC's Better Health - Now campaign, this document provides a shared framework for Campaign Participants (PCC Executive Members that support that campaign) and direction for the campaign. By publicly declaring their support of these guiding principles - by signing on to this document - PCC Executive Members thus become Campaign Participants.

Interested in engaging in the campaign? Want your organization's name on the list of participants and supporters? Get more information.

See also: Context and Summary of the Concordance Recommendations for Primary Care Payment and Investment

The COVID-19 pandemic, coupled with the heightening national awareness of the persistence of racism and other structural inequities, shone a harsh spotlight on the urgent need for a more resilient, equitable, and higher-value healthcare system for our nation. Primary care must be at the center of the transformed health system we need to ensure that everyone in the country has an equitable opportunity to attain the best possible health and wellness and bend the healthcare cost curve over time. To succeed in this transformation and improve healthcare delivery, we need better healthcare payment systems as well as significant up-front investment in health care in the communities that have been systematically under-resourced and structurally disadvantaged.

The Primary Care Collaborative (PCC) has committed to advancing a set of recommendations designed to achieve a higher-value health system built on the foundation of high-quality, comprehensive primary care1 to produce better population health, greater affordability, and the reduction of racial, ethnic, and other structural inequities that sap the health and vibrancy of many communities across the country. In the summer and fall of 2021, the PCC convened two meetings to discuss using the National Academies of Sciences, Engineering, and Medicine (NASEM) primary care report’s five payment recommendations2 as a launching point for healthcare transformation that improves value and achieves health equity.

1. Primary care payment should create pathways to rapidly transition from a predominantly fee-for-service model to a predominantly population-based prospective payment (hybrid) model coupled with up-front and ongoing investments and guardrails to ensure that patients and communities most affected by health and health care inequities, and the primary care clinicians and teams that care for them, realize the benefits of a higher-value health system.

These payment pathways should include adjustment for health status, risk, social drivers of health and social risk, historic under-investment, and other elements. Such hybrid models should be implemented and aligned across payers, while being mindful of practice heterogeneity, preserving the viability of primary care clinicians who have earned the trust of structurally disadvantaged communities, providingculturally congruent, care, and supporting greater adoption of telehealth. There should be a pathway for practices to voluntarily pursue higher levels of prospective payment at an even quicker pace with sufficient support.

2. To achieve rapid transition to and sustainability of comprehensive primary care practice models, overall healthcare spending, both in terms of ongoing payment and needed investment, must be rebalanced towards primary care. Currently, primary care spending in the U.S. amounts to only approximately 5% to 7% of total cost of care and is trending down. There is strong evidence that countries that devote considerably more resources to primary care as a share of total health spending than the U.S. achieve more equitable health outcomes, better overall population health, and much lower per capita spending.  Policymakers committed to slowing spending growth in our inefficient health system should implement needed resource shifts now, understanding that they will ultimately result in a more efficient, higher-value healthcare system.

3. Overall primary care funding levels (both ongoing payments and needed investments) must be risk-adjusted and sufficient to support multidisciplinary primary care teams that reflect, and can meet the needs of, diverse populations, with an emphasis on providing high-quality comprehensive, integrated care to communities that are structurally disadvantaged by discrimination and other social drivers as well as those with complex medical and behavioral health needs. Primary care teams should also be supported with resources to allow them to prioritize and proactively address equity within their practices, in partnership with the communities they serve.

4. To better support both patient-clinician relationships and accountability for population health outcomes, patients should be encouraged to choose a regular source of accessible, culturally centered primary care. Patients may wish to change their source of care for varied reasons, including, but not limited to, evolving medical needs, negative experiences such as discrimination in any form, accessibility requirements, or convenience. Patients should continue to have the option of changing to another source of care if their needs are not being met.

5. To close health equity gaps and successfully move toward prospective, population-based (hybrid) payment, the primary care practices, rural health clinics, community health centers, and others that care for patients who are enrolled in Medicaid, are underinsured, or lack insurance altogether need appropriate payment, upfront investments, and other support. Medicaid payment reform must be pursued in tandem with initial efforts to reform Medicare payment and investment detailed above and encourage commercial, Medicaid and other payers to align on policy initiatives and payment design. State innovations in primary care payment reform and investment represent a learning lab for Medicare and other payers and should be encouraged through federal partnerships. Primary care safety-net provider organizations such as community health centers and rural health clinics rely on federally required payment structures like the Prospective Payment System (PPS) and All-Inclusive Rate (AIR) for their continued financial viability. It is critical that future policy protect these tools while supporting these organizations’ participation in mutually agreed upon payment models that improve access and quality.

The following organizations agree with this consensus document and are signaling as much by signing onto it.   

Primary Care Collaborative

PCC Executive Member Organizations (Campaign Participants)

American Academy of Child and Adolescent Psychiatry
American Academy of Family Physicians
American Academy of Pediatrics
American Academy of Physician Associates
American Association of Nurse Practitioners
American College of Clinical Pharmacy
American College of Lifestyle Medicine
American College of Osteopathic Family Physicians
American College of Osteopathic Internists
American College of Physicians
American Psychiatric Association
American Psychological Association
Blue Cross Blue Shield of Michigan
Blue Shield of California
Catalyst Health Network,
Community Catalyst
Converging Health
Elation Health
Families USA
Harvard Medical School Center for Primary Care
Institute for Patient- and Family-Centered Care
Mental Health America
MGH Division of General Internal Medicine Stoeckle Center
National Alliance of Health Care Purchaser Organizations
National Association of ACOs
National Center for Primary Care at Morehouse School of Medicine
National Partnership for Women and Families
National Rural Health Association
Oak Street Health
PCC - Physician's Computer Company
Premise Health
Primary Care Development Corporation
Society of General Internal Medicine
Society of Teachers of Family Medicine
St. Louis Area Business Health Coalition
UCSF Center for Excellence in Primary Care



Campaign Supporters (non-PCC Executive Members)

Association of Family Medicine Residency Directors
Association of Departments of Family Medicine
Black Women's Health Imperative
Care Transformation Collaborative of Rhode Island
Center for Professionalism & Value in Health Care
IncludedHealth (Doctor on Demand + Grand Rounds)
Michigan Multipayer Initiatives
National Interprofessional Initiative on Oral Health
One Medical
Penn Center for Community Health Workers
National Association of Community Health Centers
National Association of Community Health Workers
North American Primary Care Research Group


Interested in engaging in the campaign? Want your organization's name on this list? Get more information.

1 See the Shared Principles of Primary Care and the Attributes of Advanced Primary Care.
2 See National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press.
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