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.

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.