The Toll of Primary Care Cost-Sharing
On June 23, the Primary Care Collaborative (PCC) hosted a discussion on how reducing or eliminating cost-sharing for primary care can help improve the nation’s health and enhance affordability of the health system – specifically by reducing patients’ financial barriers to care and removing red tape burdening practices. This conversation also delved deep into how unnecessary cost-sharing creates friction for patients and adds unnecessary paperwork for clinicians, as well as ideas for how to address this issue with policymakers.
Moderated by Dr. Raymond Tsai (Purchaser Business Group on Health), the discussion featured Dr. Linda Delo (American College of Osteopathic Family Physicians), Dr. Janay Johnson (American Heart Association) and Sophia Tripoli (Families USA).
Dr. Tsai began by highlighting the importance of the conversation. With clinician burden at an all-time high, cost-sharing in primary care has only exacerbated this problem. As primary care clinicians get buried in paperwork, they lose out on time that could be spent having meaningful, important conversations with a patient and can even leave the field altogether due to their frustration. As clinicians work to implement innovative new programs (like Medicare’s advanced primary care management codes) that navigate our system away from fee-for-service payment, policymakers and decisionmakers need to understand how cost sharing in primary care can undermine this important work.
Dr. Johnson then highlighted an important statistic: cardiovascular disease remains the leading cause of death in the United States, as it has for over a century. Much of this is preventable, with primary care being able to effectively identify and manage risk factors before they progress into something more serious. However, many clinicians lose out on the opportunity to foster critical relationships with patients due to cost sharing. Even something as simple as a $5 out-of-pocket cost can discourage people.
Dr. Delo argued that cost-sharing creates a two-tiered system of care. Patients with generous health coverage or supplement plans don’t incur this cost-sharing are able to keep important appointments while others are less likely to make appointments. Tripoli hammered in this point, offering a cogent reminder that health care affordability remains the number one issue for people across the country right now.
Tripoli also tied this issue to others facing primary care clinicians and patients. Providing multi-faceted, expansive care, the work of primary care clinicians and their teams is still undervalued in our current health care system. As we invest and spend more on specialty and hospital care, primary care clinicians – best equipped to manage chronic diseases and provide comprehensive care – are facing a resource squeeze.
We’re likely looking toward a future with greater chronic disease, argues Dr. Johnson. Increases by the millions in hypertension, diabetes, obesity and other heart disease risk factors could leave the United States with a sicker population and an economic cost that could balloon to $1.5 trillion annually by 2050. Investments in preventative care are critical towards reversing these trends. Dr. Delo agreed, adding that reaching out to legislators on the importance of strengthening relationships between primary clinicians and patients in improving the health of our nation.
However, Tripoli also highlighted some recent positives in the primary care space, including last year’s MPFS rule that made key improvements on primary care payment. She has also witnessed some critical conversations happening on Capitol Hill concerning how primary care can be paid differently.
The conversation then shifted to overutilization – with too many patients going to urgent care or the emergency room for issues that should instead be seen by a primary care clinician, according to Dr. Delo. Tripoli agreed, adding how this can be directly tied to access issues. For many, walking into an urgent care clinic or emergency room is a much quicker task than seeing a primary care clinician in a timely manner. She argued we need to fix our system to allow more timely care.
Ultimately, panelists agreed that there needs to be a greater investment in primary care and making comprehensive primary care more accessible to patients. Dr. Tsai also highlighted a bill pending in Congress, the Chronic Care Management Improvement Act of 2026. This piece of legislation eliminates cost-sharing for chronic care management in Medicare – an important down payment on the relief from burdensome cost-sharing that primary care clinicians and patients need. Tsai urged the audience to lend their voices to support access to comprehensive, whole-person primary care.
