Santé et Services sociaux Québec.
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Brief analytical summaries or syntheses #14

Strengthening primary and chronic care :

state innovations to transform and link small practices


This report examines the roles states are playing to reorganize the delivery of primary and chronic care to produce more efficient and effective care. Through short case studies developed via interviews with state officials and physicians in Colorado, Michigan, North Carolina, Oklahoma, Pennsylvania, and Vermont, the authors highlight several state-based initiatives that seek to create high-performing health systems by targeting local and regional strengths.


Although most of the debate preceding the passage of the Affordable Care Act in March 2010 was focused on improving access to care, it is widely agreed that without equal attention to reforms that address cost and quality, the United States is destined to continue its path of uncontrolled, spiralling costs and poor overall performance. The issues are complex, and there is no silver bullet or panacea to solve the problems. This paper examines the roles states are playing to reorganize the delivery of primary and chronic care to produce more efficient and effective care for patients and providers, with an emphasis on small practices. Federal and state governments have important roles to play in facilitating or establishing the primary care foundation, which is the backbone of an organized delivery system. There have been a number of recent initiatives to strengthen the delivery of primary care, but activity has disproportionately been focused on larger, multispecialty practices. Spreading change to smaller practices remains a challenge.

Analysis and results

The state-based initiatives highlighted in this report are evidence that states are working to create high-performing health systems using approaches and policy strategies that play to local and regional strengths and differences. The states vary greatly in their economic, social, and geographic environments.

Key features of state strategies include:

  • Pennsylvania and Vermont had high-profile support of the governor (and in Vermont, the legislature) in directing efforts toward chronic care management and controlling costs.

  • In Michigan and Oklahoma, state agencies asserted their influence to convene public and private entities in jointly planning for state-wide primary care practice transformation.
  • States use a variety of payment incentives to reimburse primary care providers for key elements infrequently reimbursed by other payers.

  • States provide support to practices to build the infrastructure for patient-centred care within the primary care setting and across the care continuum. Colorado funds community-based medical home navigators to help practices connect patients to community resources. Regional networks in North Carolina directly hire care coordinators to work within practices.

  • States can help practices by setting targets for excellence and quality through process and outcomes measurement and reporting.

  • States regulate or certify practices to ensure they meet the components for optimal primary care.

  • States are supporting small practices by providing financial incentives and education.


Moving forward, both federal and state policies will play a significant role in strengthening the delivery of primary care. Several provisions in the Affordable Care Act create noteworthy opportunities for primary care in the development of workforce, payment, and practice innovation. Many states will have expanded opportunities to continue experimenting with alternative payment and delivery structures to strengthen primary care and develop the needed infrastructure and workforce. These efforts may benefit from the growing knowledge base developed by the innovative demonstrations and broad-based initiatives under way in the leading states. Finally, the promise of 
Medicare’s participation looms as a potential significant accelerator in the next few years.

Implications and recommendations

The state policy levers and actions highlighted in this study emphasize the following five strategic themes that will be crucial in affecting change. These are:

  1. Leadership and convening: bringing public and private payers and stakeholders together and brokering multi-payer agreements;

  2. Payment incentives: using a variety of strategies to pay primary care providers for key elements infrequently reimbursed by other payers and to reward outcomes;

  3. Support for infrastructure: shared services to create a team-based approach, state-supported and organized learning, and information exchange;

  4. Information feedback and monitoring: data collection and reporting on process and outcomes; and

  5. Certification and recognition: meeting characteristics deemed necessary for optimal primary care using the certification of external organizations (such as the National Committee for Quality Assurance) or through state-conducted audits to ensure compliance.


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