High-quality primary care is the foundation of a high-functioning health care system. It ensures patients have access to essential services, prevents emergency department visits and hospital admissions, leads to better health outcomes, and improves quality of care and equity. The secret sauce that allows high-quality primary care to deliver on all these benefits is long-term relationships between patients and their primary care clinicians and other team members. Trust allows patients and clinicians to use time as a diagnostic tool, rather than reactionary tests, procedures, or referrals; long-term relationships bring cohesiveness to a health care journey that is otherwise often fragmented in the US.

Despite these benefits, primary care is under significant stress. For decades, the United States has underinvested in primary care; we spend only 5 to 7 cents of every health care dollar on it, versus 12 to 15 cents per dollar in most other high-income countries. Low reimbursement rates for non-procedural care along with burdensome administrative tasks and diminished autonomy for primary care clinicians form a “trifecta” of stressors on primary care.

In response, more than a third of states have launched initiatives to shift more of their health care dollars to primary care. Despite the poor performance indicators of our current health care system and the impressive track record of primary care delivering better health and increased equity, these efforts have often faced substantial scrutiny and legislative hurdles.

The Evidence Supporting Primary Care

Consistently, research finds that increased investment in primary care leads to better quality of care, less need for hospital services, and often, improved patient experience. Still, there is limited evidence that directly ties higher primary care spending to lower total spending.

A 2024 study by Freedman HealthCare found Massachusetts provider organizations with higher primary care investment performed significantly better on standardized measures of quality and had lower spending on inpatient and outpatient hospital services. This study demonstrated better quality with increased investment in primary care without an additional increase in overall spending.

A 2022 study found California provider organizations with higher primary care spending for commercial health maintenance organization patients had lower overall spending, performed better on quality and patient experience measures, and had fewer hospital and emergency department visits. However, results for preferred provider organization members were more mixed.

One of the characteristics most closely correlated with savings in the Medicare Shared Savings Program (MSSP) was having more primary care clinicians within an accountable care organization (ACO) and having higher provision of evaluation and management services; MSSP ACOs with at least 75 percent primary care clinicians saw $281 per capita in net savings, compared with $149 for ACOs composed of fewer primary care clinicians.

Studies of the Massachusetts Alternative Quality Contract and Rhode Island’s required increases in primary care investment—both examples of primary care investment that showed a slowdown in spending after several years—found that the savings were more directly related to limits on price and total spending, not necessarily increased primary care investment.

Shifting To Savings

Improvements in quality, better patient experience, and fewer hospital admissions and emergency department visits all improve care for patients and are worthwhile aims for states to pursue. However, as many stakeholders set savings on spending as the threshold for supporting increased investment in primary care, it’s important to take notice of the common factors plausibly related to success that are beginning to emerge across states.

Sufficient increased investment: Increased investment must be sufficient to adequately fund advanced primary care capabilities that can actually improve the delivery of care and outcomes of interest. These capabilities may include care teams to support integrated behavioral health, effective medication management and comprehensive team-based care management, and hospital discharge planning.

Prospective, predictable payments: Primary care practices are offered incentives for higher-quality care or savings on total spending, but are hesitant to hire team members and redesign workflows on the promise of future funding, especially when tied to complicated incentive programs.

Multipayer alignment: To the extent that primary care clinicians practice in a payer-agnostic way for their patients, dollars should flow proportionately and through similar payment mechanisms and amounts across commercial payers, Medicaid, and Medicare. Otherwise, investment is spread too thin, and a free-rider effect appears where one payer type, such as commercial payers, subsidizes care for the others’ members (which discourages the investment in the first place).

Financial incentives for health systems to prioritize primary care: Today’s health systems—even those with large primary care practices—lack the financial incentives to fully embrace the benefits of primary care, such as fewer hospital admissions and emergency department visits (given longstanding incentives to fill hospital beds). Making the case to redesign care delivery and redistribute internal resources is difficult without financial justification.

Accountability: State efforts that rely on transparency and public pressure to increase primary care investment generally have been less successful than those that require payers to increase investment. Medical groups and health systems also can be held accountable for ensuring new dollars reach primary care in ways that feel tangible to clinicians and patients. This type of both shared responsibility and shared reward creates a sense of multistakeholder engagement.

Long-term lens: The literature suggests that some of the savings on total spending from more robust systems of primary care may accrue over time. Profit expectations, shifting payer membership, and political winds may not offer systems and payers enough patience for new payment policies to achieve their goals. Strong state leadership can elevate small wins and may help sustain the long view.

Looking To The Future

States are beginning to heed these lessons as they seek to increase investment in primary care. For example, a bill in Massachusetts, which includes a provision called Primary Care for You (PC4You), proposed meaningful increases in primary care spending by 2029 for participating providers by requiring all commercial payers in the Commonwealth to offer prospective, per-member-per-month payments to all participating primary care practices in exchange for adopting a set of primary care transformers. Recent innovations in the Massachusetts Medicaid’s 1115 waiver offers aligned increases in primary care investment.

There are many questions that still need to be answered to support states on this journey. Future research should track the results of PC4You and other programs to assess their impact over time and could address the following questions:

• How does the organizational structure of provider organizations impact results?
• In what ways can organizations incentivize and support primary care practices to reduce overall spending?
• What is the threshold level of investment to drive improvements in quality, outcomes, and spending?
• What types of payment models and combinations of payment models support success?
• Which combination of primary care capabilities generate the highest value?

High-quality primary care delivers immense value to our health care system, and there’s growing national recognition that we should redirect more of our health care dollars to make primary care stronger and more accessible. However, policy makers and other stakeholders need more evidence on whether higher spending on primary care generates better outcomes and importantly, how new investments should be spent to generate the highest value. This research can be helpful to states, the federal government, and stakeholders as they consider how to design programs and policy that fulfill the promise of primary care.