Measuring Primary Care Spending in the US by State

Accurately measuring primary care spending is essential to improving health care delivery and outcomes.^1,2 Herein, we identify states’ estimates of primary care spending and recommend steps policymakers can take toward standardizing these estimates.

We conducted searches in Ovid MEDLINE and Cochrane Central from inception to May 2, 2023, as well as the gray literature, to identify state estimates of primary care spending. Methods are described in detail in the Agency for Healthcare Research and Quality Technical Brief No. 44,³ including how states measure primary care spending.

Nine states reported estimates of primary care spending as a percentage of total health care spending (Figure 1). Maine, Utah, Virginia, and Washington used different narrow definitions of primary care; their estimates ranged from 3.1% to 6.1% of total spending. Maryland, Maine, Virginia, Utah, and Washington used different broad definitions of primary care; their estimates ranged from 5.6% to 10.2% of total spending. Connecticut, Massachusetts, Vermont, and Colorado did not define primary care as narrow or broad; their estimates ranged from 5.1% to 10.3% of total spending.

Ten states estimated primary care spending by payer type. All 10 provided estimates for commercial payers, and some provided estimates for Medicaid, Medicare Advantage, and Medicare Fee-for-Service (Figure 2). Oregon, Colorado, Vermont, and Maine reported higher percentages of primary care spending across payer types. Colorado and Oregon included behavioral health clinicians (BHCs) in their numerator (primary care expenditures), and Colorado, Massachusetts, and Oregon did not include prescription drugs in their denominator (total health care expenditures).

In this case series, we identified sizable differences in state primary care spending estimates. We cannot determine if spending actually differs across states, time, or in response to policies because there is no standard method of measurement. This weakens a potentially powerful tool to promote and monitor investment in primary care.

States had similar intentions to base spending estimates on activities of primary care clinicians. States included family medicine, general pediatrics, general internal medicine, and adolescent medicine physicians, as well as nurse practitioners (NPs) and physicians assistants (PAs), as primary care clinicians. Some states also included obstetricians/gynecologists and BHCs. We recommend including just the primary care services delivered by obstetricians/gynecologists; doing so has a small effect on spending estimates.⁴ We recommend including BHCs, if they practice in primary care clinics.

States, however, struggle with reliably identifying the primary care workforce. For example, nationally, it is believed that less than 30% of NPs and 25% of PAs work in primary care.¹ A federal-state partnership is needed to create and maintain a public primary care database that allows for precise identification of primary care clinics and clinicians. Without this, states default to choosing settings and services that do not accurately differentiate primary care from specialty care for professionals such as BHCs, NPs, and PAs, or even internal medicine physicians who may specialize in addiction or emergency medicine. This approach contributes to wide definitional variance, lack of precision, and inflated primary care spending estimates.²

A standardized measure of primary care spending should include all payers and the primary care services provided to all people. It should include claims and nonclaims payments, as well as patient cost sharing and charity care. Total health care spending should include all health care spending; excluding some health care spending, such as prescription drug costs, distorts primary care spending estimates and may contribute to higher primary care spending estimates in some states.⁵

Incomplete or missing data in state reports and lack of clarity and consistency regarding the decisions required to operationalize a measurement of primary care spending limit the ability to make comparison across estimates and to evaluate how differences in estimating decisions might affect the spending estimate.³ A standard definition of primary care spending and a transparent way of documenting state-specific decisions is essential for monitoring and improving primary care investment. Standardization will enable policymakers and researchers to understand better how primary care spending is affected by new policies and incentives and, ultimately, how this spending is associated with health outcomes.

Accepted for Publication: March 15, 2024.

Published: May 17, 2024. doi:10.1001/jamahealthforum.2024.0913

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Cohen DJ et al. JAMA Health Forum.

Corresponding Author: Deborah J. Cohen, PhD, Departments of Family Medicine and Medical Informatics and Clinical Epidemiology, School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Mail Stop: FM, Portland, OR 97239 (cohendj@ohsu.edu).

Author Contributions: Dr Cohen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Cohen, Totten, Jabbarpour, DeVoe.

Drafting of the manuscript: Cohen, Totten, Phillips Jr.

Critical review of the manuscript for important intellectual content: Cohen, Phillips Jr, Jabbarpour, DeVoe.

Obtained funding: Cohen, Totten.

Administrative, technical, or material support: All authors.

Supervision: Totten, DeVoe.

Conflict of Interest Disclosures: Dr Totten reported support from the Agency for Healthcare Research and Quality to the Oregon Health & Science University for overarching tasks related to being an Evidence-Based Practice Center outside the submitted work. No other disclosures were reported.

Funding/Support: This research was supported by a contract from the Agency for Healthcare Research and Quality (75Q80120D00006) to Dr Cohen. This project was also funded under contract No. 75Q80120D00006 from the Agency for Healthcare Research and Quality under the US Department of Health and Human Services.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The authors of this article are responsible for its content. Statements in the article do not necessarily represent the official views of or imply endorsement by the Agency for Healthcare Research and Quality or the US Department of Health and Human Services.

Data Sharing Statement: See the Supplement.

Additional Contributions: We thank Miranda Pappas, MA, Jordan Byers, MPH, Erica Hart, MST, and Frances Hsu, MS, all of Oregon Health & Science University, for the important work that they did to identify, extract, and assist with presenting the data from the state primary care spending reports that are the subject of this Research Letter. We are deeply grateful for their contributions, for which they were compensated through the study funding.