Measuring Primary Healthcare Spending

Background. Policy leaders and researchers have identified a range of primary care spending conceptualizations, developed frameworks and methods for measuring primary care spending, and documented the pros and cons of different approaches. However, these efforts have not been comprehensive, particularly as the number of estimates has grown. We continue this work by identifying the definitions, data sources, and approaches used to estimate primary care spending in the United States. Our objective was to identify where there is and is not consensus across methods, and how initial steps toward a standardized approach to estimating primary care spending might be achieved. We approached this comparison from a societal economic perspective. Methods. Searches were conducted in Ovid MEDLINE® and Cochrane CENTRAL databases (inception to May 2, 2023), and were supplemented by manual reviews of reference lists, Scopus searches of key articles, gray literature searches of State and organization websites, and responses to a Federal Register Notice, as well as recommendations from Key Informants. Websites of States and organizations that produced reports were reviewed in November 2023 to identify updates. Publicly available estimates and reports of methods were supplemented by discussions with experts who have supported States’ estimates. Findings. We identified 67 primary care spending estimates for 2010 to 2021: 42 of these were produced by 11 State Governments for their State, 2 were published by the Veterans Health Administration, and 23 were published by researchers or other organizations, which include foundations and policy organizations. Forty-four estimates reported on primary care spending for a single State, one estimate reported spending for the New England States, and 22 reported national spending. To date, 13 State Governments have developed and/or are implementing measurements of primary care spending. When State Governments measure primary care spending, they produce regular, often yearly, estimates. States have produced one to eight estimates, demonstrating some States have more experience with this task than others. Primary care spending estimates in our sample ranged from 3.1 to 10.3 percent. These estimates started with definitions of primary care, which are often labeled narrow or broad. Estimates may use these same labels to mean different things. Narrow definitions of primary care usually include fewer providers, locations, or service types, while broad definitions include more. State, regional, or national estimates are either reported as two estimates, one using a narrow and one using a broad definition of primary care, or as a single estimate labeled neither narrow nor broad. Variations in what providers, services, and locations are included in definitions of primary care are significant and likely contribute to variation in primary care spending estimates. However, it is difficult to distinguish differences in definitions and measurement from differences in actual primary care spending. Conclusions. While there are some core similarities in how primary care spending is measured across State, regional, and national estimates, there are more differences. While there may be rationale behind some of these variations, this variation limits comparisons and what could be understood about the impact of policies. Furthermore, lack of clear, detailed reporting of methods can obscure precisely how and why estimates differ. Research is needed that quantifies the impact different decisions and measurement methods have on spending estimates. To assure the validity and reliability of estimates of primary care spending, and facilitate comparisons and links to health outcomes, Federal, State, and policy leaders need to: (1) collaborate to create a primary care clinician database that can function as a public utility for States to allow for more precise identification of primary care clinics and clinicians, and reduce reliance on Current Procedural Terminology/Healthcare Common Procedure Coding System codes; (2) develop a template for transparent reporting of methods used to estimate primary care spending; (3) foster collaboration among Federal agencies and State leaders to develop a consensus definition of primary care and process for estimating primary care spending, with consideration of methods that are easy to understand and transparent; and (4) support the development and ongoing maintenance of State All-Payer Claims Databases, expand to include nonclaims payments, and supply Medicare and Medicaid estimates for every State.