Primary Care's Essential Role in Advancing Health Equity for California MARCH 2023 AUTHORS Diane R. Rittenhouse, MD, MPH; Ann S. O'Malley, MD, MPH; and Deliya B. Wesley, PhD, MPH, Mathematica; Rishi Manchanda, MD, MPH, HealthBegins; Alexandra Ament, MA, consultant; and Janice Genevro, PhD, MSW, consultant Acknowledgments The authors wish to acknowledge Kathryn E. Phillips, MPH, associate director at the California Health Care Foundation for her guidance and contributions, and to the following advisors and reactors for their valuable insight and support in creating this report. Advisors: C. Dean Germano, MHSc, CEO, Shasta Community Health Center Kevin Grumbach, MD, Professor of Family and Community Medicine, UCSF Christopher J. King, PhD, Associate Professor and Chair of the Department of Health Systems Administration, Georgetown University Gerardo Moreno, MD, Associate Professor, UCLA Sabrina Wong, PhD, RN, Professor, University of British Columbia School of Nursing Reactors: Palav Babaria, MD, MHS, Chief Quality Officer and Deputy Director of Quality and Population Health Management, California Department of Health Care Services (DHCS) Beth Capell, PhD, Policy Advocate, Health Access California Garrett Chan, PhD, RN, President and CEO, HealthImpact Ann Greiner, MCP, President and CEO, Primary Care Collaborative Laura Miller, MD, Medical Consultant, DHCS Cary Sanders, MPP, Senior Policy Director, California Pan-Ethnic Health Network Robert Phillips, MD, MSPH, Director, Center for Professionalism and Value in Care, American Board of Family Medicine Anthony Wright, Executive Director, Health Access California Hal Yee Jr., MD, PhD, Chief Deputy Director, Los Angeles County Department of Health Services Jill Yegian, PhD, Yegian Health Insights, LLC In addition, the authors wish to acknowledge contributions from the following individuals: Tosin Ajisope, MD, MPH, Researcher, Mathematica Alva Castanou, independent consultant Jacqueline Cellini, MLIS, MPH, Digital Librarian, Mathematica Rachael Edelson, MPH, Health Analyst, Mathematica Amelia M. Kelly, Research Associate, Mathematica Kate Mulligan, Research Associate, Mathematica Brian Park, MD, MPH, Assistant Professor, Oregon Health & Science University Hector Rodriguez, PhD, MPH, Professor, School of Public Health, UC Berkeley California Health Care Foundation www.chcf.org 2 About the Authors Contents Diane Rittenhouse, MD, MPH, is a senior fellow at Mathematica. Additional authors from Mathematica 4 Executive Summary include Ann S. O'Malley, MD, MPH, senior fellow; and Deliya B. Wesley, PhD, MPH, senior director of 8Introduction health equity. 12 The Essential Role of Primary Care in Advancing Health Equity: Established in 1968, Mathematica collaborates with The Evidence public and private sector changemakers by work- ing at the intersection of data, methods, policy, and 21 A Radical Reimagining of practice to accomplish its mission: improving public California Primary Care to well-being. Advance Health Equity A Paradigm Shift to Ensure Efforts to Rishi Manchanda, MD, MPH, is founder and CEO of Strengthen Primary Care Prioritize Equity HealthBegins, a national mission-driven consulting 24 Example Recommendations for and training firm committed to driving radical California to Strengthen Primary transformation in health equity. Care and Advance Health Equity Alexandra Ament, MA, is an independent consultant. 25 Conclusion 26 Appendix A. Policy Context for Janice Genevro, PhD, MSW, is an independent Example Recommendations and consultant. Options to Advance Progress 34 Endnotes About the Foundation The California Health Care Foundation (CHCF) is an independent, nonprofit philanthropy that works to improve the health care system so that all Californians have the care they need. We focus especially on making sure the system works for Californians with low incomes and for communities who have traditionally faced the greatest barriers to care. We partner with leaders across the health care safety net to ensure they have the data and resources to make care more just and to drive improvement in a complex system. About the Primary Care Matters Resource Center CHCF informs policymakers and industry leaders, Primary care is the foundation of invests in ideas and innovations, and connects with health and health equity. changemakers to create a more responsive, patient- This report is part of a series on centered health care system. strengthening primary care in California. To learn more, visit www.chcf.org/ primary-care-matters. 3 Executive Summary What Is Primary Care? Primary care is the most fair, efficient, and accessible Primary care addresses patients' physical and way for all people - regardless of race, ethnicity, mental health needs. It is essential to keep or income - to enter the health care system and us healthy by preventing disease, managing obtain the services they need. Yet it is frequently chronic illness, and addressing social realities absent from policy conversations about advancing impacting our health. Delivered by primary care health equity in California. clinicians and teams - including physicians, nurse practitioners, physician assistants, com- This report explores the unique role of primary care munity health workers, and behavioral health in the health care system, outlines the large body of staff - primary care is the first point of contact evidence demonstrating its essential contribution in our health care system for nearly all patient to advancing health equity, calls for a paradigm shift concerns and helps coordinate care for patients in our thinking and actions, and recommends a new across the health care system, including testing and specialist care. forum for leadership and accountability. In addition, it provides example recommendations that a vari- ety of actors can take now to strengthen primary care and advance health equity in California. $ California and the US don't have enough primary care physicians, which limits access to primary Primary care is the only component of health care care for all people. Fewer medical students enter where an increased supply leads to better popula- the field, in part because they earn less than they tion health and more equitable outcomes - making would in other medical fields, making it difficult it a vital ingredient for an organized, high-function- to pay off medical school debt. Practitioners ing health care system. Having a relationship with are also unequally distributed across the state, a trusted primary care provider helps people make with higher concentrations in wealthier and good health care decisions and prevents them from predominantly White urban areas. Lower con- getting lost in or ignored by our complex health centrations of primary care physicians practice care system. This makes primary care access a uni- in rural communities and in lower-income urban versal need. and suburban areas, home to many of the state's Black, Latino/x, and other historically underrep- However, systems, laws, and policies create unequal resented racial and ethnic groups. primary care access based on socioeconomic sta- $ Primary care access is further limited among tus, race/ethnicity, and geography. Here are a few populations with low incomes because Medi-Cal examples of the obstacles highlighted in this report: fee-for-service physician reimbursement for pri- mary care is only 76% of Medicare rates. Lower $ The United States spends less on primary care rates plus a heavy administrative burden cause (about 5% of total health care spending) than many practices to not accept Medi-Cal patients. other industrialized democracies. This is a health equity issue because more than $ Decades of underinvestment have resulted in a two of every three Medi-Cal enrollees are people depleted workforce struggling to deliver high- of color,1 and about 40% of Black and Latino/x quality primary care in a weakened infrastructure. Californians and more than 20% of Asian, Native Hawaiian, and Pacific Islander people in the state rely on Medi-Cal for coverage.2 California Health Care Foundation www.chcf.org 4 "Only through the radical reimagining of our $ Continuity of care. Greater continuity of care health care system and the explicit pursuit of is associated with lower mortality rates,4 and fewer disparities in rates of recommended can- anti-racist policy and systems changes can we cer screening services among Black and Latino/x achieve health equity." populations5 and of several types of evidence- Source: Cary Sanders et al., Centering Equity in Health based, high-value services such as vaccinations Care Delivery and Payment Reform: A Guide for California (including for COVID-19).6 Policymakers (PDF), California Pan-Ethnic Health Network, December 4, 2020. $ Coordination of care. Patients with better-coor- dinated care are more satisfied and more likely to follow evidence-based recommendations for Better access to primary care (typically measured by treatment and self-care because they are less a higher concentration of primary care physicians likely to receive conflicting messages from differ- per capita) is associated with improved life expec- ent providers. More coordinated primary care is tancy and lower rates of premature mortality in both associated with reduced racial and ethnic dispar- international comparisons and across regions within ities in preventable emergency department visits the United States.3 Conversely, communities with and improved blood pressure control.7 fewer primary care physicians per capita experience greater access challenges, fragmented care, and $ Comprehensiveness. More comprehensive pri- more costly and duplicative health care services. mary care is associated with reduced disparities When facing a shortage of primary care providers, in disease severity as a result of earlier detection patients also experience a higher risk of medical and prevention across different populations.8 errors and reduced trust in health care providers. $ Whole-person orientation. Elements of whole- person care, including clinician knowledge of a Access to primary care provides important health person's overall medical history, preferences, and benefits: more complete immunization, improved family and cultural orientation, have been asso- dental health, earlier detection and treatment of ciated with improved patient self-management chronic conditions (such as hypertension, lipid dis- for chronic conditions such as hypertension, con- orders, congestive heart failure, chronic obstructive gestive heart failure, depression, diabetes, and pulmonary disease, and diabetes), and reduced asthma9; better adherence to physicians' advice; severity of disease through both effective man- and improvements in self-reported health status. agement for individual conditions and ongoing management of multimorbidity. These benefits California has embraced the charge to strengthen are important for all people, but especially for the primary care and increase sustained systemwide elderly and economically and socially marginalized investments in primary care services and teams. The groups experiencing the highest burdens of pre- authors call for a paradigm shift in our thinking and ventable illness, chronic disease (e.g., diabetes), actions to ensure these efforts prioritize equity. This and negative outcomes (e.g., amputation) associ- paradigm shift includes (1) recognizing high-quality ated with unmanaged and uncontrolled disease. primary care as a common good, (2) embracing the diversity of primary care settings and investing What explains primary care's potential for advanc- resources according to need with the intentional ing health equity? Studies have linked primary goal of reducing health and social inequities, (3) pro- care's additional defining elements to improved actively applying principles of equity and justice to all health equity in the following ways: decisions, and (4) building accountability for action. Primary Care's Essential Role in Advancing Health Equity for California 5 As a starting point, the authors present examples additional context, the authors provide selected of recommendations to strengthen primary care examples of current policies in California that sup- and advance health equity within the primary care port each recommendation and identify options to practice and the greater health care community. advance progress. Looking forward, the authors Recommendations are sorted into five key arenas recommend that California establish a primary for action: (1) community engagement; (2) work- care equity action forum to build new partnerships force education and training; (3) clinical practice and provide ongoing statewide leadership and transformation; (4) payment and spending; and (5) accountability for this important work.  data collection, measurement, and reporting. For California Health Care Foundation www.chcf.org 6 Example Recommendations to Strengthen Primary Care and Advance Health Equity in California 1. Involve people with lived experiences of dis- 8. Ask patients about their needs and in what crimination in primary care policymaking and areas they want help. Use validated screening governance bodies to identify impediments to tools to identify health-related social needs, health equity and generate solutions. and, when possible, prescribe services and 2. Expand and scale pipeline programs to recruit, activities that are tailored to the individual's prepare, and mentor students from historically needs (e.g., financial support, food access, and systematically excluded communities and trauma-informed counseling, or a walking backgrounds for careers in primary care. group). 3. Hire and mentor team members from and 9. Increase the overall proportion of health care within the community, to better reflect the com- spending that is directed toward primary care, munity's racial and ethnic composition within establishing spending targets for public and the practice. Incorporate the lived experiences private payers. of staff into training for care delivery to encour- 10.Increase Medi-Cal physician payment levels in age empathy and bring cultural context to order to incentivize service delivery to Califor- interactions with patients. nians with low incomes. 4. Support whole-person care through behavioral 11.Implement and encourage participation in health and primary care integration across all equity-focused alternative payment models practice settings, and strengthen training for that enable integration of social services, public primary care providers on behavioral health health, and community partnerships into clinical (including substance use disorder treatment) practice. and wellness. 12.Carefully collect accurate, self-identified elec- 5. Promote equitable access to telehealth by tronic health record data on race and ethnicity, improving broadband access, infrastructure, sexual orientation, gender identity, language payment models, provider readiness, and proficiency, and disability as an important first patient engagement, especially for rural and step to providing whole-person, equitable care safety-net communities. and improving provider-patient concordance for 6. Strengthen access to and quality of language diverse Californians. assistance services, including providing quali- 13.Incorporate measures on equity and social fied interpreters; translated documents in needs in data collection for clinical, quality understandable, plain language in at least all improvement, and research purposes. Collect Medi-Cal threshold languages; and a notice of and stratify data on social needs to identify and the right to language assistance services to all document health inequities. patients. 14.Use quality improvement approaches to identify 7. Provide an option for primary care continuity and analyze root causes of identified inequities after hours and on weekends. in the clinical setting. Primary Care's Essential Role in Advancing Health Equity for California 7 Introduction California is the most populous and racially diverse a more holistic view of the patient's experience by state in the nation. It is the fifth-largest economy in fostering the primary care team's awareness of the the world and leads in developing innovative pol- local social, physical, and structural determinants of icy solutions to global and national problems such health. as climate change, immigration challenges, and health insurance coverage. This report highlights These unique attributes of high-quality primary care California's unique opportunities to lead in strength- make it the most fair, efficient, and accessible way ening the primary care foundation of a high-quality, for people, regardless of race, ethnicity, or income, accessible, and affordable health care system that to enter the health care system and obtain health can improve health outcomes for all. services to meet their needs.12 As such, high-quality primary care is foundational to a high-functioning High-quality primary care is the provision of inte- health care system and essential to any discussion grated, accessible health care services by clinicians of health equity.13 Yet despite decades of evidence who are accountable for addressing a large major- demonstrating the essential role of primary care ity of personal health care needs and who develop in improving health equity, primary care is often sustained, trusting partnerships with patients over absent - or not explicitly referenced - in policy time.10 Primary care clinicians include physicians conversations about advancing health equity in trained in generalist specialties such as family medi- California. cine, pediatrics, general internal medicine, and geriatrics, and nurse practitioners trained in fam- Recent health and social crises, such as the COVID- ily, gerontological, and pediatric care. Primary care 19 pandemic and police brutality against people clinicians typically work closely with one or more of color, have dramatically changed the national members of a team that can include nurses, phy- conversation about health equity, underscoring, sician assistants, medical assistants, community for example, how systemic and structural racism health workers, behavioral health counselors, social increases exposure to unhealthy conditions and workers, and pharmacists. limits access to health-promoting resources and opportunities.14 Within California, these events High-quality primary care is unique because it is focused attention on deep and long-standing typically the first point of health care access for a health inequities for people of color; people with person experiencing new symptoms or concerns. low incomes; people with disabilities; and people High-quality primary care includes preventive ser- who identify as lesbian, gay, bisexual, transgender, vices, acute care, and ongoing management of and queer.15 Systems, laws, policies, and explicit chronic and comorbid physical and behavioral and implicit biases have created these inequities in health conditions.11 High-quality primary care also the key drivers of health, including housing, food plays an important role in coordinating care for security, and clean water.16 These same factors patients across the health system. Primary care have created inequities in the health care delivery happens in a variety of settings, including private system.17 For example, in 2019, although 39% of practices, community health centers, large health Californians identified as Latino/x, only 6% of physi- systems, and even in visits to a patient's home. To cians in California were Latino/x, resulting in a lack optimize health, primary care is ideally located in of racial and ethnic concordance between physi- the neighborhoods where people live, providing cians and patients.18 California's Medicaid program California Health Care Foundation www.chcf.org 8 (Medi-Cal) covers one in three Californians, includ- primary care from multiple vantage points, with ing over 10 million Latino/x; Black; Asian, Native equity at the forefront. To catalyze movement from Hawaiian, and Pacific Islander; and American Indian evidence to action in the meantime, however, the and Alaska Native people19. Yet Medi-Cal physi- authors present example recommendations that a cian fees for primary care are only 76% of Medicare variety of actors can take to strengthen primary care rates.20 Low provider payments and high admin- and advance health equity in California. istrative burden lead many primary care practices to not accept Medi-Cal patients because payment "Primary care is the only health care compo- does not cover the practice's cost to provide high- nent where an increased supply is associated quality care.21 This is a social justice issue that limits Medi-Cal patients' access to care and perpetuates with better population health and more equi- health disparities.22 table outcomes." Source: Linda McCauley et al., eds., Implementing High- Despite significant increases in insurance coverage Quality Primary Care: Rebuilding the Foundation of Health over the past decade, one in five Californians who Care (Washington, DC: National Academies Press, 2021), 4. identify as Latino/x still do not have a particular medical professional, doctor's office, clinic, health center, or other place where they would usually go if sick or in need of advice about their health (often called a usual source of care).23 This signals continuing challenges with access to primary care among specific population groups and exempli- fies the structural inequities that continue to drive disparities in health outcomes. For example, Black Californians have a shorter life expectancy than other racial and ethnic groups in the state; they experience the highest rates of infant and mater- nal mortality as well as the highest death rates from breast, lung, cervical, and prostate cancer.24 In this report the authors summarize the large body of compelling evidence of primary care's unique role in the health care system and its contribution to advancing health equity. To strengthen primary care in California and optimize equitable care and health outcomes, the authors make the case that incremental actions by actors in silos are insufficient and that a paradigm shift is required in how we consider, fund, and ultimately deliver primary care. They call for a new statewide forum to consider Primary Care's Essential Role in Advancing Health Equity for California 9 Defining Health Equity and Why It Matters Clearly defining health equity is important because what gets defined and measured is more likely to be addressed. In addition, a shared definition allows for collective action for improvement. Multiple definitions of health equity exist. The most recent definitions convey the imperative for broad solutions that address a wide range of factors, including public and private policies, institutional practices, norms, and cultural rep- resentations that inherently procure unequal freedom, opportunity, value, resources, advantage, restrictions, constraints, or disadvantage according to race and ethnicity,25 rural or urban location, or other group identity. Some definitions finally acknowledge that health inequity is directly shaped by racism, which structures oppor- tunity, assigns value, and unfairly disadvantages some people.,26 $ The California Health Care Foundation affirms that "all Californians should have the opportunity to achieve their fullest potential for health. This includes not only access to health care, but also other social factors like housing, food, and jobs that contribute to a person's well-being."27 $ Taking an even broader approach, the World Health Organization defines health equity as "the absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality (e.g., sex, gender, ethnicity, disability, or sexual orientation)."28 $ Other researchers and practitioners remind us that poverty, discrimination, and other health-damaging con- sequences must ultimately be addressed in order to eliminate disparities in health outcomes.29 Levels of Racism Racism can take many forms, and operates on $ Institutionalized racism refers to "discrimina- multiple levels in individuals and society. tory treatment, unfair policies and practices, and inequitable opportunities and impacts within $ Internalizedracism refers to "acceptance by organizations and institutions, based members of stigmatized races of negative mes- on race." sages about their own abilities and intrinsic $ Structural racism represents the deep and com- worth" and exists within individuals. pounding impact of racial bias across institutions $ Interpersonal racism is "the expression of racism and society, which in turn shapes and mutually between individuals," through discrimination, reinforces the patterns and experience of other harassment, or slurs. forms of racism. Source: Camara Phyllis Jones, "Levels of Racism: A Theoretic Framework and a Gardener's Tale," American Journal of Public Health 90, no.8 (Aug. 2000): 1212–1215 California Health Care Foundation www.chcf.org 10 What Is Unique About Primary Care? For decades, primary care has been defined as having five essential elements, which, when present, collec- tively differentiate primary care from specialty-oriented care30: 1.Accessible first-contact care. Primary care physical and mental health care needs, including services are available and easily accessible to prevention and wellness, acute care, and chronic patients with new medical needs or ongoing and comorbid care, to include discussing end-of- health concerns. This includes shorter waiting life care. times for urgent needs, enhanced hours, around- 4.Coordinated care. Primary care practices coor- the-clock telephone or electronic access to a dinate care across all elements of the broader member of the care team who has access to the health care system, including specialty care, hos- patient's medical record, and alternative methods pitals, home health care, and community services of communication such as patient portals. This and support. also includes providers who speak the language 5.Accountable whole-person care. Primary care cli- of the population they serve. nicians and teams are knowledgeable about and 2.Continuous care. Patients and primary care clini- oriented toward the whole person, understand- cians have a personal and uninterrupted caring ing and respecting each patient's unique needs, relationship, with ongoing exchange of relevant culture, values, and preferences within the context information about health care and health needs. of their family and community. Accountability 3.Comprehensive care. Primary care clinicians, refers to caring for the whole person, not just an working with the interprofessional primary care isolated body system. team, meet the large majority of each patient's "The focus of primary care on recognizing and meeting patients' needs (including but not limited to 'diagnoses') is the reason primary care–oriented services are associated with greater equity in distribution of health in populations. Different populations differ in the kind and extent of their health problems, with more socially deprived populations having a greater number, greater severity and greater variability in their health needs than is the case in more socially advantaged populations. Primary care, the place where needs are best recognized, is the venue by which equity in health services and, hence, equity in those aspects of health responsive to health services, is attained. Person-centered services are the essential hallmark of primary care." Source: Barbara Starfield, "Primary Care and Equity in Health: The Importance to Effectiveness and Equity of Responsiveness to Peoples' Needs," Humanity & Society 33, no. 1–2 (Feb. 2009): 62–63. Primary Care's Essential Role in Advancing Health Equity for California 11 The Essential Role of the link between health equity and primary care supply and access, then summarize evidence of the of Primary Care in link between health equity and primary care's other Advancing Health Equity: defining elements: continuity, comprehensive- ness, coordination, and whole-person orientation. The Evidence Evidence of the counterfactual is also presented Decades of patient-level studies as well as system- - what happens to patient experience and health and population-level studies reveal complex and outcomes in the absence of high-quality primary interrelated factors that support the positive asso- care. In the text boxes, the authors highlight exam- ciation between primary care and health equity.31 ples of health care systems that have strengthened In this section, the authors first summarize evidence primary care with an explicit emphasis on advanc- ing health equity. Highlight: Team-based Primary Care for Veterans - Veterans Affairs PACT The Veterans Health Administration (VHA) of the Department of Veteran Affairs (VA) began its Patient Aligned Care Teams (PACT) initiative in 2010. Based on the patient-centered medical home model, each PACT care team includes a primary care provider (physician, nurse practitioner, or physician's assistant), a clinical pharma- cist, a registered nurse care manager, a licensed practical nurse or medical assistant, and a clerk.32 Each primary care patient within the VHA is assigned to a PACT team designed to provide multidisciplinary health care sup- port that focuses on the individual needs of patients and supports them in taking an active role in their health care.33 PACT teams also emphasize wellness and disease prevention.34 VA PACT combines a comprehensive Meeting the health care needs of California's team-based approach with care that is veterans cognizant of and oriented toward the Over 1.8 million veterans call California home, the special needs of veterans. PACT care is largest number of former service members in any associated with improved health outcomes, state. California also has the largest number of vet- such as improvements in clinical outcomes erans experiencing homelessness, representing over for patients with diabetes, hypertension, 30% of the homeless veteran population nationally.35 and heart disease, and also with improved patient satisfaction.37 It also is associated Many veterans have specific health care needs as with increased receipt of preventive services a result of military service, and may require treat- such as vaccinations, screening for some ment for exposure to hazardous substances and types of cancer, and being offered medica- ongoing rehabilitation from injuries. Veterans are at tions for tobacco cessation.38 PACT care disproportionate risk of experiencing mental health and substance use disorders, post-traumatic stress has been shown in some studies to reduce disorder, traumatic brain injury, and suicide.36 emergency department visits, hospital visits, and readmissions.39 California Health Care Foundation www.chcf.org 12 Highlight: Community-Oriented Primary Care in Costa Rica Although Costa Rica differs in many important ways the first multidisciplinary teams were established from the United States, it offers an example of a in areas with less access to care. In addition, data health system that prioritizes community-oriented collected by the multidisciplinary teams are used primary care, uses multidisciplinary teams to provide to focus resources on higher-risk areas. As a result, comprehensive primary care to almost all Costa premature mortality declined overall in Costa Rica Ricans, and has improved health equity while spend- between 1980 and 2000, but larger declines were ing less on health care than the world average.40 seen in the poorest quintile of the population com- pared with the richest quintile.42 Costa Rica's model of community-oriented primary health care, which was implemented in the 1990s, is based on five main elements: (1) the integration of public health with primary care; (2) the integration Adapting Costa Rica's Community- of multidisciplinary teams - including a physician, Oriented Primary Care Model to nurse, pharmacist, medical clerk, and highly trained Other Settings advanced community health worker - into the Despite differences between health sys- community; (3) the empanelment of citizens to care tems, aspects of the Costa Rican model teams based on geographic location; (4) a focus on could be relevant to improving health measurement and quality improvement at all levels; equity in California. and (5) the integration of digital technology at all Examples include: levels. Factors that have facilitated health reform in Costa Rica are the national ethos of health as a $ Recognizing community health workers human right and the principles of universality, equity, as critical members of the primary care and solidarity - the founding principles upon which team, and providing training and policy the health system was based and continues to support to expand their role operate.41 $ Exploring possibilities for geographic empanelment and/or geographically Costa Rica has improved the quality of health care, based care health outcomes, and health equity through its pri- mary health care system. For example, deaths from $ Collecting and using data at the com- communicable diseases have dropped from 65 per munity level to guide the distribution of 100,000 people in 1990 to 4.2 per 100,00 in 2010. resources to those areas and populations Maternal and child mortality have also declined. most at risk As one approach to improve equity in outcomes, Primary Care's Essential Role in Advancing Health Equity for California 13 Highlight: Primary Care in Community Health Centers Community health centers, which include Federally Qualified Health Centers (FQHCs), FQHC Look-Alikes, community clinics, free clinics, and rural health centers, provide culturally competent, coordinated, community- directed, comprehensive medical care and supportive services to diverse populations in medically underserved areas, regardless of patients' ability to pay.43 Community health centers emerged in 1965 as part of Lyndon B. Johnson's war on poverty and the civil rights movement and are designed to reduce health disparities by providing high-quality primary care and other services to communities that would otherwise have little or no access to medical care.44 FQHCs have been shown to provide better and Community Health Centers in more cost-effective care, even when serving popula- California tions with low incomes, that have historically been There are over 1300 Community health marginalized, and that have more complex medical centers in California. In 2021, these health and social needs. FQHCs achieve higher rates of centers served 7.2 million patients, or one hypertension and diabetes control than the national in five Californians, including almost 4 average. They provide more preventive services million people whose incomes were more (such as immunizations, cancer screening, and edu- than 100% under the federal poverty level cation for tobacco cessation) than other primary care and over 300,000 people experiencing providers. FQHCs perform better on primary care homelessness. More than half of community quality measures than private practice physicians. health center patients in 2021 were Latino/x They are more likely to provide high-value care (such and about one-third of patients had limited as providing statins to patients with diabetes) and proficiency in English.45 less likely to provide low-value care (such as provid- ing antibiotics for upper respiratory infections) than To address the needs of the populations private practices. In addition, these outcomes are they serve, community health centers achieved while spending less per patient than other provide access to integrated clinical and sources of care. FQHCS save 24% per Medicaid community services, including medical, patient compared to other clinics and private physi- dental, pharmacy, and behavioral health cians' office, and costs for Medicare patients are services, and outreach, education, nutrition, 10% lower than those for patients in physician office and social services.46 patients, and 30% lower than for patients in outpa- tient clinics.47 California Health Care Foundation www.chcf.org 14 Access to stronger primary care systems is associ- Enhanced primary care access can extend beyond ated with improved life expectancy and lower rates the primary care clinician and nurse or medical of premature mortality in both international com- assistant to include the interprofessional team and parisons48 and across regions within the United community health workers (CHWs), who speak the States.49 A higher density of primary care physicians language and know the culture of their local com- (number of PCPs per capita) has been repeatedly munities. For example, a randomized controlled linked to lower avoidable morbidity and mortal- trial found that primary care patients with low ity and longer life expectancy in regions within incomes had reduced hospitalizations and better the United States.50 This association is stronger in self-reported quality of care when CHWs provided the Black population than the White population.51 support.58 CHWs also help connect individuals with Primary care physician supply is also associated low incomes to Medicaid, which opens the door to with reductions in racial disparities in referral pat- primary care.59 terns in addition to an increase in necessary hospital admissions for Black Americans compared to White In addition to access, studies have also linked pri- Americans.52 Notably, communities that have been mary care's other defining elements - continuity, marginalized have some of the lowest PCP densi- coordination, comprehensiveness, and whole-per- ties, and a recent study found that counties with son care - to improved health equity60: lower PCP density would be expected to dispropor- tionately benefit from an increase in PCPs relative $ Continuity. Greater continuity of care is to their population size.53 associated with lower mortality rates,61 fewer dis- parities in rates of receipt of recommended cancer Access to high-quality primary care helps reduce screening services among Black and Latino/x disparities in receipt of United States Preventive populations,62 and fewer disparities in rates of Services Task Force–recommended preventive ser- receipt of several types of evidence-based, high- vices (e.g., immunizations and cancer screening).54 value services.63 Continuity, which is enhanced One study found that "Black patients able to access by continuous Medicaid coverage for children, primary care receive preventive services at rates is associated with improvements in health and equal to or greater than White patients. This sug- lower spending for hospitalizations that are gests that efforts to increase delivery of preventive ambulatory care–sensitive.64 Interpersonal con- care in Black patients need to focus on access to tinuity with a primary care practitioner is also primary care."55 Access to primary care also leads associated with greater patient trust. Patients, to earlier detection and treatment of conditions, including those who are Black and/or Latino/x and reduced severity of disease by effective man- with low incomes, are more likely to adhere to agement both for individual conditions (such as recommended preventive services and medica- hypertension, lipid disorders, congestive heart fail- tions from a trusted primary care practitioner. ure, chronic obstructive pulmonary disease, and For example, patients, including those who are diabetes)56 and ongoing management of multi- Black and/or Latino/x, rate primary care clini- morbidity, which the elderly and groups who are cians as the most trusted source of information economically marginalized experience at the high- about vaccines,65 and prefer to receive vaccina- est rates.57 tions (including for COVID-19) from primary care clinicians.66 Primary Care's Essential Role in Advancing Health Equity for California 15 $ Coordination of care across providers (e.g., pri- Embedding care for more common mental mary care and specialist practitioners) and health health problems like depression and anxiety into care settings (inpatient to outpatient) and with primary care helps address many of the barriers community-based services for health-related in access to mental health care experienced by social needs is a crucial component of address- Black and Latino/x individuals, including stigma ing patients' specific physical health, mental around mental health care, mistrust, location, health, and social needs.67 Coordination also and transportation. reduces the extreme burden of interacting with $ Whole-person orientation is conceptually a fragmented and disorganized health care sys- related to comprehensiveness. Both terms con- tem for patients with multiple chronic conditions vey providing care for the whole person, across and disabling conditions.68 Generally, patients their body systems, needs, and comorbid con- with better-coordinated care are more satis- ditions. Patients from racial and ethnic minority fied69 and more likely to follow evidence-based groups and other historically marginalized popu- recommendations for treatment and self-care, lations are more likely to have complex comorbid because they are less likely to receive conflicting conditions and higher rates of behavioral health messages from different providers.70 Specifically, and other social needs.77 Primary care generalists more coordinated primary care is associated with - when functioning in a way that is consistent reduced racial and ethnic disparities in many with their generalist training - specialize in pro- important outcomes - for example, prevent- viding care for the whole person.78 Elements of able emergency department visits and improved accountable whole-person care, including clini- blood pressure control.71 cian knowledge of a person's overall medical $ Comprehensiveness. Given that more com- history, preferences, and family and cultural ori- prehensive primary care has been associated entation, have been associated with improved with better health outcomes provided at lower patient self-management for chronic conditions,79 costs,72 as well as improved health and better better adherence to physicians' advice, and self-reported health outcomes,73 it follows that improvements in self-reported health status. such care would lend itself to more equitable In addition to strong evidence that primary care patient outcomes. More comprehensive primary advances health equity, there is a large body of care is associated with greater equity, includ- research that supports the counterfactual. In the ing reduced disparities in disease severity as a absence of high-quality primary care, people expe- result of earlier detection and prevention across rience inequitable access to care, more fragmented different populations.74 Data also suggest that care, and more costly and duplicative service use behavioral health integration into primary care - - partly from poor coordination of care across an important component of comprehensiveness providers and settings.80 In a multinational study, - may help reduce mental health disparities patients' perceptions of poorer care coordination for Latinos/x.75 A consensus report by national was associated with higher odds of self-reported experts based on current literature concluded medical errors, medication errors, and labora- that the improvement of behavioral health and tory errors. Patients also experienced a decline in physical health outcomes and the elimination of patient-centeredness as the availability of primary disparities for racial and ethnic minority popula- care physicians declined due to inadequate sup- tions can best be addressed by the integration port and reimbursement.81 This directly erodes trust of behavioral health and primary care services.76 between providers and patients and dissolves the California Health Care Foundation www.chcf.org 16 continuous relationships that patients so highly measures rather than disaggregating data to iden- value. Having a generalist physician who knows tify and then eliminate inequities in access, quality them well and can care for the majority of their of care, or outcomes. The result is improvement common needs and conditions is a critical aspect efforts that preferentially benefit majority popula- of care for everyone,82 in particular for individuals tions. Additionally, policies have made it easier for in historically marginalized and under-resourced health systems to create barriers that make it harder communities. This continuity with a trusted primary for marginalized populations to access their care care clinician is particularly important for people - for example, legal issues for migrants and drug who have historically distrusted the health care sys- users.85 Even as health plans and systems commit tem due to social injustices, receipt of lower-quality to improving health equity, they may find it chal- care, and challenges navigating the system.83 lenging to avoid common pitfalls, such as failing to sufficiently engage patients and community voices, While the evidence base suggests that primary care or focusing exclusively on implicit bias trainings has tremendous potential and an important role to and avoiding looking for and explicitly addressing play in advancing health equity, it also offers impor- social and structural drivers of health inequities, tant cautionary lessons.84 Policies and incentives such as lack of housing or food. The literature sug- have made it easier for many health care systems, gests that policymakers, payers, and practitioners including primary care practices, to use one-size- can help avoid these pitfalls by ensuring that pri- fits-all approaches to care interventions and quality mary care settings are resourced, supported, and improvement efforts that focus on improving aggre- held accountable for pursuing clear equity-focused gate patient outcomes or clinical performance improvement efforts. Primary Care's Essential Role in Advancing Health Equity for California 17 Primary Care in the US Is Not Adequately Funded Although early conceptualizations of health and, equally important, a host of other social deter- services emphasized the centrality of primary minants of health, extending far beyond the walls care, it has been inadequately supported in of clinical care. Community health workers were the United States. Early conceptualizations of considered a powerful linchpin in advancing this the health services system in Great Britain in 1920 vision of health.89 Yet, in the United States, primary distinguished three major levels of health service: care services are shifting from local communities to (1) primary care centers, (2) secondary (specialist) become more centralized and consolidated under centers that provided consultative care, and (3) increasingly powerful hospital systems.90 In addi- hospitals that provided tertiary care. This framework tion, fee-for-service reimbursement rates are heavily for the organization of health services was designed influenced by hospitals, specialists, and medical to respond to levels of need for health care services imaging and device manufacturers.91 Fewer medical in the population, and provided the basis for the students pursue primary care than specialist careers reorganization of health services in many countries.86 because of lower compensation for primary care, In 1966, the Millis Commission report on medi- which makes it economically unfeasible for them to cal careers that were required to care for a society cover their burgeoning medical student debt, which noted that each person should have a primary care was $250,000 on average in 2022.92 physician.87 Later, the International Conference on Further compounding inadequate support for Primary Health Care in Alma-Ata, USSR, in 1978 and primary care, the US spends much less on primary then the Global Conference on Primary Health Care care and more on specialty care, including proce- in Astana, Kazakhstan, in 2018 emphasized primary dural services, compared to other industrialized health care as essential to equity and central to democracies.93 Despite primary care accounting for an organized health care delivery system that was 35% of US health care visits, primary care accounts the main focus of the overall social and economic for only 5.4% of health care expenditures in the development of the community.88 World leaders United States.94 Growth in the number of procedural envisaged robust community-level responsibility for specialists, combined with financial disincentives to planning and implementing primary and preven- pursue primary care, results in both fewer primary tive health care services. Acknowledging the "social care physicians and a maldistribution of primary roots of illness," they had a vision for intersectoral, care clinicians.95 This limits access to primary care, rights-based approaches to improve health care particularly for marginalized populations. California Health Care Foundation www.chcf.org 18 Primary Care and Public Health Integration In theory, public health and primary care are natural Pandemic planning and preparation were inad- partners and collaborators due to their shared goals equate (or ignored), despite repeated warnings of improving population health and preventing dis- and lessons learned from recent epidemics in other ease and disability. Achieving these goals requires places. In addition, efforts to wring inefficiencies out understanding individuals in the context of their of the public health and health care systems have communities and environment.96 Integrating health resulted in limited or no surge capacity in many care and public health services has been an aim of systems and settings. The United States was initially transformation efforts for many years, with better unable to manufacture, procure, and equitably pro- coordination and collaboration seen as important vide appropriate personal protective equipment and pathways to improving population health.97 supplies for health care workers, patients, and the population at large. Early testing for the virus was However, the reality of integration is challenging for delayed and inadequate, and contact tracing efforts many reasons. The most frequently cited reason is were hindered by the effects of prior cuts to public that both public health and primary care are chroni- health infrastructure and personnel, which have also cally underfunded, a situation that many observers hampered vaccine distribution efforts. feel has worsened, particularly for public health, in recent years. Public health and primary care lack In addition, during the pandemic many primary the infrastructure, personnel, and time needed to care practices experienced significant new stress, support the intentional development - and the often struggling to keep their practices alive finan- long-term maintenance - of the good working cially while continuing to do their best to provide relationships that are crucial to successful integra- high-quality clinical care and address patients' tion. In addition, addressing the social determinants pandemic-related needs.99 As one example of the of health is fundamental to both primary care and disconnect between primary care and public health, public health, yet neither has the resources or influ- many primary care providers were uniquely well-sit- ence to adequately address the social vulnerabilities uated to reach their socially vulnerable patients with suffered by so many. actual vaccines and with information and guidance for the vaccine-hesitant. However, they lacked infor- Over the past century in the United States, public mation from and connections with their local public health and primary care have developed distinct health departments and were not included in vaccina- cultures and professional identities, with different tion planning at the national, state, or regional level. models of training and professional preparation, and often little opportunity for cross-professional instruc- The pandemic has also drawn back the curtain, tion and the sharing of knowledge and approaches. in a dramatic and profound way, on the systemic Absent intentional and sustainable efforts to bridge health inequities that have devastated communities the two cultures during education and training, and of color. Preexisting disparities in health status left in the absence of clearly identified processes for col- these communities more vulnerable to exposure to laborating, it can be daunting for individuals in both the virus, to infection, to more severe illness, and fields to find the time and support to engage in pro- to the long-term consequences of the social and ductive partnerships, even with the best of intentions. economic disruptions wrought by the pandemic and our responses to it. The pandemic has dem- These were the circumstances prior to the COVID- onstrated, starkly and unequivocally, that reducing 19 pandemic. The continuing crisis of the pandemic health inequities must be our top priority in envi- has laid bare significant fault lines in our public sioning and building integrated public health and health and primary care systems, and in the integra- primary care systems. tion of the two.98 Primary Care's Essential Role in Advancing Health Equity for California 19 Figure 1. Advancing Health Equity Through High-Quality Primary Care Practices H E A LT H E Q U I T Y FIRST CONTACT CONTINUOUS COMPREHENSIVE COORDINATED WHOLE PERSON, ACCOUNTABLE y Care Prac ar m tic i Pr CHRONIC e CARE PUBLIC HEALTH SOCIAL SERVICES HOSPITALS SHARING PEOPLE & DATA SPECIALISTS NTS IS TA SS A RKERS MEDICAL WO H H O M E H E A LT RKERS LANGUAGE CONCORDANCE CULTURAL COMPETENCY WO MM H CO U N I T Y H E A LT CO-PAYMENTS TRANSPORTATION GEOGRAPHIC LOCATION INSURANCE COVERAGE Source: Mathematica created visual aid, March 2023. In communities across California, primary care the whole person (see Figure 1). It is not enough to practices differ substantially in their size, structure, simply address acute and preventive care needs; and governance. They also differ substantially in care for people with multiple, complex chronic con- how well they are resourced with necessary money, ditions is at the heart of high-quality primary care. technical assistance, and workforce. Practices share To advance health equity, primary care needs to people and data with numerous other entities, such be adequately resourced and supported by other as specialists, hospitals, social services, and public entities in its immediate community. Access barri- health departments. Each practice is surrounded ers such as health insurance coverage and benefit by its own unique community of organizations and design, transportation, and language issues need resources, health plans, purchasers, and other key to be addressed. In turn, primary care practices influencers. need to wisely invest the additional resources in High-quality primary care practices strive to deliver people and services with the explicit intention of accessible first-contact care that is also continuous, advancing health equity. comprehensive, coordinated, and accountable for California Health Care Foundation www.chcf.org 20 A Radical Reimagining a common good promoted by responsible public policy and supported by private-sector action."100 of California Primary State government/policymakers, purchasers, health Care to Advance Health plans, and others that command resource-allocation decisions should invest resources (including money, Equity staffing, and technical assistance) to strengthen the primary care infrastructure and adopt payment Without universal access to high-quality primary models and incentives that support high-quality care, California will struggle to improve the health primary care with the ultimate goal of improving of its population and to reduce disparities. But population health, reducing disparities, improving primary care in the United States has been under- worker productivity, and decreasing total cost of resourced for decades, resulting in a depleted care statewide.101 workforce struggling to deliver care in a weakened infrastructure. As a result, health indicators across Embrace the diversity of primary care practice the state have slipped, and troubling disparities settings, and invest resources according to need persist. Investments in primary care have declined with the intentional goal of reducing health and over the past decade, both in California and nation- social inequities. ally, putting many primary care practices into crisis. To turn course, California needs a focused effort to California should recognize the diversity of primary strengthen primary care. Ensuring that equity is at care settings in which high-quality primary care can the center of this effort will require a paradigm shift be delivered and provide support according to in our thinking and our actions. need. Variations in primary care settings can impact available resources such as staffing, electronic This section explores the authors' vision for this health record capabilities, and even patient ser- paradigm shift; the following section and Appendix vices, so the necessary resources (money, staffing, A provides example recommendations that poli- and technical assistance) to strengthen primary care cymakers and regulators, purchasers and payers, will differ depending on the type of practice and health system leaders, and primary care providers the community context. This commitment is partic- and teams can use to advance primary care and ularly important because populations at the highest health equity. risk for health disparities - for example, Black and American Indian and Alaska Native (AIAN) popula- tions - are more likely to live in communities that A Paradigm Shift to Ensure have weak primary care infrastructure (as measured Efforts to Strengthen Primary by PCP density) and face access barriers related Care Prioritize Equity to insurance or transportation. State government/ policymakers, purchasers, health plans, and others Recognize high-quality primary care as a com- that command resource-allocation decisions should mon good. ensure that their quality and performance improve- California should adopt the framing of the National ment programs include historically marginalized Academies of Sciences, Engineering, and Medicine practices (e.g., small practices, rural health care (NASEM) that "high-quality primary care is not providers) and support programs that require and a commodity service whose value needs to be reward disparity reduction (not simply aggregate demonstrated in a competitive marketplace but improvement). Primary Care's Essential Role in Advancing Health Equity for California 21 Proactively apply principles of equity and justice disabilities, and children. Lastly, for primary care to all decisions. to maximize its impact on health equity, patients, families, and caregivers need to be involved in care Advancing equity in all sectors, including health delivery and quality improvement efforts. care, requires attention to economic and political power (as determinants of health102) and community Build accountability for action. and personal empowerment (as a critical process103). Ultimately, efforts to reduce disparities will require Progress will happen only if we hold our sys- efforts to address social risk factors such as lack tems, ourselves, and each other accountable. The of housing, transportation, education, job oppor- NASEM report quoted above recommends creat- tunities, income, neighborhood safety, access to ing a new federal leadership council and an annual nutritious foods, opportunities for physical activity, scorecard to ensure progress in the implementation and access to primary care,104 as well as to confront of high-quality primary care across the nation.105 A and uproot structural determinants of health inequi- similar structure is needed in California to guide ties, including structural racism. Embracing equity the strengthening of and sustain accountability for in health policy requires that policy decisions be high-quality primary care as an essential contributor informed by those affected by that policy, including to advancing health equity in the state. The authors groups that are often marginalized from political, view a statewide primary care equity action forum social, and economic opportunities, such as those as the vehicle needed in California to propel prog- with lived experience of poverty, people with men- ress in this work. See the accompanying box for tal illness or substance use disorders, people with more information. California Health Care Foundation www.chcf.org 22 Convening a Primary Care Equity Action Forum The National Academies of Sciences, Engineering, and Medicine's 2021 consensus study report, Implement- ing High-Quality Primary Care: Rebuilding the Foundation of Health Care, is a compelling call to develop and expand collaboration across sectors and silos to establish an overarching vision and leadership for primary care nationally. This is a call to action and innovation in California as well; as a state, we are poised to lead the nation in this work. A new type of entity and a new approach are needed to facilitate the desired paradigm shift, identify specific action steps, and engage existing and previously unrepresented groups to work together to advance health equity through the strengthening of primary care. The authors view a statewide primary care equity action forum as the vehicle needed in California The Virginia Task Force on to propel progress in this work. The forum would Primary Care address the policy topics of primary care spending, The Virginia Task Force on Primary Care, payment models, workforce, innovative delivery originally developed in response to the models, information technology, and metrics and COVID-19 pandemic, is one model of accountability, among others, to forge a collabora- a statewide body designed to foster tive plan of action. All forum activities would keep collaboration, action, and accountability health equity - including issues of language, trust, to improve primary care. Staffed by the maldistribution of resources, and other barriers to Virginia Center for Health Innovation, the and facilitators of equitable care - at the forefront task force brings together primary care and as the primary goal. The forum could also pro- clinicians, health plan representatives, vide an ongoing opportunity for primary care and patient advocates, employers, and state health equity leaders across the state to collectively government to strengthen primary care for review and make sense of reports, evidence, and all people in the state. scorecards, and use them as the basis for new policy recommendations. Primary Care's Essential Role in Advancing Health Equity for California 23 Example Recommenda- 4. Support whole-person care through behavioral health and primary care integration across all tions for California to practice settings, and strengthen training for Strengthen Primary Care primary care providers on behavioral health (including substance use disorder treatment) and Advance Health and wellness. Equity 5. Promote equitable access to telehealth by improving broadband access, infrastructure, To guide future planning, the authors offer a set payment models, provider readiness, and of example recommendations for how to advance patient engagement, especially for rural and primary care and health equity within the state. safety-net communities. Progress will require action from multiple actors, working individually and in collaboration, includ- 6. Strengthen access to and quality of language ing policymakers and regulators, purchasers and assistance services, including providing quali- payers, health system leaders, and primary care fied interpreters; translated documents in providers and teams. The authors offer their own understandable, plain language in at least all recommendations, as well as recommendations Medi-Cal threshold languages; and a notice of drawn from other sources.106 The list is not exhaus- the right to language assistance services to all tive; rather, these examples are offered as a starting patients. point for planning. Refinement and prioritization of 7. Provide an option for primary care continuity a more exhaustive list of recommendations is nec- after hours and on weekends. essary, but was beyond the scope of this report. 8. Ask patients about their needs and in what areas 1. Involve people with lived experiences of dis- they want help. Use validated screening tools to crimination in primary care policymaking and identify social determinants of health-related governance bodies to identify impediments to social needs, and, when possible, prescribe health equity and generate solutions. services and activities that are tailored to the individual's needs (e.g., financial support, food 2. Expand and scale pipeline programs to recruit, access, trauma-informed counseling, or a walk- prepare, and mentor students from historically ing group). and systematically excluded communities and backgrounds for careers in primary care. 9. Increase the overall proportion of health care spending that is directed toward primary care, 3. Hire and mentor team members from and within establishing spending targets for public and pri- the community, to better reflect the commu- vate payers. nity's racial and ethnic composition within the practice. Incorporate the lived experiences of 10.Increase Medi-Cal physician payment lev- staff into training for care delivery to encourage els in order to incentivize service delivery to empathy and bring cultural context to interac- Californians with low incomes. tions with patients. California Health Care Foundation www.chcf.org 24 11.Implement and encourage participation in equity- focused alternative payment models that enable Conclusion integration of social services, public health, and California is the most populous and racially diverse community partnerships into clinical practice. state in the nation. While over 90% of Californians have health insurance, millions do not have access 12.Carefully collect accurate, self-identified elec- to affordable, high-quality primary care. This report tronic health record data on race and ethnicity, explores the unique role of primary care in the sexual orientation, gender identity, language health care system and outlines the large body of proficiency, and disability as an important first evidence demonstrating its essential contribution step to providing whole-person, equitable care to advancing health equity. It goes further by call- and improving provider-patient concordance for ing for a paradigm shift – in both our thinking and diverse Californians. our actions -- that includes: (1) recognizing primary 13.Incorporate measures on equity and social care as a common good, (2) embracing the diver- needs in data collection for clinical, quality sity of primary care practice settings and investing improvement, and research purposes. Collect resources according to need with the intentional and stratify data on social needs to identify and goal of eliminating health and social inequities, (3) document health inequities. proactively applying principles of equity and justice to all decisions, and (4) building accountability for 14.Use quality improvement approaches to identify action. and analyze root causes of identified inequities in the clinical setting. To advance health equity, primary care practices need to be adequately resourced and supported by other entities in their immediate community. A To help readers understand the policy con- variety of primary care influencers can take equity- text for these recommendations, the authors focused actions today to strengthen primary care have provided for each recommendation a in five key policy arenas outlined in this report, few illustrative examples of relevant policies including community engagement; workforce edu- and programs in California, as well as options cation and training; clinical practice transformation; to further progress. These are presented in payment and spending; and data collection, mea- Appendix A. surement, and reporting. Going forward, California can ensure meaningful statewide progress by establishing a primary care equity action forum that would build new partnerships and provide leader- ship and accountability for this important work. Primary Care's Essential Role in Advancing Health Equity for California 25 Appendix A. Policy Context for Example Recommendations and Options to Advance Progress In Table A1, the authors have sorted 14 example recommendations into five key arenas for action: (1) community engagement; (2) workforce educa- tion and training; (3) clinical practice transformation; (4) payment and spending; and (5) data collection, measurement, and reporting. To help readers understand the policy context for these recommendations, the authors have provided a few illustrative existing policies and programs in California, as well as some examples of potential options for consideration to further advance progress. Table A1. Policy Context for Example Recommendations and Options to Advance Progress EXAMPLE SELECTED EXAMPLES OF RELEVANT POLICIES OPTIONS TO RECOMMENDATION AND PROGRESS IN CALIFORNIA ADVANCE PROGRESS Community engagement Involve people with lived $ In 2022, the California Department of Health Care Services $ Identify and implement opportunities to add people with lived experiences of discrimi- (DHCS) created a Medi-Cal Consumer Advisory Committee experience of discrimination to additional primary care policy- nation in primary care in recognition of the need to address structural racism and to making, advisory, and governance bodies, such as the new policymaking and gover- provide an active voice for communities and individuals that Office of Health Care Affordability (OHCA). nance bodies to identify have been historically marginalized in informing and designing $ Require health care organizations with governing bodies, includ- impediments to health DHCS's programs. Recruitment is underway. ing health plans, to include patients in governance, not only in equity and generate advisory capacities. solutions. $ In its rollout of CCO 2.0, the Oregon Health Authority imple- mented policies to strengthen Community Advisory Council (CAC) and Community Care Organization (CCO) partnerships by requiring CCOs to have two CAC representatives, one of whom is an Oregon Health Plan consumer, on the CCO board. California Health Care Foundation www.chcf.org 26 EXAMPLE SELECTED EXAMPLES OF RELEVANT POLICIES OPTIONS TO RECOMMENDATION AND PROGRESS IN CALIFORNIA ADVANCE PROGRESS Workforce education and training Expand and scale pipeline $ The 2022–23 Governor's Budget included a one-time $1.7 billion $ Scale successful programs such as the University of California programs to recruit, investment over three years in care economy workforce devel- Programs in Medical Education (UC PRIME), making them the prepare, and mentor opment - across agencies - that will create opportunities standard instead of a specialty program. students from histori- to recruit, train, hire, and advance an ethnically and culturally $ Develop and support pathway programs for all degreed health cally and systematically inclusive health and human services workforce, with improved care positions (e.g., nursing, advanced practice nursing, physi- excluded communities and diversity, wages, and health equity outcomes. Programs include cian assistant) modeled after successful physician pathway backgrounds for careers in a focus on community health workers; training and career programs (such as the California Medical Scholars Program or primary care. advancement for people with barriers to employment, particu- UC PRIME). larly from disadvantaged communities; and vocational pathways for English language learners. $ Support summer enrichment programs, academic career advis- ing programs, mentoring, research opportunities, and exam $ The California Department of Health Care Access and preparation, in both high schools and community colleges as Information (HCAI) expanded its pipeline programs in 2022, well as for those pursuing advanced degrees (such as the UC including the following actions: Postbaccalaureate Consortium), particularly in underserved $ It launched the Health Professions Pathways Program, in communities. support of and alignment with the California Future Health $ Support tuition waivers, room-and-board stipends, and paid Workforce Commission recommendations 1.1 and 1.2, and internships for economically disadvantaged students. awarded $40.7 million to 20 organizations to develop and implement pipeline programs. $ Invest in and increase linkages across programs and educational levels, such as the Associate Degree for Transfer (ADT) and $ It awarded $600,000 through its Health Professions Careers Community Health Scholars. Opportunity Program. $ Financially incentivize nursing and medical schools to create $ It launched the new Health Workforce Education and Training formal mentoring programs and other initiatives to diversify their Council. This public body, established in statute, has begun faculties and student bodies. examining ways to build a pipeline to increase health workforce diversity. $ Invest in pathway programs for ancillary health workers to transi- tion into the nursing and medical professions. $ The 2021–22 Governor's Budget allocated $10.5 million in one-time support to pilot the California Medicine Scholars $ Provide support for ongoing research and evaluation of pathway Program, providing resources for a regional pipeline to prepare programs to inform workforce development strategies. community college students for careers as primary care physi- cians in underserved communities. Hire and mentor team $ DHCS added Community Health Worker (CHW) services as $ Support health systems and managed care plans in understand- members from and within a Medi-Cal benefit starting July 1, 2022, after receiving CMS ing and leveraging the new CHW/P Medi-Cal benefits and how the community, to better approval for State Plan Amendment (SPA) 22-0001. Providers to engage, support, and use CHW/Ps effectively; and increase reflect the community's who work with CHWs and promotores (CHW/Ps) and meet knowledge and reduce confusion surrounding how CHW/ racial and ethnic composi- the requirements outlined in the recently published Medi-Cal Ps, doulas, and behavioral health coaches intersect with one tion within the practice. Provider Manual for the CHW benefit will be able to bill another in the context of Medi-Cal and primary care. Incorporate the lived experi- Medi-Cal for those services. $ Expand access to resources to improve community engagement ences of staff into training $ Governor Gavin Newsom allocated $1.8 million to HCAI to and partnerships between primary care providers and trusted for care delivery to encour- increase the supply of CHW/Ps in California by creating a CHW/P community leaders, including CHW/Ps, faith-based groups, age empathy and bring certification process and support for CHW/P training programs. and neighborhood coalitions. Examples of resources include cultural context to interac- HCAI is in the process of implementing this funding via a stake- A Toolkit to Advance Racial Health Equity in Primary Care tions with patients. holder-led process. Improvement and the Engaging People with Lived Experiences Toolkit. $ Payers could expand reimbursement for peer-based staff, such as patient navigators and CHWs, to include those who share characteristics with groups that experience health inequi- ties. Examples are available from the Center for Health Care Strategies (toolkit) and the Rural Health Information Hub (toolkit). Primary Care's Essential Role in Advancing Health Equity for California 27 EXAMPLE SELECTED EXAMPLES OF RELEVANT POLICIES OPTIONS TO RECOMMENDATION AND PROGRESS IN CALIFORNIA ADVANCE PROGRESS Clinical practice transformation Support whole-person care $ CalAIM, California's Medi-Cal redesign effort, includes several $ Measure and evaluate access and outcomes by race and ethnic- through behavioral health enhancements for behavioral health integration, for example: ity to make disparities visible. and primary care integration $ A "no wrong door" policy to ensure beneficiaries receive $ Increase cross-training opportunities in primary care and behav- across all practice settings, mental health services regardless of the delivery system from ioral health education to improve integration and collaboration and strengthen training for which they seek care (county behavioral health, Medi-Cal and reduce stigma. primary care providers on managed care plan, or the fee-for-service delivery system). behavioral health (includ- $ Move away from traditional fee-for-service payments to ing substance use disorder $ A Population Health Management Initiative to establish a payments for behavioral health and primary care integration, treatment) and wellness. comprehensive, accountable plan of action for addressing linking to quality and value instead. Promising models include member needs and preferences across the continuum of care, the following: providing care management and coordination across delivery $ Massachusetts ties ACO payment to health-related social systems, and linking public health and social services. needs screening and many behavioral health quality measures, $ HCAI offers several grant programs to help increase behav- such as depression remission or response, emergency ioral health training in primary care and social service settings. department (ED) visits for individuals with mental illness, and Examples include the following: initiation and engagement of alcohol or other drug abuse or $ A Community-Based Organization (CBO) Behavioral Health dependence treatment. Workforce Grant Program to recruit and retain behavioral $ Pennsylvania's Office of Mental Health and Substance Abuse health personnel. Services created its own Value-Based Purchasing (VBP) $ A Peer Personnel Training and Placement Program to support Program. individuals with lived experience as a mental/behavioral health $ Make Medi-Cal reforms, including the CalAIM framework, more services consumer, family member, or caregiver. flexible to allow for the addition of community-defined evidence $ Psychiatric Education Capacity Expansion grants to increase practices (CDEPs) to the suite of outpatient behavioral health the number of psychiatric/mental health nurse practitioners. services available to people of color and LGBTQ Medi-Cal consumers. $ A Train New Trainers Primary Care Psychiatry Fellowship to support providers who wish to receive advanced training in $ Strengthen health information exchanges (HIEs), including primary care psychiatry. supporting county behavioral health participation in regional HIEs. $ California payment and policy changes, as well as clinical and lay leadership, allowed for the rapid and widespread rollout of $ Explore universal consent agreements across all levels and medication-assisted treatment (MAT) for opioid disorders in sectors of care. primary care settings. Promote equitable access $ In 2021, DHCS convened the Telehealth Advisory Workgroup $ Research the impact of telehealth on access, quality, equity, and to telehealth by improv- to increase access and equity and reduce disparities in the cost from both patient, provider, and payer perspectives. ing broadband access, Medi-Cal program. $ Identify and address disparities in access by demographics, infrastructure, payment $ DHCS has continued and expanded many of the telehealth geography, and service type. models, provider readiness, policies from the COVID-19 public health emergency. and patient engagement, especially for rural and $ Currently, California is one of a few states to commit to safety-net communities. reimbursing a broad array of services at parity when delivered via audio-only visits (i.e., telephone calls). $ HCAI, through the California State Office of Rural Health, provides technical assistance to rural health organizations, including promotion of telehealth resources. $ Governor Newsom made a historic investment of over $6 billion in California's broadband infrastructure in 2021. It will take time for the law and changes to take effect. California Health Care Foundation www.chcf.org 28 EXAMPLE SELECTED EXAMPLES OF RELEVANT POLICIES OPTIONS TO RECOMMENDATION AND PROGRESS IN CALIFORNIA ADVANCE PROGRESS Strengthen access to $ SB 853: The Health Care Language Assistance Act, was the first $ Expand high-quality medical interpreter training programs to and quality of language of its kind in the nation, holding health plans accountable for develop sufficient workforce and strengthen access to language assistance services, includ- the provision of language services. Despite substantial progress services. ing providing qualified made because of this law, advocates indicate that there is still a $ Reduce wait times and improve responsiveness of Medi-Cal interpreters; translated need to strengthen enforcement and accountability. managed care plan language lines for providers that don't have documents in understand- $ An evaluation of the state's Medical Interpreter Pilot Program on-site capacity for interpretation in a specific language. able, plain language in at (MIPP) is underway to help inform expansion strategies for inter- least all Medi-Cal threshold $ Incentivize practices to build their own capabilities for language preter training programs. interpretation, and allow for billing and reimbursement for staff languages; and a notice of the right to language interpretation. assistance services to all patients. Provide an option for $ Many FQHCs, for example, Tiburcio Vasquez Health Center, $ Provide incentive payments for after-hours care, or deem primary care continu- provide Saturday clinics using regular staff to maintain continuity after-hours care critical infrastructure and incorporate it in value- ity after hours and on at the team level. based payments. weekends. $ Some independent practice associations (IPAs), like Allied Pacific, have helped connect small practices to each other in neighborhoods to build the after-hours coverage network and define the collective standards for care. Ask patients about their $ In 2024, Covered California will add a Social Needs Screening $ Purchasers and payers can incentivize or require attainment needs and in what areas and Intervention (SNS-E) measure to its required stratified of Joint Commission accreditation for eligible entities, which they want help. Use measure list for qualified health plans. requires health care organizations to screen all patients for social validated screening tools $ The DHCS Population Health Management Initiative will require needs. to identify social determi- insurers to identify health-related social needs. $ Expand guidance and resources to help primary care practices nants of health and social pursue social needs screening and referral interventions, linking needs, and, when possible, them to quality and equity goals. prescribe services and activities that are tailored to the individual's needs (e.g., financial support, food access, trauma-informed counseling, or a walking group). Primary Care's Essential Role in Advancing Health Equity for California 29 EXAMPLE SELECTED EXAMPLES OF RELEVANT POLICIES OPTIONS TO RECOMMENDATION AND PROGRESS IN CALIFORNIA ADVANCE PROGRESS Payment and spending Increase the overall propor- $ California's major public purchasers, which participate on the $ The new Office of Health Care Affordability (OHCA) should tion of health care spending Primary Care Investment Coordinating Group of California consider enforcement mechanisms to support primary care that is directed toward (PICG), have committed to measuring and reporting primary spending thresholds, once established. primary care, establishing care spending and to considering setting a target or floor for $ The OHCA should consider whether Medi-Cal should have a spending targets for public increased spending. Specifically, contracts adopted by Covered discrete target for primary care investment that reflects the and private payers. California (for 2023), DHCS (for 2024), and CalPERS (for HMO in needs of Medi-Cal members and serving providers, reflects 2024) require contracted plans to do the following: the structure of the Medi-Cal benefit package, and addresses $ Report on total primary care spending and percentage of historic under-investments in Medicaid payments to providers. spending within each Health Care Payment Learning & Action $ Consider opportunities to employ global budget and total costs Network Alternative Payment Model (HCPLAN APM) category. of care (TCOC) payment models to help increase the proportion Additionally, DHCS will require contracted plans to stratify the of health care spending directed to primary care. reporting of primary care spending as a percentage of total spending by age and by race/ethnicity. $ Report on the number and percentage of contracted primary care clinicians paid using the HCPLAN APM framework categories and subcategories $ Analyze the relationship between the percentage of spend- ing for primary care services with performance of the overall delivery system. $ The California Quality Collaborative and the Integrated Healthcare Association have convened a coalition of large commercial health care payers to coordinate on primary care measurement and reporting, payment, investment, and practice transformation with the goal of strengthening primary care and improving practice-level performance. The memorandum of understanding includes commitment to setting a primary care investment target. $ California's Office of Health Care Affordability (OHCA), housed in the Department of Health Care Access and Information, is charged with measuring and reporting on primary care spend- ing as a share of total health care expenditures and with setting a benchmark for primary care spending. While OHCA has not released a timeline for data collection on primary care spend- ing, it is anticipated that data will be included in the first annual report, to be released in mid-2027 - implying data collection not later than 2026 for calendar year 2025. $ The Pacific Business Group on Health created the Health Value Index, a set of key performance indicators that reflects the priorities of its large-employer and public-purchaser members in communicating with contracted health plans. The focused measure set includes primary care spending as a percentage of the total cost of care. $ Other examples of California initiatives focusing on primary care can be found on the California Health Care Foundation website under Primary Care Matters, Current Efforts. California Health Care Foundation www.chcf.org 30 EXAMPLE SELECTED EXAMPLES OF RELEVANT POLICIES OPTIONS TO RECOMMENDATION AND PROGRESS IN CALIFORNIA ADVANCE PROGRESS Increase Medi-Cal physician $ In 2016, voters passed Proposition 56. The majority of these $ All payers should review their payment rates and consider payment levels in order to funds were released for provider and supplemental payments to whether current rates are sufficient to support high-quality incentivize service delivery physicians. However, these funds are declining. primary care for diverse populations, including populations with to Californians with low $ As a condition of enhanced federal funding for the Providing a high burden of social needs that impact health. incomes. Access and Transforming Health (PATH) Initiative, CMS has required California to increase and (at least) sustain Medi-Cal fee-for-service provider base payment rates and Medi-Cal managed care payment rates in primary care, behavioral health, and obstetrics care by closing the gap between Medicaid and Medicare rates by at least 2 percentage points, should the state's average Medicaid-to-Medicare provider rate ratio be below 80% in any of these categories, effective January 1, 2024. Similar Medicare-Medicaid primary care payment parity policies are already in effect in Arizona, Oregon, and Massachusetts. Implement and encourage $ CalAIM will enable Medi-Cal managed care plans to couple $ Identify and adopt best strategies used in other states or participation in equity- clinical care with a range of new nonmedical services. These national programs to reduce and eliminate disparities in health focused alternative payment services, which will be reimbursed by Medi-Cal, include housing and health care by aligning payment reform and quality improve- models that enable integra- supports, medical respite, personal care, medically tailored ment efforts. For example, Advancing Health Equity: Leading tion of social services, meals, and peer supports. CalAIM will also require plans to Care, Payment, and Systems Transformation is a national program public health, and commu- coordinate access to services provided by counties and commu- supported by the Robert Wood Johnson Foundation; it consists nity partnerships into nity-based organizations. of teams composed of government leaders, insurers, and care clinical practice. $ Some California FQHCs and other primary care providers have providers from 12 states (seven in the first cohort in 2018, with an leveraged alternative payment models to enable the integration additional five teams joining in 2023). of social services and community partnerships with primary care. $ Large health systems could invest their reserves in community For example, AltaMed Health Services created an IPA to take health, for example: on risk for primary care patients and better coordinate primary $ UCSF launched a Community Investment Program supporting care, specialty care, and hospital use for its patients. housing and minority-owned small businesses to augment its $ In 2024, DHCS will launch an alternative payment model Anchor Institution Initiative. program for FQHCs. This FQHC APM program will translate the $ Kaiser Permanente has made it an explicit goal "to foster current encounter-based reimbursement system into a prospec- health and equity … by addressing the root causes of health, tive, capitated, per-member per-month payment and remove such as economic opportunity, affordable housing, health and current restrictions on billable provider types and sites of wellness in schools, and a healthy environment," increasing its service. These changes will enable participating FQHCs to more investment in community health programs. fully and sustainably integrate behavioral health, social services, and community partnerships. $ Consider opportunities to employ global budgets to enable integrated models of health and social care. Examples include the following: $ The Pennsylvania Rural Health Model, which provides rural hospitals with an annual global budget based on patient volume, revenue, and services instead of payment for each service provided, and enables support for food access, transportation, or health literacy. $ The Community Health Access and Rural Transformation (CHART) Model, also designed specifically for rural communities. $ Provide incentives and support for participation in APMs, especially for independent primary care practices that serve Medi-Cal enrollees. $ See additional national recommendations from the Health Care Payment Learning & Action Network (HCPLAN). Primary Care's Essential Role in Advancing Health Equity for California 31 EXAMPLE SELECTED EXAMPLES OF RELEVANT POLICIES OPTIONS TO RECOMMENDATION AND PROGRESS IN CALIFORNIA ADVANCE PROGRESS Data collection, measurement, and reporting Carefully collect accurate, $ The California Health and Human Services Agency has devel- $ Increase training and incentives for health programs and provid- self-identified electronic oped a statewide data exchange framework that will require ers to collect REaL (race, ethnicity, and language) and SOGI health record data on health care entities to share health information including (sexual orientation and gender identity) data. race and ethnicity, sexual demographic data, race/ethnicity, ancestry, language, sexual $ Update race/ethnicity data fields to more specifically repre- orientation, gender orientation, gender identity, and disability data by 2024. sent California's population; for example, separate and create identity, language profi- $ Covered California's equity and disparity reduction plan contrac- additional categories within Asian, Native Hawaiian, and Pacific ciency, and disability as tually requires qualified health plans to collect demographic Islander groupings. an important first step to data, specifically race and ethnicity, and language preference. In providing whole-person, $ Standardize the data collected across payers and providers. 2023, Covered California implemented financial penalties tied to equitable care and improv- disparities reduction. $ Purchasers and plans can tie performance guarantees to equity ing provider-patient measures. For example, JPMorgan and Kaiser Permanente plan to concordance for diverse $ The California Association of Public Hospitals and Health Systems roll out performance guarantees tied to health equity on certain Californians. (CAPH) saw large increases in hospital system ability to collect quality measures for JPMorgan employees beginning in 2023. and report REaL (race, ethnicity, and language), sexual orienta- tion, and gender identity data through financial incentives in the Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program. Some systems were even able to leap from zero collec- tion to almost 100% REaL data percentages in five years. Incorporate measures on $ DHCS has expanded provision of community supports to help $ Support California providers to improve data collection, strati- equity and social needs in address identified social needs using Community Supports. fication, and analysis. Assistance and support should be made data collection for clini- Through its Comprehensive Quality Strategy and Population available statewide and through existing regional and local cal, quality improvement, Health Management (PHM) Initiative, DHCS is working toward networks and HIEs to ensure that primary care data collection and research purposes. requiring Medi-Cal managed care plans to have a PHM strategy efforts are part of broader infrastructure development efforts to Collect and stratify data on that includes the collection of social determinants of health data strengthen clinical, public health, and social sector data sharing. social needs to identify and and to increase data collection for social needs and inclusion of $ The National Quality Forum (NQF) convened a multistake- document health inequities. social needs data in the risk stratification process. holder group, the Measure Applications Partnership (MAP), to $ The National Committee for Quality Assurance (NCQA) and provide consensus-based recommendations for the selection Covered California are requiring select measures, deemed to and removal of measures from federal quality and performance be highly correlated with equity, to be reported stratified by programs. NCQA is expanding the race and ethnicity strati- race and ethnicity starting in 2022. The measures are colorec- fication to eight HEDIS measures in measurement year 2023, tal cancer screening, controlling high blood pressure, diabetes bringing the total number of stratified measures to 13. Other HbA1c control, and childhood immunization status (combo 10). large-scale health or accreditation programs could emulate this work by requiring that select measures be reported stratified by race and ethnicity or other demographic variables. California Health Care Foundation www.chcf.org 32 EXAMPLE SELECTED EXAMPLES OF RELEVANT POLICIES OPTIONS TO RECOMMENDATION AND PROGRESS IN CALIFORNIA ADVANCE PROGRESS Use quality improvement $ A growing number of medical schools and health professional $ California plans, providers, and policymakers can accelerate approaches to identify training programs are teaching "structural competency," which efforts to translate existing resources into action by support- and analyze root causes of builds on existing cultural competency and cultural humility ing regional and local networks of clinical providers to embed identified inequities in the training efforts to situate an understanding of social deter- equity in primary care–based quality improvement efforts. clinical setting. minants of health in a structural context. By helping the next $ California plans, providers, and policymakers can implement the generation of clinicians understand how unjust social structures standards and recommendations from national organizations. lead to harm and inequities, this approach can help inform For example: and improve quality improvement approaches that attempt to address root causes of health inequities and poor outcomes. $ NCQA has developed Health Equity Accreditation and Health Equity Accreditation Plus programs. NCQA also adopted new $ Equity and Quality at Independent Practices in LA County disparities reduction and health equity requirements, includ- (EQuIP LA) is a two-year quality improvement collaborative for ing standards for completion of REaL data in HEDIS, into other small, independent primary care practices and IPAs serving recognition and certification programs, including the Patient- Medi-Cal enrollees of color in Los Angeles County. The program Centered Medical Home (PCMH) Recognition program and is a joint project of Purchaser Business Group on Health's Population Health Program Accreditation. California Quality Collaborative, the California Health Care Foundation, Community Partners, Health Net, and L.A. Care $ In 2022, the Joint Commission published new requirements to Health Plan. reduce health care disparities. $ Additional resources on this topic include the following: $ California policymakers, training organizations, and funders can expand training and technical assistance opportunities to help $ A Toolkit to Advance Racial Health Equity in Primary Care quality improvement leaders in primary care and health plans Improvement, which includes tips and recommendations for develop structural competency to strengthen quality improve- implementing upstream, equity-focused quality improvement ment efforts. approaches. $ The California Improvement Network curates a collection of tools, insights, and strategies to center equity into clinical quality improvement efforts in primary care. $ In Spring 2023, the American Medical Association will publish freely accessible, online continuing education modules to help clinicians and caregivers develop core competencies and skills in upstream quality improvement as well as structural compe- tency. Notes: ACO is accountable care organization. CalAIM is California Advancing and Innovating Medi-Cal. CalPERS is California Public Employees' Retirement System. CMS is Centers for Medicare & Medicaid Services. FQHC is Federally Qualified Health Center. HEDIS is Healthcare Effectiveness Data and Information Set. HMO is health maintenance organization. LGBTQ is lesbian, gay, bisexual, transgender, and questioning and/ or queer. Sources: Brian Park et al., "Revisiting Primary Care's Critical Role in Achieving Health Equity: Pisacano Scholars' Reflections from Starfield Summit II," Journal of the American Board of Family Medicine 31, no. 2 (Mar. 2018): 292–302; Azza Eissa et al., "Implementing High-Quality Primary Care Through a Health Equity Lens," Annals of Family Medicine 20, no. 2 (Mar.–Apr. 2022): 164–69; Braden O'Neill et al., "Improving Equity Through Primary Care: Proceedings of the 2019 Toronto International Conference on Quality in Primary Care," Annals of Family Medicine 18, no. 4 (July 2020): 364–69; Rishi Manchanda, Sadena Thevarajah, and Sara Bader, Health Equity Strategies from the Accountable Health Communities Model, HealthBegins and Mathematica, June 21, 2022; Rishi Manchanda, Roza Do, and Nasaura Miles, A Toolkit to Advance Racial Health Equity in Primary Care Improvement, California Health Care Foundation, April 2022; Larry McNeely et al., Primary Care: A Key Lever to Advance Health Equity, Primary Care Collaborative, May 2022; "Health Equity System Transformation Project: Fact Sheets," California Pan-Ethnic Health Network, January 18, 2019; Cary Sanders et al., Centering Equity in Health Care Delivery and Payment Reform: A Guide for California Policymakers, California Pan-Ethnic Health Network, December 4, 2020; and Meeting the Demand for Health: Final Report of the California Future Health Workforce Commission (PDF), California Future Health Workforce Commission, February 2019. Primary Care's Essential Role in Advancing Health Equity for California 33 Endnotes 1. Len Finocchio, James Paci, and Matthew Newman, Medi-Cal "Medicaid Managed Care in Florida and Racial and Ethnic Facts and Figures: Essential Source of Coverage for Millions, Disparities in Preventable Emergency Department Visits," California Health Care Foundation, August 2021. Medical Care 56, no. 6 (June 2018): 477–483; and Jonathan C. Hong et al., "Care Management to Reduce Disparities and 2. According to statistics provided in Finocchio, Paci, and Control Hypertension in Primary Care: A Cost-Effectiveness Newman, Medi-Cal Facts and Figures; and "QuickFacts: Analysis," Medical Care 56, no. 2 (Feb. 2018): 179–85. California," US Census Bureau, accessed February 23, 2023. 8. Starfield, Shi, and Macinko, "Contribution of Primary Care"; 3. Barbara Starfield, Leiyu Shi, and James Macinko, Mulyanto, Kunst, and Kringos, "The Contribution of Service "Contribution of Primary Care to Health Systems and Density"; Robert L. Phillips Jr. and Andrew W. Bazemore, Health," Milbank Quarterly 83, no. 3 (Sept. 2005): 457–502; "Primary Care and Why It Matters for U.S. Health System Leiyu Shi et al., "Primary Care, Social Inequalities, and All- Reform," Health Affairs (Millwood) 29, no. 5 (May 2010): 806– Cause, Heart Disease, and Cancer Mortality in US Counties, 10; and Kerr L. White, "Primary Medical Care for Families 1990," American Journal of Public Health 95, no. 4 (Apr. - Organization and Evaluation," New England Journal of 1, 2005): 674–80; Barbara Starfield et al., "The Effects of Medicine 277, no. 16 (Oct. 19, 1967): 847–52. Specialist Supply on Populations' Health: Assessing the Evidence," Health Affairs (Millwood) 24, suppl. 1 web 9. Starfield, Shi, and Macinko, "Contribution of Primary Care"; exclusives (Jan.–June 2005): W5-97–107; Joko Mulyanto, Molla S. Donaldson et al., eds., Primary Care: America's Anton E. Kunst, and Dionne S. Kringos, "The Contribution of Health in a New Era (Washington, DC: National Academy Service Density and Proximity to Geographical Inequalities Press, 1996); and Edward H. Wagner et al., "Improving in Health Care Utilisation in Indonesia: A Nation-Wide Chronic Illness Care: Translating Evidence into Action," Multilevel Analysis" (PDF), Journal of Global Health 10, no. Health Affairs (Millwood) 20, no. 6 (Nov./Dec. 2001): 64–78. 2 (Dec. 2020): 020428; Sanjay Basu et al., "Estimated Effect 10. Barbara Starfield, Primary Care: Balancing Health Needs, of Increased Diagnosis, Treatment, and Control of Diabetes Services, and Technology (New York: Oxford University Press, and Its Associated Cardiovascular Risk Factors Among Low- 1998). Income and Middle-Income Countries: A Microsimulation Model," Lancet 9, no. 11 (Nov. 2021): E1539–52. 11. Barbara Starfield, Primary Care: Balancing Health Needs, Services, and Technology (New York: Oxford University Press, 4. Frank L. Farmer et al., "Poverty, Primary Care and Age- 1998); and Donaldson et al., Primary Care. Specific Mortality," Journal of Rural Health 7, no. 2 (Mar. 1991): 153–69; Leiyu Shi, "Primary Care, Specialty Care, 12. McCauley et al., Implementing High-Quality Primary Care; and Life Chances," International Journal of Health Services Larry McNeely et al., Primary Care: A Key Lever to Advance 24, no. 3 (1994): 431–58; and Denis J. Pereira Gray et al., Health Equity, Primary Care Collaborative, May 2022; David "Continuity of Care with Doctors - a Matter of Life and M. Levine, Bruce E. Landon, and Jeffrey A. Linder, "Quality Death? A Systematic Review of Continuity of Care and and Experience of Outpatient Care in the United States Mortality," BMJ Open 8, no. 6 (June 28, 2018): e021161. for Adults with or Without Primary Care," JAMA Internal Medicine 179, no. 3 (2019): 363–72; Starfield, Primary Care; 5. Ann S. O'Malley et al., "Continuity of Care and the Use Donaldson et al., Primary Care; James Macinko, Barbara of Breast and Cervical Cancer Screening Services in a Starfield, and Leiyu Shi, "The Contribution of Primary Care Multiethnic Community," Archives of Internal Medicine 157, Systems to Health Outcomes Within Organization for no. 13 (July 14, 1997): 1462–70. Economic Cooperation and Development (OECD) Countries, 6. David M. Levine, Jeffrey A. Linder, and Bruce E. Landon, 1970–1998," Health Services Research 38, no. 3 (June "Characteristics of Americans with Primary Care and Changes 2003): 831–65; L. Shi et al., "Primary Care, Social Inequalities over Time, 2002-2015," JAMA Internal Medicine 180, no. 3 and All-Cause, Heart Disease and Cancer Mortality in U.S. (Mar. 1, 2020): 463–66; and Bruce Guthrie et al., "Continuity Counties: A Comparison Between Urban and Non-Urban of Care Matters," BMJ 337 (Aug. 7, 2008): a867; Sarah Klein Areas," Public Health 119, no. 8 (Aug. 2005): 699–710; and Martha Hostetter, The Room Where It Happens: The Starfield et al., "The Effects of Specialist Supply"; D. S. Role of Primary Care in the Next Phase of the COVID-19 Kringos et al., "The Contribution of Primary Care to Health Vaccination Campaign, Commonwealth Fund, July 7, 2021. Care System Performance in Europe," in The Strength of Primary Care in Europe, ed. D. S. Kringos (Utrecht, 7. "Chapter 2. What Is Care Coordination?," in Kathryn M. Netherlands: Nivel, 2012); and Sanjay Basu et al., "Estimated McDonald et al., Care Coordination Measures Atlas Update, Effect on Life Expectancy of Alleviating Primary Care Agency for Healthcare Research and Quality, last reviewed Shortages in the United States," Annals of Internal Medicine June 2014; Tianyan Hu, Karoline Mortensen, and Jie Chen, 174, no. 7 (July 2021): 920–26. California Health Care Foundation www.chcf.org 34 13. Robert L. Phillips, "Implementing High-Quality Primary 23. Megan Thomas and Allison Valentine, Health Disparities by Care: To What End?," Annals of Family Medicine 20, Race and Ethnicity in California: Pattern of Inequity (PDF), no. 2 (Mar.–Apr. 2022): 107–8; John S. Millis et al., The California Health Care Foundation, October 2021. Graduate Education of Physicians: The Report of the 24. Thomas and Valentine, Health Disparities by Race and Citizens Commission on Graduate Medical Education (PDF), Ethnicity. American Academy of Family Physicians Foundation, August 1, 1966; Primary Health Care: Report of the International 25. Braveman et al., "Systemic and Structural Racism." Conference on Primary Health Care, Alma-Ata, USSR, 6-12 26.Starfield, Primary Care; Donaldson et al., Primary Care; and September 1978, World Health Organization, 1978; and Camara Phyllis Jones, "Confronting Institutionalized Racism," Donaldson et al., Primary Care. Phylon 50, no. 1/2 (2002): 7–22. 14. Paula A. Braveman et al., "Systemic and Structural Racism: 27."Our Approach to Health Equity," California Health Care Definitions, Examples, Health Damages, and Approaches to Foundation, March 23, 2022. Dismantling," Health Affairs (Millwood) 41, no. 2 (Feb. 2022): 171–78. 28."Health Equity," World Health Organization, accessed February 9, 2023. 15. Cary Sanders et al., Centering Equity in Health Care Delivery and Payment Reform: A Guide for California Policymakers, 29. Paula Braveman, "A New Definition of Health Equity to California Pan-Ethnic Health Network, December 4, 2020. Guide Future Efforts and Measure Progress," Health Affairs Forefront [blog], June 22, 2017. 16. Joseph R. Betancourt and Roderick K. King, "Unequal Treatment: The Institute of Medicine Report and Its Public 30.Starfield, Primary Care; Donaldson et al., Primary Care; Health Implications," Public Health Reports 118, no. 4 "Patient Centered Medical Home (PCMH)," Agency for (July–Aug. 2003): 287–92; Chloë FitzGerald and Samia Hurst, Healthcare Research and Quality (AHRQ), last reviewed "Implicit Bias in Healthcare Professionals: A Systematic August 2022; and "The 7 Joint Principles of the PCMH," Review," BMC Medical Ethics 18, no. 1 (Mar. 1, 2017): 19; AmeriHealth Caritas, accessed February 9, 2023. and Linda Cummings, Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good 31. Kurt C. Stange and Robert L. Ferrer, "The Paradox of Primary Health, California Health Care Foundation, October 2022. Care," Annals of Family Medicine 7, no, 4 (July 2009): 293–99. 17. Azza Eissa et al., "Implementing High-Quality Primary Care Through a Health Equity Lens," Annals of Family Medicine 32. Patient Aligned Care Team (PACT)," U.S. Department 20, no. 2 (Mar.–Apr. 2022): 164–69; Elizabeth R. Wolf et al., of Veterans Affairs, 2022; and "Resources – PACT," U.S. "Caregiver and Clinician Perspectives on Missed Well-Child Department of Veterans Affairs, 2022. Visits," Annals of Family Medicine 18, no. 1 (Jan. 2020): 33."VA PACT Improves Outcomes," Center for Health Equity 30–34; and Cummings, Listening to Black Californians. Research and Promotion, 2017; and "Patient Aligned Care," 18. Alana Pfeffinger et al., Recovery with Limited Progress: U.S. Department of Veterans Affairs. Impact of California Proposition 209 on Racial/Ethnic 34. "Patient Aligned Care," U.S. Department of Veterans Affairs. Diversity of California Medical School Matriculants, 1990 to 2019, Healthforce Center at UCSF, December 9, 2020; 35."Veterans," CA Census 2020, 2020; and Fact Sheet: and Janet M. Coffman, Emmie Calimlim, and Margaret Fix, Homelessness in California (PDF), California State Senate California Physicians: A Portrait of Practice (PDF), California Housing Committee, May 2021. Health Care Foundation, March 2021. 36. M. Olenick, M. Flowers, V.J. Diaz, "US Veterans and 19. Len Finocchio, et all, Medi-Cal Facts and Figures, California Their Unique Issues: Enhancing Health Care Professional Health Care Foundation, August 2021. Awareness," Advances in Medical Education and Practice 6, (2015): 635–9. 20."Medicaid-to-Medicare Fee Index," KFF (Kaiser Family Foundation), 2019. 37."Veterans Health Administration - Patient Aligned Care Team (PACT)," Primary Care Collaborative, 2019; and "Resources – 21. Dulce Gonzalez et al., Racial, Ethnic, and Language PACT," U.S. Department of Veterans Affairs. Concordance Between Patients and Their Usual Health Care Providers, Urban Institute, March 23, 2022. 38. "Veterans Health," Primary Care Collaborative; and 22. Tiffany N. Ford and Jamila Michener, "Medicaid 39. "Resources – PACT," U.S. Department of Veterans Affairs; Reimbursement Rates Are a Racial Justice Issue," To the and "Veterans Health," Primary Care Collaborative. Point (the Commonwealth Fund blog), June 16, 2022; and 40. A. VanderZanden et al., "What Does Community-Oriented Michael Wilkes and David Schriger, "Op-Ed: Why Won't UC Primary Health Care Look Like? Lessons from Costa Rica," Clinics Serve Patients with State-Funded Health Insurance?," The Commonwealth Fund, March 16, 2021; and M. Pesec, H. Los Angeles Times, April 4, 2022. Ratcliffe, A. Bitton, Building a Thriving Primary Health Care System: The Story of Costa Rica (PDF), Ariadne Labs, 2017. Primary Care's Essential Role in Advancing Health Equity for California 35 41. VanderZanden et al., "What Does;" and Pesec, Ratcliffe, Alberga Machado et al., "Effective Interventions to Bitton, Building a Thriving. Increase Routine Childhood Immunization Coverage in Low Socioeconomic Status Communities in Developed Countries: 42. VanderZanden et al., "What Does." A Systematic Review and Critical Appraisal of Peer-Reviewed 43. Community Health Center Chartbook, National Association Literature," Vaccine 39, no. 22 (May 21, 2021): 2938–64; and of Community Health Centers, 2022; "What is a Health Ann S. O'Malley and Christopher B. Forrest, "Immunization Center?," Health Resources & Services Administration, 2021; Disparities in Older Americans: Determinants and Future and "About Us," California Primary Care Association, 2021. Research Needs," American Journal of Preventive Medicine 31, no. 2 (Aug. 2006): 150–58. 44. "What is a Health," Health Resources & Services Administration. 55. R. L. Williams, S. A. Flocke, and K. C. Stange, "Race and Preventive Services Delivery Among Black Patients and 45. Community Health Centers 2021 State Profile (PDF), White Patients Seen in Primary Care," Medical Care 39, no. California Primary Care Association, 2021. 11 (Nov. 2001): 1260–67. 46. Community Health, National Association of Community 56. Levine, Linder, and Landon, "Characteristics of Americans Health Centers. with Primary Care." 47. Community Health, National Association of Community 57. Karen Barnett et al., "Epidemiology of Multimorbidity Health Centers. and Implications for Health Care, Research, and Medical 48. Macinko, Starfield, and Shi, "The Contribution of Primary Education: A Cross-Sectional Study," Lancet 380, no. 9836 Care Systems"; Shi et al., "Primary Care, Social Inequalities," (July 7, 2012): 37–43. Public Health; Starfield et al., "The Effects of Specialist 58. Shreya Kangovi et al., "Effect of Community Health Worker Supply"; Kringos et al., "The Contribution of Primary Care"; Support on Clinical Outcomes of Low-Income Patients Across and Basu et al., "Estimated Effect on Life Expectancy." Primary Care Facilities: A Randomized Clinical Trial," JAMA 49. Shi et al., "Primary Care, Social Inequalities," Public Health. Internal Medicine 178, no. 12 (Dec. 1, 2018): 1635–43. 50. Sanjay Basu et al., "Association of Primary Care Physician 59. Nadia Islam et al., "Integrating Community Health Supply with Population Mortality in the United States, 2005- Workers Within Patient Protection and Affordable Care Act 2015," JAMA Internal Medicine 179, no. 4 (Feb. 18, 2019): Implementation," Journal of Public Health Management and 506–14; James Macinko, Barbara Starfield, and Leiyu Shi, Practice 21, no. 1 (Jan.–Feb. 2015): 42–50; and Sonali Saluja "Quantifying the Health Benefits of Primary Care Physician et al., "Community-Based Health Care Navigation's Impact Supply in the United States," International Journal of Health on Access to Primary Care for Low-Income Latinos," Journal Services 37, no. 1 (2007): 111–26; L. Shi et al., "Income of the American Board of Family Medicine 35, no. 1 (Jan.– Inequality, Primary Care, and Health Indicators," Journal Feb. 2022): 44–54. of Family Practice 48, no. 4 (Apr. 1999): 275–84; Barbara 60. Ann S. O'Malley et al., "Disentangling the Linkage of Primary Starfield, "Primary Care and Health: A Cross-National Care Features to Patient Outcomes: A Review of Current Comparison," JAMA 266, no. 16 (Oct 23, 1991): 2268–71; Literature, Data Sources, and Measurement Needs," Journal and Benson S. Ku and Benjamin G. Druss, "Associations of General Internal Medicine 30, suppl. 3 (Aug. 2015): Between Primary Care Provider Shortage Areas and County- 576–85. Level COVID-19 Infection and Mortality Rates in the USA [letter]," Journal of General Internal Medicine 35, no. 11 61. Farmer et al., "Poverty, Primary Care and Age-Specific (Nov. 2020): 3404–5; and Basu et al., "Estimated Effect on Mortality"; Shi, "Primary Care, Specialty Care, and Life Life Expectancy." Chances"; and Pereira Gray et al., "Continuity of Care with Doctors." 51. Barbara Starfield, "Primary Care and Equity in Health: The Importance to Effectiveness and Equity of Responsiveness 62. O'Malley et al., "Continuity of Care." to Peoples' Needs," Humanity & Society 33, no. 1–2 (Feb. 63. Levine, Linder, and Landon, "Characteristics of Americans 2009): 56–73. with Primary Care"; and Guthrie et al., "Continuity of Care 52. J. Basu and C. Clancy, "Racial Disparity, Primary Care, and Matters." Specialty Referral," Health Services Research 36, no. 6 pt. 2 64. Andrew B. Bindman, Arpita Chattopadhyay, and Glenna M. (Dec. 2001): 64–77; and Starfield, "Primary Care and Equity Auerback, "Medicaid Re-Enrollment Policies and Children's in Health." Risk of Hospitalizations for Ambulatory Care Sensitive 53. Basu et al., "Estimated Effect on Life Expectancy." Conditions," Medical Care 46, no. 10 (Oct. 2008): 1049–54. 54. Levine, Linder, and Landon, "Characteristics of Americans 65. Sarah Klein and Martha Hostetter, The Room Where It with Primary Care"; Ann S. O'Malley et al., "Disparities Happens: The Role of Primary Care in the Next Phase of the Despite Coverage: Gaps in Colorectal Cancer Screening COVID-19 Vaccination Campaign, Commonwealth Fund, Among Medicare Beneficiaries," Archives of Internal July 7, 2021. Medicine 165, no. 18 (Oct. 10, 2005): 2129–35; Amanda California Health Care Foundation www.chcf.org 36 66. Ann S. O'Malley et al., "The Role of Trust in Use of Preventive 76. Katherine Sanchez et al., Enhancing the Delivery of Services Among Low-Income African-American Women," Health Care: Eliminating Health Disparities Through a Preventive Medicine 38, no. 6 (June 2004): 777–85; Mickeal Culturally & Linguistically Centered Integrated Health Care Pugh Jr. et al., "Racism, Mental Health, Healthcare Provider Approach: Consensus Statements and Recommendations, Trust, and Medication Adherence Among Black Patients in US Department of Health and Human Services, Office of Safety-Net Primary Care," Journal of Clinical Psychology in Minority Health and Hogg Foundation for Mental Health, Medical Settings 28, no. 1 (Mar. 2021): 181–90; Yendelela June 2012. L. Cuffee et al., "Reported Racial Discrimination, Trust in 77."Chapter 2: The State of Health Disparities in the United Physicians, and Medication Adherence Among Inner-City States," in Communities in Action: Pathways to Health African Americans with Hypertension," American Journal of Equity, James N. Weinstein et al., eds. (Washington, DC: Public Health 103, no. 11 (Nov. 2013): e55–62; and Vanessa National Academies Press, 2017), 57–97. B. Sheppard, Ruth E. Zambrana, and Ann S. O'Malley, "Providing Health Care to Low-Income Women: A Matter of 78. Kurt C. Stange, "The Generalist Approach," Annals of Family Trust," Family Practice 21, no. 5 (Oct. 2004): 484–91. Medicine 7, no. 3 (May 2009): 198–203; Starfield, Primary Care; and Starfield, Shi, and Macinko, "Contribution of 67. "Chapter 2. What Is Care Coordination?," in McDonald et al. Primary Care." 68.Starfield, Primary Care. 79.Starfield, Primary Care; Donaldson et al., Primary Care; and 69. Roger Anderson, Angela Barbara, and Steven Feldman, Wagner et al., "Improving Chronic Illness Care." "What Patients Want: A Content Analysis of Key Qualities 80. Leiyu Shi et al., "Racial and Socioeconomic Disparities That Influence Patient Satisfaction," Journal of Medical in Access to Primary Care Among People with Chronic Practice and Management 22, no. 5 (Mar–Apr. 2007): Conditions," Journal of the American Board of Family 255–61. Medicine 27, no. 2 (Mar.–Apr. 2014): 189–98; Levine, Linder, 70.Starfield, Primary Care. and Landon, "Characteristics of Americans with Primary Care"; Starfield, Primary Care; Donaldson et al., Primary 71. Hu, Mortensen, and Chen, "Medicaid Managed Care in Care; "Patient Centered Medical Home," AHRQ; "The 7 Florida"; and Hong et al., "Care Management to Reduce Joint Principles," AmeriHealth Caritas; Laura C. Pinheiro Disparities." et al., "Healthcare Fragmentation and Cardiovascular Risk 72. Starfield, Shi, and Macinko, "Contribution of Primary Care"; Control Among Older Cancer Survivors in the Reasons for Kringos et al., "The Contribution of Primary Care"; Phillips Geographic and Racial Differences in Stroke (REGARDS) Jr. and Bazemore, "Primary Care and Why It Matters"; Study," Journal of Cancer Survivorship 15, no. 2 (Apr. 2021): White, "Primary Medical Care for Families"; Albert Lee et al., 325–32; Lisa M. Kern et al., "Healthcare Fragmentation and "Improving Health and Building Human Capital Through an the Frequency of Radiology and Other Diagnostic Tests: A Effective Primary Care System," Journal of Urban Health 84, Cross-Sectional Study," Journal of General Internal Medicine no. 3 suppl (May 2007): i75–85; and Barbara Starfield, "State 32, no. 2 (Feb. 2017): 175–81; and Lisa M. Kern et al., of the Art in Research on Equity in Health," Journal of Health "Fragmented Ambulatory Care and Subsequent Healthcare Politics, Policy and Law 31, no. 1 (Feb. 2006): 11–32. Utilization Among Medicare Beneficiaries," American Journal of Managed Care 24, no. 9 (Sept. 1, 2018): e278–84. 73. Starfield, Shi, and Macinko, "Contribution of Primary Care"; Kringos et al., "The Contribution of Primary Care"; Phillips 81. Ana L. Hincapie et al., "Relationship Between Patients' Jr. and Bazemore, "Primary Care and Why It Matters"; Lee Perceptions of Care Quality and Health Care Errors in 11 et al., "Improving Health and Building Human Capital"; and Countries: A Secondary Data Analysis," Quality Management Susan Wilhelmsson and Malou Lindberg, "Prevention and in Health Care 25, no. 1 (Jan.–Mar. 2016): 13–21. Health Promotion and Evidence-Based Fields of Nursing – A 82. Joel J. Alpert and Evan Charney, The Education of Physicians Literature Review," International Journal of Nursing Practice for Primary Care (PDF), US Department of Health, Education, 13, no. 4 (Aug. 2007): 254–65. and Welfare Public Health Service, Autumn 1973; Leiyu Shi 74.Starfield, Shi, and Macinko, "Contribution of Primary Care"; et al., "Vulnerability and the Patient-Practitioner Relationship: Kringos et al., "The Contribution of Primary Care"; Phillips The Roles of Gatekeeping and Primary Care Performance," Jr. and Bazemore, "Primary Care and Why It Matters"; and American Journal of Public Health 93, no. 1 (Jan. 2003): White, "Primary Medical Care for Families." 138–44; and Starfield, Primary Care. 75. Ana J. Bridges et al., "Does Integrated Behavioral Health 83. Jessica Valente et al., "Importance of Communication and Care Reduce Mental Health Disparities for Latinos? Initial Relationships: Addressing Disparities in Hospitalizations Findings," Journal of Latino/a Psychology 2, no. 1 (Feb. for African-American Patients in Academic Primary Care," 2014): 37–53. Journal of General Internal Medicine 35, no. 1 (Jan. 2020): 228–36. Primary Care's Essential Role in Advancing Health Equity for California 37 84. Marshall H. Chin, "Advancing Health Equity in Patient Safety: 96. Paul J. Wallace et al., Primary Care and Public Health: A Reckoning, Challenge and Opportunity," BMJ Quality & Exploring Integration to Improve Population Health Safety 30, no. 5 (May 2021): 356–61. (Washington, DC: National Academies Press, 2012). 85.Patrick O'Donnell et al., "Exploring Levers and Barriers to 97. J. Lloyd Michener et al., eds., The Practical Playbook: Accessing Primary Care for Marginalised Groups and Public Health and Primary Care Together (New York: Oxford Identifying Their Priorities for Primary Care Provision: University Press, 2016). A Participatory Learning and Action Research Study," 98. Janice Genevro et al., "Six Steps to Better Integrate International Journal for Equity in Health 15, no. 1 (Dec. 3, Primary Care and Public Health in the Wake of COVID-19," 2016): 197. Mathematica Blog, June 14, 2021. 86. Lord Dawson of Penn, "Medicine and the State. The 99."Quick COVID-19 Survey," The Larry A. Green Center, Presidential Address to the Section of State Medicine in the accessed February 15, 2023. Brussels Congress of the Royal Institute of Public Health, May, 1920," British Medical Journal 1, no. 3100 (May 29, 100. McCauley et al., Implementing High-Quality Primary Care, 1920): 743–45. 8–9. 87. Millis et al., The Graduate Education of Physicians. 101. Primary Care Investment Coordinating Group of California Guiding Principles and Recommended Actions (PDF), 88. Declaration of Alma-Ata [International Conferencee on California Health Care Foundation, April 2022; and Primary Health Care: Alma-Ata, USSR, 6–12 September Consensus Recommendations on Increasing Primary Care 1978], World Health Organization, 1978; and Declaration Investment, Primary Care Collaborative, August 2018. of Astana [Global Conference on Primary Health Care: Astana, Kazakhstan, 25–26 October 2018], World Health 102. Daniel E Dawes, The Political Determinants of Health Organization, 2019. (Baltimore, MD: Johns Hopkins University Press, 2020). 89. Rishi Manchanda, "Practice and Power: Community Health 103. Marjory L. Givens et al., "Power: The Most Fundamental Workers and the Promise of Moving Health Care Upstream," Cause of Health Inequity?," Health Affairs Forefront [blog], Journal of Ambulatory Care Management 38, no. 3 (July– February 1, 2018. Sept. 2015): 219–24. 104. "Social Determinants of Health," US Department of Health 90. Brent D. Fulton, "Health Care Market Concentration Trends and Human Services, Office of Disease Prevention and in the United States: Evidence and Policy Responses," Health Health Promotion, accessed February 15, 2023. Affairs (Millwood) 36, no. 9 (Sept. 2017): 1530–38; and 105. McCauley et al., Implementing High-Quality Primary Care. Starfield, Primary Care. 106. Brian Park et al., "Revisiting Primary Care's Critical Role in 91.Starfield, Primary Care. Achieving Health Equity: Pisacano Scholars' Reflections 92. Melanie Hanson, "Average Medical School Debt," Education from Starfield Summit II," Journal of the American Board of Data Initiative, updated November 22, 2022; Reform of Family Medicine 31, no. 2 (Mar. 2018): 292–302; Eissa et al., the Dysfunctional Healthcare Payment and Delivery System "Implementing High-Quality Primary Care"; Braden O'Neill (PDF), American College of Physicians, 2006; and Allan H. et al., "Improving Equity Through Primary Care: Proceedings Goroll et al., "Fundamental Reform of Payment for Adult of the 2019 Toronto International Conference on Quality Primary Care: Comprehensive Payment for Comprehensive in Primary Care," Annals of Family Medicine 18, no. 4 (July Care," Journal of General Internal Medicine 22, no. 3 (Mar. 2020): 364–69; Rishi Manchanda, Sadena Thevarajah, and 2007): 410–15. Sara Bader, Health Equity Strategies from the Accountable Health Communities Model, HealthBegins and Mathematica, 93.Spending on Primary Care: First Estimates (PDF), Organisation June 21, 2022; Rishi Manchanda, Roza Do, and Nasaura for Economic Co-operation and Development (OECD), Miles, A Toolkit to - Advance Racial Health Equity in Primary December 2018. Care Improvement, California Health Care Foundation, 94. Michael E. Johansen, Sheetal M. Kircher, and Timothy R. April 2022; McNeely et al., Primary Care; "Health Equity Huerta, "Reexamining the Ecology of Medical Care," New System Transformation Project: Fact Sheets," California England Journal of Medicine 374, no. 5 (Feb. 4, 2016): Pan-Ethnic Health Network, January 18, 2019; Sanders et 495–96; and Spending on Primary Care, OECD. al., Centering Equity in Health Care Delivery; and Meeting the Demand for Health: Final Report of the California Future 95. Goroll et al., "Fundamental Reform of Payment"; and Health Workforce Commission (PDF), California Future Thomas Bodenheimer, "Revitalizing Primary Care, Part 1: Health Workforce Commission, February 2019; personal Root Causes of Primary Care's Problems," Annals of Family communication with field experts. Medicine 20, no. 5 (Sept.-Oct. 2022): 464–68. California Health Care Foundation www.chcf.org 38