For nearly three decades, PCDC demonstrated the potential of strategic and coordinated investment in primary care, alongside partners, funders, and policymakers. With the opening of our Los Angeles office in 2020, we join a focused effort toward achieving health equity in California. By formally concentrating services — capital investment, technical assistance, and advocacy — in California, PCDC builds on its history of expanding primary care access in low-income, underserved communities throughout the state. PCDC is one of many dedicated organizations working to increase primary care access for all Californians. This collective expertise will help reinforce a shared goal: healthier, more equitable communities.
California Policy Issues
REBALANCING HEALTH CARE SPENDING
Define, measure, report, and increase the proportion of the health care dollar allocated to primary care.
In 2018, California primary care stakeholders introduced AB-2895, the Primary Care Spending Transparency Act. This bill would have required health insurance payers to annually report the proportion of total health care spending allocated to primary care, and would have established a Primary Care Payment Reform Collaborative to advise on best practices for increasing primary care investment. While this bill did not pass, California primary care champions are still working towards increased primary care investment through other means. PCDC supports these efforts as well as the rollout of the California all payer claims database which should provide initial insight into spending on primary care. We strongly believe that California must act to rebalance their health care system by defining, reporting and increasing the amount of health care dollars invested in primary care.
PROTECTING THE 340B DRUG DISCOUNT PROGRAM
Preserve the 340B Drug Pricing Program to protect medically underserved communities.
Governor Newsom’s 2020-2021 budget proposal directs the Department of Health Care Services (DHCS) to transition all pharmacy services for Medi-Cal managed care to Fee For Service (FFS) by January 2021, which could effectively end the savings received through the 340B program and ultimately limit services and access for California’s low-income, vulnerable communities. The 340B Program entitles qualifying entities — Health Resources and Services Administration (HRSA)-supported health centers, AIDS drug assistance programs, and safety net hospitals and providers — to receive discounts on eligible outpatient drugs. Covered entities may provide 340B drugs to all eligible patients, regardless of a patient’s payer status or how the drug is administered. PCDC is gravely concerned about the downstream effects of limiting the 340B program and strongly supports rescinding this proposed policy.
The 340B discounts allow community health centers, critical access hospitals, and other safety net health providers to obtain life-saving medicine at a reduced cost. According to the California Primary Care Association (CPCA), community health centers are projected to lose as much as $150 million in 340B savings after implementation of this policy. Because 340B providers exclusively see the most vulnerable populations, limiting the program will disproportionally impact these already hard-hit communities. PCDC strongly supports policies that safeguard the program and its vital benefits.
RE-FOCUSING DELIVERY SYSTEM TRANSFORMATION ON PRIMARY CARE
Primary care must be a central priority in delivery system transformation efforts.
PCDC supports efforts made in California to transform the health care system, including using 1115 Medicaid Waivers to implement initiatives such as DSRIP. These and other efforts have resulted in promising strategies to advance health care payment and delivery system reform models — ultimately strengthening community health, improving clinical outcomes, and reducing costs. However, the desired transformation can only be accomplished with sufficient, quality primary care that is accessible to all families and communities.
SUPPORTING CALIFORNIANS EXPERIENCING HOMELESSNESS
Ensure that populations experiencing homelessness have a strong connection to essential health services by expanding access to primary care.
Housing and health care are intrinsically linked. Supporting Californians experiencing homelessness does not end with efforts to provide housing alone – it must include ensuring sustained connection to quality health care and services. These efforts begin with increasing access to primary care. California currently has the largest population struggling with homelessness across the country, with about 1 in 4 Americans experiencing homelessness living in California. The homelessness epidemic cannot be solved without a concerted effort to address the health of the population simultaneously. Innovative care models that focus on providing holistic, team-based care, such as the Patient Centered Medical Home (PCMH), are an integral part of addressing the health issues many housing insecure individuals face. Primary care that is both culturally appropriate and integrated with behavioral health services can act as an essential source of support for individuals experiencing homelessness and serve as a link to other social services they might not otherwise be connected to. Primary care is often the first point of contact with the health care system and can prevent, identify, and treat illnesses as well as promote wellness. As the first point-of-contact to the medical system for patients, primary care providers can identify the physical, behavioral and social needs of housing insecure populations and help connect them to necessary services. PCDC strongly encourages increased efforts to ensure that housing and health care access efforts in California go hand in hand to improve the wellbeing of communities struggling with homelessness across the state.
FACILITATING BEHAVIORAL HEALTH INTEGRATION
Streamline integrated facility requirements and create financial incentives for integrated care reimbursement models.
Currently, California does not allow community health centers receiving Medi-Cal reimbursement to bill for and provide physical and mental health visits on the same day. PCDC supports California’s efforts to allow same day billing for both physical and mental health visits. According to the California Future Health Workforce Commission Report in February 2019, approximately 25% of all people seen at community health centers have a diagnosable mental illness. The report also states that traditional primary care physicians have little to no psychiatric training. However, they are often the first point of contact for people with a diagnosable mental illness.
Community health center patients, who frequently face transportation barriers and less flexibility in the workday and arranging for childcare, must have the ability to see a primary care physician and mental health specialist on the same day. This will allow patients to minimize their time away from work, decreases no-show rates for appointments, and maintains both physical and mental health continuity of care. Furthermore, current Medicaid and Medicare billing structures do not allow for reimbursing core integrated care services such as provider consultation time and care team meetings, and value-based payment does not yet fully cover these and other integration costs. Delivery system payment reform must meaningfully adhere to the needs of integrated care models.
STREAMLINING PRIMARY CARE FACILITY REGULATIONS
Reduce the administrative burden associated with meeting primary care facility requirements in order to increase the ability to develop and expand primary care practices.
The licensing and certification process, as currently administered, can be a source of great difficulty and confusion for community clinics and health centers (CCHCs). PCDC supports primary care practices by advocating for reducing the burden of complexity they face and improving the functionality of the licensing and certification process. The licensing and certification process utilizes standards defined in state and federal law and regulations to evaluate health facility compliance and is intended to both ensure public safety at CCHCs. However, the current operational requirements for this process, including construction and safety requirements, are complex, burdensome and lack alignment with the needs of primary care facilities. This barrier deters expansion of existing sites as well as the initiation of the construction of others. It is essential that these construction and safety standards be amended to reflect the type of facility, the needs of the patients served, and the types and levels of services provided.
COMMUNITY DEVELOPMENT FINANCING
Create and protect funding programs that allow for greater investment in and development of underserved communities.
PCDC is one of many Community Development Financial Institutions (CDFIs). CDFIs are private organizations that meet the needs of economically disadvantaged rural and urban communities by addressing challenges through responsible, affordable lending. PCDC supports efforts to expand the critical work of CDFIs in California such as SB 1230, which would establish a California State CDFI Fund to bring investment and resources to low-income communities. Based on the success of the federal CDFI Fund, the replication of the Fund at the state level would bring much needed equity to under-resourced communities in the form of grants and affordable loans. California is already a leader in the CDFI space. This initiative would allow California CDFIs to provide critical capital in low-income and minority communities that might not otherwise be able to access it. With such transformative potential for so many communities, PCDC advocates for the expansion and support of such critical investment programs.
A research brief developed by PCDC examines multiple aspects of primary care access across the state of California. Disparities in access are observed, and a closer analysis of the four largest cities in California reveals further disparities that are aligned with socioeconomic indicators.