fter completing Rethinking Primary Care Investment Strategy, it became clear that state-level executives could benefit from a framework to help them organize “a multi-year planning, development, and implementation effort involving numerous public and private sector stakeholders, including payers, providers, employers and NGOs,” as described in Lever 1: Authorizations, Goals and Objectives. The result is nine key levers depicted in the diagram below. This is the third article in the series, following Lever 1 and Lever 2: Needs Assessment & Resource Allocation. This article addresses Lever 3 i.e. the rules and structures that states need to ensure that primary care investment produces durable, mission-aligned results.
Key Points
Consolidation has reshaped who controls primary care in most states. Hospital systems, investor-backed organizations, payer-owned models, and out-of-state corporations now own practices that were once independent, and their priorities are not always aligned with what states expect primary care to accomplish. Governance rules that define acceptable ownership, require clinician control, and condition funding on accountability are prerequisites of a primary care investment strategy intended to revitalize primary care to meet the health needs of the state’s population.
- Governance must address ownership and control. Primary care investment will not achieve its intended results if new funds flow into organizations whose ownership, incentives, or operating priorities are misaligned with the primary care mission.
- States should establish enforceable ownership rules before transactions arise. Those rules should define which buyers, conditions, and ownership structures are acceptable for primary care practices before financial distress or acquisition offers force case-by-case decisions.
- Rules of governance for primary care organizations should require control by primary care clinicians and adequate patient/consumer representation. Funding should be conditioned on meeting those standards and demonstrating continuous improvement over time.
This article also reviews recent state legislation and regulatory activity that may help planners identify practical options for ownership and control safeguards. These examples are not a model statute, but a starting point for state-specific design.