Translating Spending Targets into Better Healthcare Delivery
Introduction
Over the past several years, a growing number of states have adopted or are actively considering primary care spending targets. These targets are typically associated with familiar aspirations: better access to care, better health outcomes, better management of chronic disease, lower avoidable emergency department utilization, lower avoidable hospital utilization, greater health equity, and better long‑term value from healthcare spending. They are intended to produce a stronger and more effective primary care system.
States that have already set a primary care spending target now face a major task, translating that target into a detailed set of staffing requirements and developing a realistic plan to build that workforce over the next several years. Key Lever 4 (Workforce Development) addresses that question by describing the essential ingredients of an aspirational workforce plan that details the additional primary care capacity the state aspires to and how that capacity will be built in light of the current shortage of primary care clinicians.
The materials reviewed in this report suggest that in many states this translation work is still at an early stage. Much of their currently visible work focuses on maintenance‑level staffing, describing the staffing needed to preserve today’s level of service as populations grow and age. But an aspirational‑level staffing plan needs to specify the additional primary care capacity required to achieve better access, stronger care teams, reduced avoidable hospital and emergency department use, and improved outcomes. That is a more complex process that depends heavily on earlier work on Goals and Objectives (Key Lever 1) and a well-conceived Needs Assessment (Key Lever 2).
The purpose of this report is to clarify how Key Lever 4 fits into the Nine Key Lever framework and to outline the basic elements of an aspirational primary care workforce plan. The goal is to suggest what a strong workforce plan should contain and make it easier for stakeholders to assess a state’s progress toward a complete and realistic workforce development plan, one of the keys to a successful and cost‑effective primary care funding strategy.
The original purpose of this paper was to explain Key Lever 4 Primary Care Workforce in the context of the nine Key Levers depicted in the graphic below and especially in the context of Authorizations, Goals & Objectives (Key Lever 1), The State Primary Care Spending Paradox: best definition vs most ambitious target and Needs Assessment (Key Lever 2). But in researching this article we discovered some anomalies that raise serious questions concerning states’ ability to convert primary care spending targets into a more effective primary care delivery system, as discussed below.
What States Are Doing Now
By our count, sixteen states have adopted or are pursuing primary care spending targets, but far fewer appear to have developed primary care staffing targets. Based on the state materials reviewed to date, seven states stand out as being in more visible stages of workforce planning: California, Texas, Oregon, Massachusetts, Rhode Island, Michigan, and Florida. Their materials include a mix of numerical benchmarks, supply‑demand projections, needs assessments, planning mandates, and shortage estimates.
- California has the clearest numerical benchmark: roughly 10,500 additional primary care providers by 2030.
- Texas has detailed supply‑demand projections.
- Oregon has a workforce needs assessment process that could support workforce planning.
- Massachusetts has a formal primary care task force charged with workforce planning, but no published numerical staffing objective yet.
- Rhode Island is building planning and data capacity but does not yet have a clear staffing plan.
- Michigan and Florida have staffing shortage estimates, but no clear state‑level primary care workforce plans.
Some terminology is useful before proceeding.
- Maintenance‑level staffing refers to the workforce needed to preserve today’s level of service after adjusting for population growth, changing demographics, disease trends, clinician retirements, and workforce attrition. It does not imply improved coverage, better access, or better care.
- Aspirational‑level staffing refers to staffing above the maintenance-level: the additional primary care capacity required to achieve the objectives associated with aspirational spending targets, including improved access, stronger care teams, reduced hospital and emergency department use, and better health outcomes.
Based on the latest information available, only California appears to have something approaching an aspirational staffing benchmark. The other states’ materials consist of a mix of maintenance requirements, supply‑demand projections, needs assessments, planning mandates, and shortage estimates—valuable inputs, but generally oriented toward maintenance‑level rather than aspirational‑level staffing.
Taken together, these observations point to a central question for states that have adopted primary care spending targets. Given the state’s primary care goals and spending target, how much additional primary care capacity can be created, what kinds of clinicians and teams will be needed, and what benefits will that capacity produce for the population?
The Primary Care Definitions Paradox
State primary care planners face a primary care definitions paradox. The narrowest definition will create the greatest financial headroom. But a definition that is broader than the broad AHRQ definition is needed to identify all of the workforce and support components needed to enable primary care organizations at a high level. The workforce requirement cannot be inferred from a primary care spending target alone.
California and Massachusetts illustrate the funding point. California has adopted a 15 percent primary care spending target, which would represent roughly a 25 percent increase in primary care spending based on the way California currently defines primary care. By contrast, the Massachusetts Primary Care Task Force has recommended a 15 percent primary care spending target that would roughly double primary care spending. Two states can therefore adopt the same numerical target and still have very different amounts of financial room for workforce expansion, depending on how they define primary care.
In most states, primary care spending targets are measured using either a narrow or a broad definition of primary care. Under a narrow definition, primary care typically includes a limited set of physician specialties (family medicine, general internal medicine, and general pediatrics) and a short list of office‑based evaluation and management and preventive services. Under a broad definition, primary care usually includes additional clinicians and services, such as nurse practitioners, physician assistants, obstetrician‑gynecologists, behavioral health clinicians, and some primary care infrastructure and team‑based support services. Even AHRQ’s broad definition, however, excludes several categories that are essential for primary care capacity:
- Care management staff: the non‑billing workforce (social workers, care coordinators, community health workers).
- Health IT and EHR systems: the connective tissue of coordinated care.
- Practice infrastructure loans and grants: the physical capacity to see patients.
- Facility construction: FQHCs, rural health clinics, school‑based health centers.
- Workforce pipeline investments: loan forgiveness, residency slots, school‑based training programs.
The narrow and broad definitions of primary care used to measure spending targets are based on national definitions, not staffing blueprints. It would be inappropriate, from a staffing perspective, to restrict workforce planning to only those clinician types and services that “count” under these definitions. For workforce planning, the relevant question is the total staffing required to deliver primary care, including physicians, advanced practice clinicians, behavioral health clinicians, nurses, care managers, community health workers, and other support staff.
So, to recap, if a state uses a broad definition of primary care in connection with its spending target, it will generate a much smaller increase in funding than if the state used a narrow definition. And if workforce planners adhere to a narrow definition for workforce planning purposes, they will have a lot more financial headroom but a lopsided staffing plan that only includes a few physician specialties and no advanced practice clinicians or support staff. That would not make clinical or policy sense.
Key Components of an Aspirational Workforce Plan
An aspirational workforce plan therefore needs to think in terms of care teams, not just individual clinicians. The purpose of additional primary care funding is not simply to increase the number of physicians, but to build teams and support structures that can deliver better access, stronger ongoing relationships, and more effective management of chronic disease. From that perspective, the central questions shift from “How many physicians can we afford?” to “What mix of clinicians and support staff is needed to deliver primary care for the population we intend to serve, and how will we create that mix over time?”
An aspirational staffing objective is only a starting point. To be meaningful, it must be accompanied by a workforce development plan that explains how the state will move from its current workforce to the workforce required to achieve its primary care goals.
Both Ends of the Training Pipeline
As Walter N. Kernan has argued[1], the primary care workforce pipeline has two ends. It is not enough to attract students and trainees into primary care; states must also create conditions that allow them to become and remain practicing clinicians in sustainable primary care roles. A meaningful workforce plan therefore has to address both entry into the pipeline and successful arrival at the destination.
Graduate Medical Education Capacity and Placement
Another important consideration is graduate medical education. For many states, the near-term constraint on physician workforce growth may be less the number of medical students than the number, specialty mix, and distribution of internship and residency positions. A serious workforce plan should therefore consider graduate medical education capacity and placement, including the role of community clinics and health centers as training sites for future primary care clinicians.
Making Primary Care a Preferred Destination
An aspirational workforce plan cannot stop at headcounts. It must also make primary care a more appealing destination of choice for clinicians by reducing friction and improving day‑to‑day work life. From a state leader’s perspective, the question is not just “How many primary care positions do we need?” but also “Why would clinicians choose and remain in those positions?”
- Compensation and career path. Competitive compensation remains necessary, but not sufficient. A workforce plan should describe how primary care clinicians can see a viable long‑term career, including opportunities for leadership roles in team‑based models and population health.
- Team support. Primary care becomes more sustainable when physicians practice at the top of license, supported by advanced practice clinicians, behavioral health specialists, pharmacists, care coordinators, and community health workers. An aspirational plan should specify how teams will evolve, not just how many physicians are needed.
- Administrative burden. Excessive prior authorization requirements, documentation rules, and fragmented payer processes are strong deterrents to primary care careers. The Massachusetts task force, for example, has identified reducing prior authorization and paperwork as important elements of a primary care strategy. A credible workforce plan should state how the state will use its regulatory and purchasing authority to reduce administrative burden.
- Technology and workflow. Information technology and AI‑enabled tools can either add to primary care workload or help manage it. Workforce planning should assume deliberate investment in tools that support panel management, documentation, and care coordination rather than simply adding clicks and inbox messages.
- Work environment. Finally, aspirational staffing requires realistic panel sizes, predictable schedules, and support for mentorship and professional development. If additional funding does not translate into better working conditions, primary care recruitment and retention will remain difficult.
Linking Workforce, Budgets, and Reimbursement
A workforce development plan does not set reimbursement policy on its own, but it cannot ignore the economic and practice assumptions on which its staffing objective depends. Its role is to make those assumptions explicit: the level of compensation, team support, training capacity, and working conditions under which the projected workforce can realistically be recruited and retained—so they can inform the Needs Assessment and Resource Allocation Plan and the reimbursement work that translate them into concrete budgets and payment models. From a budgeting perspective, these workforce assumptions are one input into a broader allocation choice: how to balance spending on compensation with investments in training pipelines, infrastructure, and organizational capacity that make additional staff usable and sustainable.
Taken together, these elements help determine whether a staffing objective is a realistic plan for building additional primary care capacity. The practical question for state leaders is not simply whether more primary care clinicians are needed, but whether the state has identified the key components of a workforce development plan that can realistically produce them.
Key Questions
In order to evaluate a primary care workforce development effort, we would start by asking a few basic questions that are intended to reveal how much progress the workforce development group has made to date.
1. Is this plan aspirational, or just maintenance? Does the workforce plan clearly distinguish between maintenance-level staffing (simply keeping up with population growth and attrition) and staffing tied to the state’s primary care goals?
2. Do we have the right definition of primary care for workforce planning? Is the plan based on a working definition of primary care that gives a complete picture of the staffing required for a high-functioning primary care organization, including team-based care and all relevant clinicians and support functions, rather than on AHRQ’s narrow or broad definition of primary care?
3. Do we have a credible needs estimate and budget? Do we have a quantified estimate of current, maintenance-level, and aspirational-level primary care capacity and staffing by geography and team composition, based on that comprehensive definition of primary care, and do we know roughly what budget would be required to move from where we are now toward that aspirational-level?
4. Do we understand the main obstacles and have a realistic path to deal with them? Are we clear about the main limitations and obstacles to reaching the aspirational-level, including training and graduate medical education capacity, community training sites, practice infrastructure, and the current practice environment, and do we have a plan with concrete steps and near term milestones to address them within the likely budget?
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Mr. Wadsworth has had a career at the intersection of finance, management, and healthcare policy at organizations including IBM, McKinsey & Company, Kidder, Peabody & Co., Blue Cross Blue Shield and the public sector. He is co-founder of the Better Healthcare Policy Group.
[1] Walter N. Kernan, “The Primary Care Workforce Training Pipeline Has Two Ends,” Journal of General Internal Medicine 39, no. 9 (2024)