States are increasingly focusing on health equity, and in particular racial health equity, as a key priority within their Medicaid programs ― often explicitly building health equity requirements into managed care contracts. Ensuring equitable access to high-quality and comprehensive primary care is central to achieving meaningful progress toward this goal. As a result of structural and interpersonal racism, people of color are more likely than white individuals to face barriers to primary care access, including reporting discrimination within the health system. One opportunity for states to advance more equitable primary care is to set standards for primary care practices by building on a common framework: the patient-centered medical home (PCMH).
PCMH is a care delivery model aimed at providing patient-centered, accessible, coordinated, and comprehensive primary care with a commitment to quality improvement. The fact that state PCMH programs are both widespread and focused on patient needs and preferences, make these programs a strong starting point for developing capabilities to support health equity at the practice level. Moreover, practice-level standards can be complementary to managed care contracting requirements, helping to align efforts to advance equity across the health system.
Setting Health Equity-Focused Primary Care Standards
States can build on the existing PCMH foundation to explicitly make health equity a focus of primary care standards and incentivize practice-level activities aligned with broader state health equity goals. In particular, states can set standards related to the following PCMH components:
- Improved data collection: PCMH programs have long emphasized collecting data to support population health activities, which can also support identifying and addressing disparities across populations. Collection of self-reported data, including data on race, ethnicity, language, disability status, sexual orientation, and gender identity, is critical to understanding inequities and reducing disparities. States may consider both requiring self-reported demographic data collection at the practice level and aligning data collection requirements with broader state and national data standards. For example, NCQA recently proposed enhanced data collection standards for its PCMH certification that would require direct collection of race and ethnicity data from patients, in alignment with Office of Management and Budget categories. At the state level, Rhode Island encourages enhanced data collection among Medicaid accountable care organizations by implementing a pay-for-reporting measure of completeness of race, ethnicity, and language data collected through primary care.
- Quality improvement activities related to reducing health disparities: To turn data collection into action, states may consider requiring practices to use data to identify existing health disparities, set goals for reducing disparities, and develop interventions to achieve health equity goals. While working toward quality improvement goals are central to most PCMH programs, improving quality for the population as a whole does not necessarily reduce disparities within the population. Standards requiring an explicit focus on disparities reduction can address this gap. For example, New York State Patient-Centered Medical Home standards, which build on NCQA standards, require practices to assess and take action to address identified health disparities.
- Access to culturally and linguistically appropriate care: A core tenet of PCMH is supporting access to care the meets patients’ “needs, culture, values, and preferences.” Provision of culturally and linguistically appropriate care is an important aspect of reducing inequitable barriers to and providing high-quality care. As such, states may consider opportunities to strengthen related standards. For example, Oregon’s Patient-Centered Primary Care Home (PCPCH) program requires all practices to offer time-of-service translation to patients in their language of choice, and requires its most advanced practices to offer written materials in “non-English languages spoken by populations served at the clinic.” Ohio’s PCMH program recently implemented standards requiring that all direct care staff participate in cultural competency and implicit bias training.
- Enhanced patient and community engagement and partnership: Engaging patients and communities experiencing disparities is essential to identifying and understanding root causes of health disparities and developing strategies to provide culturally appropriate care. PCMH standards generally require practices to collect patient feedback, but do not necessarily provide guidance on how patient feedback should be used or strategies for developing patient partnerships. To advance health equity, states may consider raising standards for patient engagement, such as requiring practices to partner with patients experiencing disparities and involving patients in quality improvement efforts. As one example, Oregon’s PCPCH program requires its most advanced practices to have a formal mechanism to integrate patient, family, and caregiver advisors into “quality, safety, program development and/or educational improvement activities.” Practices may get further credit toward PCMH recognition for integrating patients into peer support or training roles within the practice.
The practice-level focus and flexibility of the PCMH framework makes it a valuable policy lever for states seeking to advance equity goals. To support successful implementation, it is also essential for states to consider how to adequately support practices in achieving these advanced capabilities, especially practices that have been historically under-resourced and serve marginalized communities. Enhanced payment, technical assistance, and state-level health information technology infrastructure are particularly critical for supporting capacity building. For example, North Carolina Medicaid piloted an initiative that enhanced payments to primary care practices in areas with high poverty rates. California has proposed allocating funds to support providers, including pediatric primary care practices, in developing capabilities to reduce racial and ethnic disparities in care. With adequate supports in place, practice-level standards can be a powerful complement to other states programs and policies to align and advance health equity efforts across the health system.
To further explore PCMHs and other policy levers to support advanced primary care, see CHCS’ Advancing Primary Care Innovation in Medicaid Managed Care Toolkit, as well as an upcoming webinar on February 22 at 2 pm ET that will explore how states can develop and promote strong primary care standards within managed care, with a focus on supporting high quality and equitable pediatric care. It will feature perspectives from an Ohio Medicaid representative and a Washington State-based provider and researcher.