Large purchasers press for higher primary‑care investment, launch aligned multi‑payer pilots in California and Puget Sound

Elizabeth Mitchell, president and chief executive officer of the Purchasers Business Group on Health, told the PTAC listening session that employers and public purchasers are demanding payment changes to enable expanded primary care and are actively piloting aligned payment models in multiple markets.

Mitchell said primary care is a top priority for purchaser members and that many large purchasers are moving from traditional fee‑for‑service toward prospective population‑based payment and direct contracting to give practices the flexibility to provide team‑based care and integrated behavioral health. "Primary care is a top priority for them as is changing the payment system to enable it," Mitchell said.

Why it matters: Panelists argued that stronger primary care can improve access, equity and outcomes while lowering total cost of care. Mitchell said primary care accounts for roughly 35% of visits but influences ‘‘90% of spending’’ and—despite that role—receives a small share of total spend in most markets. Purchasers are pressing to increase the share of total health spending directed to primary care and are building contract language and aligned measures to do so.

Mitchell described two linked strategies her organization is pursuing: (1) a national purchaser agenda to define an advanced primary care measure set and payment expectations and (2) hands‑on technical assistance in California through the California Quality Collaborative to help practices meet the standards. She said purchasers have convened employers such as CalPERS and large private employers and that some members have moved to direct contracting when multi‑payer alignment proved difficult to achieve through health plans.

Pilot programs and payment designs: Mitchell said a recently launched Puget Sound initiative uses common measures, aligned contracts and the same payment model across employers, naming Boeing and eBay among participating purchasers. In California, she said several health plans worked with purchasers to adopt a common measure set and aligned payments for a 30‑practice pilot. Key payment elements described included a mix of capitation and fee‑for‑service (informally called "fee‑for‑service plus"), prospective per‑member‑per‑month (PMPM) population health payments, and performance‑based payments with an upside of up to 15%.

Mitchell stressed that payment is the primary barrier to practice transformation: short, fee‑for‑service visits and legacy plan systems do not reimburse for integrated behavioral health, community health workers, population analytics or longer visits. A common reporting platform was cited as another enabling infrastructure; Mitchell credited the Integrated Healthcare Association in California for collecting aligned measures and providing a reporting feed for participating practices.

Barriers and next steps: Panelists described a set of operational hurdles that slow adoption—different plan measure sets, plan contracting constraints, legacy payer IT and the limited capacity of small practices to ingest disparate plan reports. Mitchell urged purchasers, plans and provider groups to commit to multi‑payer alignment, invest in practice transformation and accept that contractual changes and multi‑year timelines (two to three years) are likely needed.

Panel reaction and questions: During a committee Q&A, members asked how purchasers think about net cost trends and guardrails to avoid underuse. Mitchell said many large purchasers are seeking flat or very low trend—often in the 1%–3% annual range for total cost—in part through a system‑wide approach that reinvests savings in primary and behavioral health. When asked about spreading California’s aligned approach nationally, Mitchell said it requires sustained relationship building and regional infrastructure and that it took multiple years to build consensus in California. "I would love to export it, and I'm happy to partner on doing that," she said.

Ending: Panelists asked PTAC members to consider how federal programs and demonstration models might support payer‑agnostic reporting platforms, more consistent measures and incentives to engage smaller practices. Mitchell and other presenters offered to share measure sets and implementation lessons with committee staff.