Access to quality primary care has long been recognized as a cornerstone for improving population health and reducing healthcare disparities. People who can get to a doctor more easily are more likely to do so—and not just when they’re critically ill or facing an emergency. Conversely, for people who live in so-called primary care deserts, the extra logistical challenges that come with simply getting to a doctor’s office in a different part of a big city can add up to measurably worse outcomes.
So the question remains: What can we do to address these challenges? To answer that, we first have to look at where these primary care deserts are and how they came to exist in the first place.
Neighborhoods with higher uninsured rates and higher proportions of Black and Hispanic residents are more likely to have low access to primary care. In recent decades, the healthcare landscape has been increasingly dominated by large, multi-specialty groups and integrated delivery systems, in which primary care practices serve as a source of referrals to bring high-reimbursing, commercially insured patients into the more lucrative specialty practices, hospitals and related facilities. In this model, uninsured or underinsured residents can fall through the cracks.
Related: AMA, AHIP, NAACOS issue value-based care data-sharing guidelines
While public hospitals, free clinics and federally qualified health centers all provide elements of care for underserved communities, their efforts in primary care have long been underfunded and are often not flexible enough to meet all the needs of the patients in the communities they serve.
This is where value-based care models may offer a solution. The differential financial incentives afforded through value-based contracting aimed at improving the quality of care and patient outcomes allow organizations to invest dollars into areas that are needed the most, such as social needs.
To find out whether the value-based care model could lead to an increase in the number of primary care practices in historically underserved neighborhoods, we conducted an internal analysis of primary care centers in two major markets with highly diverse and disparate neighborhoods: Chicago and Philadelphia.
We started by identifying ZIP code locations of care centers owned and operated by selected value-based primary care entrants (Oak Street Health, ChenMed, JenCare and Cano Health) as well as those of primary care and family medicine centers operated by regional academic medical centers and private health systems. We then cross-referenced those ZIP codes against the Social Deprivation Index (SDI) created by the Robert Graham Center. The index was developed to measure neighborhood-level community disadvantage and its association with health outcomes and inequities. A higher SDI indicates an individual lives in a community that is more disadvantaged related to social determinants of health and therefore likely has more limited access to care, often resulting in unmet needs and poor patient outcomes.
Our analysis found that, compared with primary care centers operated by regional academic medical centers and private health systems, value-based care operated centers were more likely to be located in ZIP codes with higher SDIs.
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In Chicago, 69% of the 35 ZIP codes with primary care centers operated by value-based care organizations were in the highest third of the SDI (in other words, the highest third of community disadvantage) compared with a range of 7% to 20% for centers operated by major health systems. Just 3% of ZIP codes with value-based primary care centers were in the lowest third of the SDI, compared with 20% to 64% for the large major health systems. Those trends held true in Philadelphia, where 93% of the 15 ZIP codes with value-based primary care centers and just 13% to 38% of centers operated by health systems were in the highest third of the SDI.
It appears from our analysis that value-based entrants have established primary care centers more frequently in marginalized communities than the legacy, fee-for-service systems, at least in the cities we analyzed. In fact, value-based organizations’ presence in vulnerable neighborhoods in these cities mirrors that of federally funded Health Resources and Services Administration centers, whose explicit purpose is to expand care to underserved populations. No other systems came close to reflecting this footprint. Fifty-four percent of Chicago-area ZIP codes with HRSA-funded health centers and 71% in Philadelphia were in the highest third of the SDI.
For underserved communities, value-based care could therefore offer a potentially powerful solution to address long-standing, structural disparities in public health outcomes. But we can’t stop there. Policymakers must continue to support and iterate on federal models like ACO REACH, which seek to drive investment in under-resourced neighborhoods and reduce inequities. And medical educators must turn their attention toward replenishing the diminishing pipeline of primary care physicians dedicated to serving these areas.