1. Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org 1 Spending on Primary Care Ellen Schneiter Maine Health Management Coalition

2. Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org Spending on Primary Care in Maine Why do we care? – Primary care is the backbone of our health care delivery system Systems of care built on a strong foundation of primary care have better quality of care, good population health and lower costs As compared to other nations, the US has lagged behind in these system attributes – This is likely due in part to a lack of investment in primary care 2

3. Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org So, how much do we spend in Maine? First pass – “quick & dirty” adaptation of Rhode Island approach RI Affordability Standards – Designed to reallocate medical care expenditures to primary care w/o increasing overall spend – Applicable to commercial market OHIC has established a detailed approach to calculating spend, using data provided in annual filings by commercial payers – RI does not yet have an APCD 3

4. Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org RI Approach OHIC defines primary care spending* as medical expenses paid to Family Practice, Internal Medicine, Pediatrics and providers with credentials = MD, DO, NP and PA Excludes “dual” providers who provide both primary and specialty care except in those situations where the specialist is paid on a PC provider fee schedule * RI Annual Health Statement Supplement Instructions 4

5. Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org Our calculation We used claims data from the APCD – CY2013 – Excluded claims associated with supplemental coverage plans – Only included members with a full year of eligibility (N=587k less 140k w/o continuous elig) – ID’d primary care providers using NPI taxonomy Included NP/PA providers if NPI ID’d them as PC – Only FFS claims are included 5

6. Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org Our calculation, con’t Total spend (denominator) includes NPIs that ID provider as other than PC as well as claims with provider “unknown” – a considerable number – There are claims that we were unable to classify as primary care (e.g. integrated practices billing out under a single TIN) or that were missing servicing provider – 5% – Rx, all pd claims other than PC 6

7. Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org Our calculation, con’t Total spend used in denominator $1.02 billion (inc $290m Rx) Of that total, primary care spend $53 million 5.2% primary care spend Remember, though, there is some slack in this calculation! – Limitations of data; no non-claims spend 7

8. Maine Health Management Coalition | 11 Bowdoin Mill Island, Suite 260 | Topsham, ME 04086 | (207) 899-1971 | www.mehmc.org | www.getbettermaine.org Considerations Is this the best way to define primary care? – Definition driven by provider type v. codes Data limitations And once you figure out the spend, then what? – What is the “right” amount to spend? 8