In the search for ways to tackle health care spending, some policymakers and states have advocated spending more on primary care as a way to lower total health care spending.

Assistant professor of health care policy and medicine Zirui Song, MD, PhD, and Harvard Medical School student Suhas Gondi investigate the potential implications of this approach in JAMA.

Primary care has been associated with better quality care, patient experience, and outcomes including lower mortality. The idea behind increasing primary care spending  to lower total spending is based on the proposition that if patients receive more preventive care, they will require less emergency and inpatient care. In other words, primary care could be a substitute for more expensive, downstream care.

Some states have instituted policies requiring insurers to invest more in primary care. Rhode Island, for example, saw slower overall health care spending growth after the proportion of spending on primary care was raised by 1% per year, although simultaneous price controls largely explained this slowing in total spending. A randomized trial that provided primary care appointments to 1,228 uninsured adults in Virginia showed a decrease in emergency department visits, but no effect on overall spending relative to the control group. While the evidence has been sobering, the content, context, and timing of studies to date are varied, and the evidence should be interpreted with caution.

Given that studies have thus far not shown consistent evidence of increased primary care replacing more expensive downstream care to lower total spending, Song and Suhas suggest other interventions that policymakers may consider alongside primary care oriented approaches. Payment reform, policies or competition to address prices, and value-based insurance design may assist in influencing overall spending. Improving the substance of primary care by reducing administrative burdens and defensive medicine may also be beneficial in place of or addition to increased primary care spending.

In summary, increased primary care spending may improve quality of care and patient outcomes, but it has not consistently reduced or slowed total health care spending. Despite this, increased primary care spending itself should not be interpreted negatively, as much of primary care can be cost effective even if it is not cost saving. Policymakers aiming to address health care spending growth through primary care oriented investments may be aided by consideration of the nuanced evidence to date.