Promote High Value System Performance

Primary Care Investment Benchmark

OHCA is responsible for setting statewide investment benchmarks for primary care spending as a percent of total health care spending. To set this benchmark, OHCA is required to consider current and historic underfunding of primary care services and to promote sustained systemwide investment in primary care.  

In October 2024, the Health Care Affordability Board approved two related primary care investment benchmarks:  

  1. Annual improvement benchmark: 0.5 percentage points to 1 percentage point per year increase in primary care spending as a percent of total medical expense for each payer for performance years 2025 through 2033; and  
  1. Statewide investment benchmark: 15 percent of total medical expense allocated to primary care for all payers by performance year 2034. 

The annual improvement benchmark applies to each payer by line of business and product type, resulting in four market segments for public reporting: commercial HMO/POS, commercial PPO/EPO, Medicare Advantage, and Medi-Cal. The statewide investment benchmark will be measured across payers, lines of business, and product types. OHCA will include an analysis of primary care spending and performance against the benchmarks in its annual report. 

Primary Care Spending Measurement 

OHCA will measure primary care spending through claims and non-claims payments. Claims-based primary care spending is defined as a primary care service delivered in a primary care place of service by a primary care provider. All three aspects of the definition must be met for the spend to count as primary care spending.  

With input from the Investment and Payment Workgroup and other stakeholders, OHCA has developed an approach to allocate a portion of non-claims payments, such as capitation payments, to primary care spending. 

For further information, please refer to the OHCA Primary Care Investment Benchmark memo.