Healthcare Payments Data (HPD) Primary Care Utilization Report

Key Findings#

• In 2024, 43% of insured Californians did not see a primary care provider. 
    
  
  • Among those with Medi-Cal, over 50% did not see a primary care provider, about 15 percentage points higher than Commercial or Medicare members (38% and 37%).  
    
  • Only 26% of those with one chronic condition did not see a primary care provider. As the number of chronic conditions increases, the percentage of members without a primary care visit decreases.
• In 2024, the median distance from a rural member’s residence to their primary care visit was 15.3 miles compared to 6.4 miles for members living in non-rural areas. Across all reporting years, the median distance is over twice as far for rural residents.
• Of the members who do utilize primary care services, specifically those with multiple primary care visits in a single year (2+ visits), Medi-Cal members are more likely to have continuous care (seeing the same provider over time) than Medicare or commercial members. In 2024, 41% of Medi-Cal members with at least two primary care visits have continuous care compared to 36% of Medicare members and 31% of commercial members.
• Members with at least two primary care visits living in a rural area have a higher likelihood of continuous care (43%) than their counterparts living in non-rural areas (35%). A similar pattern can be seen in each of the previous five years.

Glossary#

Population#

Population 

The data displayed in the HPD Primary Care Utilization Report is from medical claim records available within HPD, California’s All-Payer Claims Database (APCD). Members, also referred to as insured Californians in this report are individual with enrollment records available in HPD. Population counts used to calculate rates were based on member enrollment. Medical claims and enrollment records were limited to records with service or coverage dates from 2019-2024.

Data Elements#

• Reporting Year: The year of the service date of the visit. 
• Age Band: The age reported on an individual’s enrollment records for the reporting year. 
• Chronic Condition Count: The sum of the number of chronic conditions an individual is diagnosed with based on the Chronic Condition Warehouse (CCW) list of conditions and specifications. 
• Sex: An individual’s reported sex identified from their member enrollment information. 
• Rural Designation: Members’ residential census tracts are classified as rural or non-rural using the Federal Office of Rural Health Policy’s (FORHP) definition of rural areas.
  
  Payer Types: Payers are the companies, programs, and organizations that oversee insurance plans and reimburse healthcare providers. The payer assignments are determined based on the primary payer reported only. Three main types of payers make up the majority of the insurance market.
  • Medicare: A federal health insurance program funded by the Centers for Medicare & Medicaid Services (CMS) under the Social Security Amendments of 1965 that provides healthcare benefits to those aged 65 years and over or to disabled beneficiaries of any age. Includes Traditional Medicare (Medicare Fee-for-Service) and Medicare Advantage.  
  • Medi-Cal: A public health insurance program that provides free or low-cost medical services and healthcare benefits to low-income individuals, financed from state and federal funds; California’s version of Medicaid. Includes Medi-Cal Fee-for-Service (FFS) and Medi-Cal Managed Care.
  • Commercial: Insurance products for which the coverage premium is paid by a private party, such as an employer, individual, or other entity. 

Metrics#

• Primary Care Utilization Rate: Calculated by dividing the total count of primary care visits during the reporting year by the total sum of member enrollment months and multiplying the result by 12,000. 
  • Preventative Visit Rate (a visit for age-appropriate screenings and preventive services, vaccinations, annual exams, etc.), Telehealth Visit Rate, and New Patient Visit Rate use the same formula for utilization.
• Median Distance to Primary Care: The median distance in miles between a member’s residential address to an in-person primary care visit (one way).
• Percent of Members Without a Primary Care Visit: The percentage of members in the reporting population (all insured Californians in HPD with coverage in the year) that did not have a visit with a primary care provider during the reporting year.
• Percent of Members with Continuous Care: The percentage of members that received continuous care during the reporting year according to the Bice-Boxerman Continuity of Care Index. Members who see the same provider consistently over time will have a higher index score than those who see different or new providers. At least two primary care visits are required during the reporting year to calculate an index score and individuals with an index score of greater than or equal to 0.7 are identified as having continuous primary care.
  • “2+ Visits”: the number of members with continuous care divided by only the count of members with a continuity score from at least two primary care visits during the reporting year.
  • “All Members”: the number of members with continuous care divided by the count of all insured members in the reporting population, including members without a continuity score because they had less than two primary care visits during the reporting year.
• Continuity of Care Metrics: The Continuity of Care dashboard tab contains two distinct metrics, which are separated by color in the visualization:
  • Blue: Represents the number of members with continuous care divided by only the count of members with a continuity score from at least two primary care visits during the reporting year.
  • Orange: Represents the number of members with continuous care divided by the count of all insured members in the reporting population, including members without a continuity score. Members without a continuity score had less than two primary care visits during the reporting year.

See the Technical Note for lists of the procedure codes used to identify visit types.

Additional Information#

Topic: Cost Transparency/Healthcare Utilization
Source Link: Cost Transparency – Healthcare Payments Data
Citation: HCAI – Healthcare Payments Data (HPD): Primary Care Utilization Report, 2019-2024
Temporal Coverage: 2019-2024
Spatial/Geographic Coverage: Statewide, Rural/Non-Rural
Frequency: Annually