Medicaid expansion has created an “urgent need” to engage primary care practices in serving the expanded Medicaid population, wrote the author of an invited commentary in JAMA Internal Medicine.1

Allan H. Goroll, MD, of the Division of General Internal Medicine at Massachusetts General Hospital and Harvard Medical School in Boston, Massachusetts, described the challenges facing Medicaid following the expansion of eligibility by the Patient Protection and Affordable Care Act (ACA).

Dr Goroll noted that the rates paid by Medicaid are only a fraction of those paid by Medicare and commercial insurance. Most primary care practices found that they could not afford to take on Medicaid patients, although the expansion resulted in increasing numbers of patients looking for physicians. To encourage physicians to expand their practice to include Medicaid patients or more Medicaid patients, the ACA legislated a normalization of Medicaid payments so that they matched Medicare fee-for-service rates.

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Yet, as Dr Goroll observed in an article published in the same issue of JAMA Internal Medicine, those researchers found that the increase in reimbursement did not have a positive effect on overall participation in Medicaid or in Medicaid service volume.2 As a result, primary care practices are forced to maximize volume to remain solvent at the cost of quality patient care.

The authors of the ACA established the Center for Medicare & Medicaid Innovation (CMMI) to campaign for and put into practice large-scale reforms of the payment system, yet many primary care practices hold a “better the bad system I know” attitude and fail to adopt reforms.

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Dr Goroll and an informal group of colleagues suggested a more fundamental reform of payment for primary care, calling for a base payment to cover all practice expenses with a 25% bonus to encourage cost, quality, and patient experience goals. He believes that by making payment prospective and risk adjusted, practices will have the resources necessary to adjust to the needs of their patient populations. Dr Goroll and colleagues have been urging CMMI to make more ambitious reforms, and recently CMMI has launched the Comprehensive Primary Care Plus initiative. This initiative will serve as a test of a primary care payment system and involve more than 5000 practices.

One of the primary challenges that remain is to overcome the fearful attitude of many primary care physicians toward adoption of reforms. As Dr Goroll observed, “the stakes are high, but the potential payoff is substantial for improving this foundational segment of our health care delivery system.”


  1. Goroll AH. Reforming payment for primary care-it’s not just the money, it’s the payment system. JAMA Intern Med. 2018;178(8):1049-1050.
  2. Mulcahy AW, Gracner T, Finegold K. Associations between the patient protection and Affordable Care Act Medicaid primary care payment increase and physician participation in Medicaid. JAMA Intern Med. 2018;178(8):1042-1048.