How should primary care physicians be paid?

Primary care plays a vital role in maintaining the health of patients, but is often undervalued, with physicians being paid less for it than other specialties. With an increasing focus on health care costs in this country, combined with primary care practices taking a big financial hit because of the COVID crisis, reimbursement is coming under greater scrutiny.

Medical Economics spoke with Christopher Crow, MD, founder and CEO of Catalyst Health Network, to discuss the state of primary care reimbursement and what needs to change.

Christopher Crow, MD

Editor’s note: The transcript has been edited for brevity and clarity.

Medical Economics: What's wrong with how we pay for primary care today?

Christopher Crow: In short, you could say that there are incongruent incentives. You have to have some agreement there that we're trying to incentivize what people have called the triple aim and maybe even the quadruple aim, which is how do we get a better clinical outcome for patients, a better experience for patients, a lower cost of care or a more valuable cost of care for the system, and then the providers that are providing that care have to have a satisfaction level with the work that they do, as well. Right now, the way fee for service works for primary care, there's an incongruence with how that's paid for for the care that's delivered, if you want to actually achieve those outcomes.

Right now, fee for service means that you have to come into my 10 by 10 exam room for me to actually get reimbursed for caring for you. But that's not the only way or the best way to get better clinical outcomes. It certainly is not the only way or the best way to have a good patient experience. And then from the provider standpoint, you've heard about burnout is going up and up for the physicians.

If you want good primary care, primary care is a relational-based care model. Physicians and their patients in primary care stay with each other for years. It's not an episode. It's not a one-time thing. It's potentially a multi-year, multi-decade, multi-generational, lifetime relationship. And therefore, it should be paid more smoothly over time, what we call proactive payment or prospective payment, rather than this reactive care. If you're only going to do reactive care, then you're not going to get all the benefits of encouraging people to get better. The relationship of fee for service is such that it doesn't allow for the proactive nature of care delivery that primary care is trained to do to take care of the whole person. But the payment model requires a 10 by 10 room with an in-person visit with that physician. So those really need to be unlocked from each other.

Medical Economics: How does the prospective payment model fix these faults? And how is it different than what's been tried before?

Crow: Let's go back to the 90s, where people were using things words like capitation, that scared people. The difference between now and then is dramatic. Number one is the technology we have today is drastically different than we had 30 years ago. There’s data and information that we can have on both sides of the transaction that wasn't there before to learn if there's involvement with a patient. You also now have exploding health care costs, so there's a heightened sense from all purchasers, whether it be the government or employers or patient, about the cost of care. Right now, in Medicare Advantage, we're already seeing this payment model happen and we have for the last five or 10 years, and you've seen a fairly high growth of the Medicare Advantage product across America. The reason it's growing, in my opinion, one of the reasons is it does align the incentives with a prospective payment model to the primary care physician to align the right outcomes and to be incentivized for it.

It's not necessarily a silver bullet, but it gets you on the right field of play, for sure. Attaching a care delivery model with the appropriate financing model is the key right now. It's a primary care as a relational, longitudinal-based care model, that then in a prospective payment model would organize care not only episodically in a 10 by 10 exam room, you then become more team based in how you do things. Right now, there's nothing in fee for service that pays for team-based care and nothing that pays for coordination of care. We all know that teams perform better than individuals. And why wouldn't we do it in any care setting that makes sense, including the home?

In a prospective payment model, it unlocks so much of the rigor of today's model that doesn't get the outcomes we want. It affords the incentive on the patient to go ahead and engage more with the physician and their team and affords the physician and the team the incentive to engage more proactively with the patient, because you actually have a payment model that's paying you for ongoing care. So it really does bring together the care delivery model and the financing model to a more congruent state to deliver the outcomes.

Now, you still have to build the right incentives and the right outcomes that you're measuring. But at least now you're on the right playing field. COVID has shown that what a destruction in that congruence can be, because all of a sudden, when we're told across the country to shelter at home, which is the right thing to do for our health. The only way that physicians can get paid most of the time is in the 10 by 10 exam room and that's no longer available. You've absolutely crushed the primary care layer of health care in America. I mean, absolutely decimated. That happens to be the layer that's needed at all times, but especially in the COVID moment, to help people with all their extra issues around coordinating care, getting medications, making sure their chronic diseases are being monitored. We need our primary care layer more than ever, yet the incongruence of the payment model and delivery model have absolutely decimated it in this moment.

Medical Economics: Will a prospective payment model allow small and rural practices to survive, and will they have to change how they do business?

Crow: I don't think this switch from fee for service to prospective payment necessarily has a strong geographical or necessarily a size difference in practice impact. I think what I would say around the smaller businesses, the smaller practices, they are going to want to be connected to something that allows them to dock into some teams and technology, so that if you are being paid prospectively and the patients are wanting to see you in new and different ways, from a technology standpoint and modality standpoint, you're going to need to be able to provide those services and have that type of technology. So if you're in a smaller rural setting, you're going to want to be able to attach to an organization that they can help you in that way. The physicians in small towns, big towns­­—no matter what, we're going to need that capability to better care for the patients they serve.

Medical Economics: What are the benefits to the patient under the prospective payment model?

Crow: There's three stakeholders: the payer, the provider, and the patient. From the patient advocacy standpoint, with a prospective payment, first off, it's a reorientation from “I only worry about my health care and when it's bad enough that I'll go have to pay some dollars to do that.” We all have different socioeconomic statuses and so that's why you see these disparities that happen, because people are delaying care, because of the way we reactively have to pay for it. In a prospective payment model, it's more like a subscription. If you can align the incentives right, when the financial burdens are spread out and not hit you every time you're sick, in the worst moment, you can start to think about your health differently. In COVID, we're finding that people who are unhealthy or overweight are getting disproportionately affected by this disease. So there’s a heightened sense now of, I need to care about my health in a different way. Is that email, is that text, is that video, is that going into the office—it could be any of those depending on the circumstances. You could choose the right context, depending on your health, and you can use any location, as well. You don't necessarily have to be tied to the to the physician's office.

Right now we hear about surprise billings all the time; your primary care should have no barriers to you to get good primary care. The way we actually get to a better cost structure in America is to invest upstream in primary care, have the alignment happen with the care delivery model and the prospective payment so that patients and physicians alike and their teams will want to work together to lower downstream costs by creating better health on the front end.

Medical Economics: During the pandemic, many patients with chronic conditions have delayed their care. What effect is this going to have on primary care physicians as we move forward?

Crow: That's going to be a really interesting thing to watch. And on some sense, there's a worry about all of a sudden there's going to be a flood of people. In another sense, you could say, well, chronic disease kind of has this slow roll. That happens. And so everyone's chronic disease may have just hit a new curve of getting worse over time faster, kind of in a compounding effect. It's another reason why prospective payment is so important, so that if you could actually take care of people in multiple modalities in ways right now, those relationships will compound positively, rather than what we're seeing now—the health of people compounding negatively because they're not able to get into a physician's office.

So I think in the beginning, the power of teams versus individuals are really important in this because it's going to take a multimodality of a team-based care environment and primary care to help these people kind of get back to a certain level of health. If it all comes bombarding back all at once, that'd be very difficult. Now part of me also thinks that's not going to come back anyway, that we're going to get that the there's a big piece of America that is scared to get out and about these days, especially those with chronic disease and elderly. And so it's going to be harder if we require them to be in this fee for service model that we have to see them physically in our 10 by 10 exam room, that they're just not going to come back, which means they're going to sit in their house, and they're going to continue to get worse and worse and worse.

Medical Economics: Do you see any major changes facing primary care once we get through the COVID crisis?

Crow: If you're going to stay in the fee-for-service model, that's going to be very, very difficult. There'll be more prospective payment for sure. So living in both of those models at the same time is going to be difficult. You're going to have to make sure that you have good telehealth capabilities. We really need to lock that in, because it's absolutely ridiculous that we would ever go back to the only form of payment a physician practice can get would be through a 10 by 10 office visit. It's punitive to the physician, it's punitive to the patient, it's punitive to whoever's paying for it. So we need to open up all the other channels we have to reach the best possible care delivery and outcomes for patients. Those types of technologies are going to need to be in place and kind of locked in, and that's going to be potentially a challenge, as some of the public health emergency things that got removed, like HIPAA come back online. You're going to have to make sure we're in compliance with some of those things, and that could be difficult.