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Saving primary care: Physician experts outline three approaches

Key Takeaways

  • Value-based care and hybrid payment models can enhance primary care but face challenges like administrative burdens and billing complexities.
  • Primary care is in crisis due to worsening access, increased complexity post-COVID-19, and persistent health inequities.
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NIHCM hosts online forum with prescriptions to help a sector of health care that is in crisis.

Value-based care payments, a redesigned primary care system, and progressive partnerships between physicians and the payers who cover patients all could ways to improve primary care in the U.S. health care system.

Primary care physicians were among the speakers outlining potential solutions in “The Future of Primary Care: Quality, Access, and Costs,” a Feb. 25 webinar hosted by the National Institute for Health Care Management Foundation (NIHCM). The nonprofit is dedicated to transforming health care through evidence and collaboration.

As for evidence, the four physician experts agreed: Investing in primary care improves patient health at reasonable cost. It is in dire condition, but creative approaches could renew it with better outcomes medically and financially for individual patients and health care as a whole.

Policy threats to primary care?

The online forum was hosted by Sheree Crute, MA, director of communications and of NIHCM’s journalism grant program. The session included a question-and-answer session, with a query about now the new administration of President Donald J. Trump could affect policies on primary care, insurance through the Affordable Care Act (ACA), and health equity.

“I think we all have reason to be concerned, and I think it's also a call to action for all of us here,” said presenter and primary care physician Priscilla G. Wang, MD, MPH. “You know, there's so much great work to be done in the redesign of primary Care, but we can't do that if we don't have a functional health system and for us to have a functional health system, that means that individuals have to be able to participate in health care in a way that's affordable, first of all, and accessible.”

© Harvard Medical School

Priscilla G. Wang, MD, MPH
© Harvard Medical School

Potential cuts to ACA, Medicaid and food and nutrition benefits all could affect primary care, she said.

The medical community has a huge power through the voices of people working in health care. When speaking to lawmakers, personal anecdotes about the human impact of primary care may go further than pages of statistics, Wang said.

Doctors can start by finding out who their legislators are, she said.

“When you see things, don't be silent,” Wang said. “Align with other advocacy organizations, and get the word out there.

“I always say it's not about politics, it's about good policies, and what's best for people,” she said. “And I think we can all agree health is critical for people and primary care is critical for health, so I hope that all of us we can work together on that.”

Creating a hybrid payment plan

Fundamentally, value-based payment got a shot in the arm through the 2010s, through experimental payment models from Medicare and other payers, said Amol S. Navathe, MD, PhD, in his presentation, “Population-Based Hybrid Payments for Primary Care.” Navathe is professor of health policy, medicine, and health care management, and senior Fellow, Leonard Davis Institute for Health Economics, University of Pennsylvania. He also is vice chair of the Medicare Payment Advisory Commission.

© University of Pennsylvania

Amol Navathe, MD, PhD
© University of Pennsylvania

There has been progress, but with fits and starts, he said, and it is worth asking why physicians should care about value-based payment.

That model could have great promise for primary care when the health care system is aligned with how patients want to receive care. “They want to receive care where it makes the most sense, when it makes the most sense, and by the clinician who makes the most sense, right?” he said.

But it has been difficult to get the billing codes correct,” Navathe said. Value-based payment has been challenging because it requires change, and it has been difficult to get incentives right, he added.

“On one hand, we want clinicians to be, perhaps to some extent, aware of the resources that they're using, maybe cost conscious to some extent,” he said. “At the same time, we want to ensure that we have access to really high-quality care. That access should be unfettered, right? We want people to be able to get where they need to get, and so that's challenging.”

Navathe said described himself as “incredibly optimistic,” with the advent of hybrid models that balance population-based payment with some fee-for-service transactional payments. He cited examples such as the Multi-Payer Advanced Primary Care Practice of 2014 to 2017; the Comprehensive Primary Care+ model of 2017 to 2021; and the Primary Care First Model that started in 2021 and continues now. Those were run by the U.S. Centers for Medicare & Medicaid Services.

There is evidence those models can support higher quality of care, with decreased hospitalization and emergency department use, with greater use of telehealth, he said. The models also have challenges, not least administrative burdens that require clinicians and practices to do a lot of data entry and reporting. Navathe noted that is the number one factor in surveys that ask clinicians what leads to burnout.

Can primary care be saved?

Wang presented “Can Primary Care Be Saved? Redesigning primary care for quality, sustainability and meaning,” She is a primary care physician at Massachusetts General Hospital and associate medical director for primary care health equity, Mass General Brigham and Harvard Medical School.

That title was somewhat provocative, she said, but primary care is in crisis in at least three ways:

  • Patient access is worsening rapidly, with physicians retiring or departing and an inadequate pipeline to replace them.
  • Work of primary care has become more complex and difficult since the COVID-19 pandemic.
  • Primary care patients continue to experience poor health outcomes and health inequities.

To improve primary care, she outlined a five-point plan, starting with the rethinking of continuum of care: what care a system provides, to whom and by whom. Medical and social complexity, intervention length, and site of care all are variables in that continuum.

She cited examples from her own patients. A 75-year-old Black man with aphasia, early dementia, severe vascular disease, heart failure and social isolation will have different health care needs than a 24-year-old Asian woman and domestic violence survivor who needs housing and food, and is dealing with anxiety.

  • Then, define a baseline of care for all, standardizing and automating as much as possible.
  • Create team-based models based on patient needs that are mapped and identified.
  • Maximizing reimbursement and aligning with value-based care contracts will create financial sustainability.
  • Physicians and other clinicians also must “preserve the heart and humanity of primary care as well,” Wang said.

“I want to be the first to admit, coming from my system, we are actively struggling, we're grappling with these challenges, so I do not want to come across as, you know, having that we've solved it all. We absolutely have not,” Wang said. “But one thing I do want to put out as we close is that I strongly believe the cure cannot be worse than the disease, and I am really wary of some of the consultant models or things that we've seen being proposed that seem to treat a patient like a collection of body parts.”

Joining forces for good health care

A model of collaboration exists in Washington, where nonprofit Premara Blue Cross serves as the state’s “hometown health plan,” said Premara Chief Medical Officer Romilla Batra, MD, MBA. Premara has partnered with Kinwell Medical Group, and she presented “Collaborating to Improve Access to Primary Care” with Mia Wise, DO, that group’s chief medical officer.

© Premera Blue Cross

Romilla Batra, MD, MBA
© Premera Blue Cross

© Kinwell Medical Group

Mia Wise, DO
© Kinwell Medical Group

Now more than 90 years old, Premara serves about 2.8 million members with the goal to make health care work better for members, Batra said. They are guided by the quintuple aim to improve clinical outcomes, patient experience, provider satisfaction, and health equity, she said.

To do so, the insurer invested in Kinwell to build a network of statewide clinic with virtual care and no co-pay for primary care visits, which are timely. There are rural health and rural clinic initiatives, and integrated physical and behavioral health care.

It is a young endeavor, so both organizations are learning and growing, and it is exciting, Wise said. She described it as multiple systems running simultaneously, as the other speakers alluded to with multiple service lines happening all at once around the patient's needs.

Instead of focusing on transactions, the alignment allows physicians and other clinicians “to step off of the fee-for-service treadmill and move towards focusing on the shared outcomes and experience,” Wise said.

Instead of focusing on relative value units, the clinicians stay curious and develop their craft by solving problems for patients — “get back to why they went to medical school in the first place,” Wise said.

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