The case for paying primary care more than specialists

Value-based care was supposed to upend U.S. healthcare. Changing incentives and how the massive amounts of money circulating through the system flowed so providers were rewarded more for prevention and good outcomes and less for volume and intensity would be nothing if not disruptive.

Has it played out that way? “It depends on what you mean by disruption,” says Suzanne Delbanco, Ph.D., M.P.H., executive director of the Catalyst for Payment Reform, a nonprofit group founded in 2010 that has large employers such as Walmart and Home Depot as its members. “If the question is, has it disrupted providers and payers, I think the answer is yes. Has it disrupted the outcomes we were hoping for, meaning has it significantly improved quality or saved money? The answer is no.”

Quality measurement alone has become a “massive industry,” continues Delbanco. “The amount of effort to measure performance and outcomes to tie it back to payments has taken on a life of its own and has not necessarily led to better outcomes.”

One reason value-based care has fallen short, in Delbanco’s view, is the consolidation of providers and rising prices: “Payment reform, value-based payment, value-based care — whatever you call it — does not address prices.” And although payment reform may be making providers more efficient, if prices are high, those who use and pay for healthcare are not going to experience the benefits, she says.

If you are looking to truly disrupt healthcare, Delbanco has the provocative suggestion of flipping physician payment so primary care physicians are paid more, not less, than specialists. “We spend so much more on specialists than we do on primary care. While a specialist can help people who are already ill, primary care doctors can help people frombecoming ill,” she says.

Accountable care organizations have been billed as a way to channel more healthcare dollars into primary care, but Delbanco says they leave intact the wide gap in payments between primary care physicians and specialists.Boosting payment to primary care physicians might start to fix American medicine’s turn away from primary care, says Delbanco, who mentions that her father, Tom Delbanco, is a primary care physician and an internist and professor at Harvard Medical School.

“It used to be that the best and the brightest went into primary care because it was the most challenging,” Delbanco says. “I don’t mean because you have to see a patient every five minutes. I mean that every time a patient walks through the door, you don’t know what’s going to come at you, and you have to be prepared for anything.”