Where is the future of primary care headed?

The ground is shifting under primary care physicians.

The election of Donald Trump and the resulting uncertainty over the future of the Affordable Care Act and Medicare is only the latest tremor. The move away from the fee-for-service payment model toward value-based care, new regulatory requirements, the migration of independent practices to healthcare systems, the emergence of new models of care-they’ve all left primary care physicians (PCPs) unsure of what’s to come and how they will be affected.

And even as primary care struggles to keep its footing, it’s being called on to do more than ever before: coordinate care for an aging population beset by chronic disease, improve the overall wellness of the population, control costs and eliminate waste and fraud. These tasks validate the importance and necessity of primary care, but they present daunting challenges nonetheless.

“Is primary care going to survive? You bet. We’re going to be very much needed, but it’s morphing,” says Ripley Hollister, MD, a primary care physician in Colorado Springs, Colorado, and a board member of The Physicians Foundation, an advocacy group for better healthcare.

In fact, after decades of losing control and income to specialists, hospitals and other providers, this could be an opportunity for primary care to retake its position at the center of the U.S. healthcare system, says Joe Flower, a healthcare futurist and consultant.

“It’s not just whether primary care docs will get more money and control,” says Flower, the author of Healthcare Beyond Reform: Doing it Right for Half the Cost. “It’s whether we rebuild our healthcare system around them.” 

Decision time

This will be the year when many PCPs make fundamental decisions that go a long way toward determining their futures. 

Among the questions to be answered: whether to remain independent, whether to seek reimbursement under the Medicare Access and CHIP Reauthorization Act (MACRA) or pursue a different practice model that would exempt them, such as concierge or direct primary care, and how to retool their practices to align with the coming world of value-based care. Some older physicians may decide to retire earlier than planned to avoid the new regulations and requirements.    

“There is no one solution for everybody,” says healthcare management consultant David Zetter, CPC, CHBC. He suggests practices familiarize themselves with MACRA and other trends affecting primary care, then undertake a thorough self-assessment of everything from finances and staffing to patient population health and office procedures.  

That audit will give them a better idea of their strengths and weaknesses and what they need to change to succeed in a value-based care system. 

Those changes could be significant. For example, Zetter says, practices that have not implemented EHRs will have to do so in order to meet MACRA’s reporting requirements. Others might need to become more proactive in managing patient health through a new emphasis on patient compliance or do a better job of collecting and analyzing patient data. 

Value-based care

Primary care has been moving toward a
value-based delivery and reimbursement model for years, but for many physicians 2017 will be the year the shift hits home. Most everyone agrees that the fee-for-service model is too expensive and doesn’t deliver coordinated care. Value-based care is designed to deliver better care while lowering costs and increasing pay for PCPs.   

Many physicians have already been participating in a variety of value-based programs, but the stakes are higher in 2017 as they come to grips with MACRA’s new performance standards, reporting requirements, penalties and bonuses. Passed in 2015 and finalized in October, MACRA represents Medicare’s no-turning-back commitment to value-based care and it comes with financial rewards and sanctions to achieve its goal.

And it’s not only Medicare. Private payers also are moving to value-based care. The Health Care Transformation Task Force, a coalition of private insurers and provider organizations, has announced that its members, including such major payers as Aetna and Blue Shield of California, are committed to moving 75% of their contracts to value-based payment models by 2020.

“You can’t hide from this. Hiding from MACRA is one thing; hiding from value-based reimbursement is another,” says Zetter.

A team approach

Adopting a value-based approach to care means making space in the exam room for more providers. 

Two of the fastest-growing delivery models, patient-centered medical homes (PCMHs) and accountable care organizations, require teams of providers. These models are built on the concept that doctors, mid-levels, nurses, therapists, nutritionists and social workers, as well as organizations such as healthcare systems, hospitals and nursing homes can coordinate on the delivery of high-level care.

Much of the coordinating will fall to primary care doctors. While many say they welcome the added responsibility and chance to improve care, they also worry about the extra work involved and whether they will be compensated for it. 

“Primary care needs to be paid more just so we can do the everyday things required of us for integrating care,” says Hollister. While MACRA is intended to raise pay for high-performing PCPs, earning those bonuses can come with a cost. For example, Hollister’s three-provider practice has hired one staff member to handle metrics, reporting and data, and a patient navigator to ensure patients are getting the help they need.

And since their compensation will depend on patient outcomes and costs, PCPs also will need to be aware of the cost and quality of the care delivered by the other providers on the team, says Zetter.  

The pursuit of efficiency will reshape how care is delivered, says Flower. “The model of one-to-one interaction is going to disintegrate. That’s way too inefficient and you can deliver healthcare in different ways,” he says.

At the same time, physician assistants and nurse practitioners are likely to play a greater role in diagnosing and treating patients. Likewise, patients will increasingly seek primary care in non-traditional settings, such as retail clinics and through app-based services such as Doctor on Demand.   

Losing independence?

In the future, primary care is more likely to be delivered by employed doctors than by independent practitioners.

A 2015 report from the consulting firm Accenture forecast that the percentage of physicians in independent practice would decline from 57% in 2000 to 33% by the end of 2016. Most are joining hospital practices, citing familiar reasons: reimbursement pressures and overhead costs. 

Depending on their patient base, many small practices are exempt from MACRA, but value-based contracts with commercial payers will pressure them to join healthcare systems or otherwise affiliate with larger organizations, says Flower.

“What’s being created is an environment that’s not friendly for independent, small organizations,” he says, adding, “There is no significant reason to be small.” 

Many young doctors don’t even regard independent practice as an option anymore. For example, Mara Gordon, MD, a 30-year-old resident in the family medicine program at the University of Pennsylvania Health System in Philadelphia, says she can’t imagine being her own boss.

“There are headaches that come from being affiliated with a large healthcare system, but I think the benefits outweigh the costs,” she says, citing job and income security, administrative support and access to the latest research and innovations.

It’s also unclear what effect value-based care will have on efforts to address the shortage of primary care doctors. If it results in better pay, greater prestige and more control for physicians, more medical students might be inclined to choose primary care practice. 

If not, the field may become even less attractive to new physicians.

Remaining independent

Independent PCPs who don’t want to become employees will have to work hard to retain their status. While value-based care is designed to increase payments to high-performing practices, meeting the reporting requirements and coordinating care for patients could overtax small practices already struggling to remain open.

“I hope I can remain independent. In all honesty, I’m also keeping my options open because it’s a scary time,” says Linda Delo, DO, owner of Delo Medical Associates, a solo primary care practice in Port St. Lucie, Florida. 

Delo has done everything she can to position herself for success. Her practice is a Level 3 PCMH and achieved Meaningful Use Stage 2 in 2015. She has earned quality-based performance bonuses from commercial insurance payers. Her practice embraces coordinated and value-based care and she thinks she will earn bonuses under the new system, but still worries it won’t be enough to remain independent.  

To do that, many practices will have to find alternative models, such as direct patient care, says Flower. He also suggests PCPs with a large number of patients from a single employer work with that employer to offer primary care on a fee-per-employee basis, eliminating third-party payers. 

Opting out

Even as most PCPs come to terms with MACRA and value-based care, others are stepping away from primary care or finding new practice models that aren’t part of that system. 

A 2016 survey of more than 17,000 U.S. physicians by The Physicians Foundation found that 48% plan to reduce hours, retire, take a non-clinical job, switch to concierge medicine or take other steps to cut back on the number of patients they see.

Internist Ben Fischer, MD, has rejected private insurance and MACRA in favor of direct primary care (DPC), a practice model he says works better for him and his patients. After eight years in an independent, 25-doctor practice in North Carolina, Fischer could no longer tolerate the over-scheduling, too-brief appointments, wrangling with insurance companies and other common doctor complaints. 

“I was sick of being a gerbil running on a wheel set on someone else’s schedule,” he says. So he quit the practice and last year opened Fischer Clinic in the back of a 100-year-old pharmacy in Raleigh. The DPC practice is just Fischer and a nurse treating 600 patients, but he’s happy with it. “Direct primary care seemed to be totally stripped down to the basics of the doctor-patient relationship,” he says.

DPC, in which physicians don’t any third-party payments, but instead charge a flat monthly fee for primary care, has grown to include more than 500 practices nationwide, according to the Direct Primary Care Coalition. Proponents say that by eliminating the billing, coding and negotiating that comes with insurance, doctors are able to spend more time with patients and provide better care at a lower cost.

DPC practices can be opened anywhere, though some states classify it as a health insurance plan subject to state regulation, something advocates are working to change. Whether the model is scalable enough to truly revolutionize primary care remains to be seen, but believers like Fischer say it’s the best option they’ve found.

“I don’t believe that what I’m doing is going to save the world, but I do think we’ve often gotten stuck thinking about a big solution (to healthcare). Often, the right solution is a lot of people doing the right thing,” he says.

A technical future

To thrive under value-based care, primary care practices are going to have to reconfigure their offices and workflows around technology, according to researchers at the Connecticut Institute for Primary Care Innovation (CIPCI), a collaboration between St. Francis Hospital and Medical Center in Hartford and the University of Connecticut School of Medicine.

To achieve maximum efficacy and efficiency, physicians should delegate any tasks they’re now doing that a non-physician could do and make sure everyone in the practice is working to the top of their licenses, says internist Adam Silverman, MD, director of outreach for CIPCI.

He envisions a practice where the waiting room is used for educating patients and exam rooms are supplemented by open spaces for group appointments and clinical team huddles. Outside the practice walls, patients and providers communicate using a variety of digital platforms, with patient health monitored remotely and routine interactions facilitated by technology. Those changes will not only improve care, they’ll boost doctor morale and reduce burnout, says Silverman.       

Flower predicts that patients with chronic conditions, such as diabetes, will have their health monitored by primary care practices through devices such as skin patches, which can detect blood sugar levels, and implanted “wisdom teeth” that can report on various conditions by analyzing saliva.

But the inevitable advance of technology in primary care also concerns some physicians, including internist Nitin Damle, MD, president of the American College of Physicians, who thinks it could lead to the depersonalization of medicine and a weakening of the patient-physician bond. 

 “There is a lot going on with technology and we have to embrace that because that is not slowing down, but we also have to make sure we don’t burn out over it,” Damle says.

While dependence on technology and the shift toward value-based care are here to stay, the future of primary care is likely to be determined by struggles and negotiations among the many stakeholders, including PCPs, specialists, politicians, Medicare, Medicaid, commercial insurers and healthcare systems, Damle says.   

“We don’t have an overarching plan for revitalizing internal medicine. Everyone is going to have to work together and probably give up some ground to get it done,” he says.