The state of U.S. primary care: Daunting challenges, achievable solutions

Value-focused efforts to shore up primary care require bold initiatives that increasingly are being implemented but continue to encounter obstacles, according to insights from a recent conference.

“We have answers in a kind of amazing array of [physician] practices all over the country that are generally doing an aligned thing,” said Asaf Bitton, MD, associate professor of healthcare policy at Harvard Medical School and executive director of Ariadne Labs, during a November conference hosted by the Health Care Payment Learning & Action Network.

 “They work with teams powered by data, caring for patients and communities, not just within the four walls of the clinic, and not just waiting for people to come into the clinic, but proactively reaching out.”

Other noteworthy aspects of advanced primary care practices include integrating behavioral healthcare, screening for and addressing social determinants of health, and looking to incorporate financial accountability measures.

Yet significant potential remains unrealized.

“The only part of the healthcare system in which investments routinely and predictably result in better outcomes, with more equity at sustainable costs, is primary care,” Bitton said.

As the literature indicates, “If you want better outcomes with better equity at a reasonable price, you double primary care spend,” he added. “Is that easy for you in your health system, with all the other issues, to do, and find and hire and train the right people? No, but look what happens when you do that.”

Striving for payment solutions

Prospective payment for primary care seems like an obvious approach yet still is not as prevalent as policy experts recommend.

“The resiliency that [that] sort of prospective payment brings is really important because things happen at the practice level day to day,” said Nicholas Minter, director of the Division of Advanced Primary Care at the Center for Medicare & Medicaid Innovation. “It is [the] independent primary care providers — those that have a really strong connection to their community and fidelity to keeping their patients healthy — that are the most vulnerable to those sorts of disruptions.”

CMS and private payers need to “figure out how to move away from fee for service and pay primary care — not total cost of care, not to look at the whole book of business — but to parse that out and pay that prospectively, [and that’s] difficult,” Minter said.

One consideration is how to deal with the potential for fraud and abuse in such payment mechanisms. Safeguards need to be installed, but in general, Minter said, “The perfect can’t be the enemy of the good. It is really important to provide the resiliency to the backbone of the healthcare continuum to [help it] be able to subsist and to focus more on patient care … removing boundaries between the provider and patient care.”

Payment cadence is key, said Eileen Testa, administrator with Philadelphia-based Ninth Street Internal Medicine.

“The payments have to come in more regularly,” she said. “They can’t come in a lump sum one time a year. You can’t budget that way. It’s just impossible.”

Unwieldy quality measures

The Trinsic clinically integrated network (CIN), an initiative of Intermountain Health and UC Health, has value-based payment (VBP) contracts with all the major payers and also participates in the Medicare Shared Savings Program, noted Amy Scanlan, MD, chief medical officer. That makes the organization responsible for roughly 130 different quality measures, which it must try to condense into a single scorecard for physicians.

Said Bitton, “It seems hard to imagine that the shared goals of this 10-plus, 15-year [VBP] endeavor can be met without really hard choices on parsimonious measure sets that aren’t perfect, and no one’s fully happy about, but [that] allow [for] focus to change the things that should be changed.”

Judy Zerzan-Thul, MD, chief medical officer with the Washington State Health Care Authority, said frequently utilized HEDIS metrics are “not really adequate to get at: How do you measure changes in this population’s health? And in particular, how do you measure changes in chronic conditions over time?”

A long-running concern with measurement is that the better an organization performs, the steeper the curve it faces in continuing to earn incentive payments.   

“There needs to be the ability, [with] practices that are at the highest level of their measures, not to punish them or say, ‘Well, you still have to show levels of improvement year over year,’ because sometimes that’s not sustainable,” Testa said.

She said her practice has a 90% rate of colorectal screening across payers, for example.

“Where do we go from there? How do I get to 100%? That’s not going to happen,” Testa said. “But I have to show improvement [to] all of my payers.”

Future areas of focus

Nicholas Stine, MD, population health fellow and executive-in-residence at the University of California Berkeley, said models should try to incorporate specific public-health goals, such as collaboration among stakeholders to eradicate hepatitis C now that an antiviral cure is available.

“You talk to clinicians, they would love to do something,” Stine said. “It’s so satisfying to actually cure a chronic disease. How often do we get to do that? If we can figure out in some of these models how to have a little bit more wind at the back from a policy and payment perspective to drive that, we can do great things.”

Another area that should be a greater focus of payment models is the between-visit space, Scanlan said.

For example, her CIN uses virtual-care huddles to support physicians in ensuring patients receive the requisite attention and resources in the months after a visit.

She added that payer-sponsored care management programs “are great, but they’re a level removed, and oftentimes what we find is they don’t reach the patient in the same way that it does if you’re in the office or if you’ve got a care manager who’s associated with the actual clinic calling [you].”

But a challenge is to ensure physicians have the bandwidth to participate in the huddles instead of saying they cannot find the time amid the need to churn through patient visits and paperwork, Bitton and Scanlan said.

“We continue to have some pushback,” Scanlan said. “We have been very clear with our practices [that] this has to happen for the first three months. After that, if it’s really not valuable, come talk to us.”