Everyone seems to agree that we need a better way to pay for primary care, but most health plans are doing little to improve primary care payments. High administrative burdens, simplistic performance standards and low payments in today’s ‘value-based’ payment systems failed to improve the quality of patient care and cause many primary care practices to close. Rather than tackling these issues, Medicare’s new “Primary Care First” demonstration take a step back, offering lower payments than the Comprehensive Primary Care Plus (CPC +) demonstration and penalizing practices that support patients with high needs.
We to propose a radically different approach: a patient-centered payment system that would adequately pay for each of the three main types of primary care services – wellness care, acute care and chronic disease management – and ensure appropriate care and high quality for each patient according to their individual needs.
Align payments to services
Adequate payment for primary care is essential. Health insurance payments to primary care practices should be aligned with how services should be provided. This can be done through a two-part payment approach:
One monthly payment per patient for wellness care and chronic disease management. Wellness care and chronic disease management should be proactive services designed to prevent problems, rather than reactive care that only occurs when a patient comes to the office. In addition, many aspects of these services can be delivered by nurses and other staff as well as a clinician. A monthly payment provides the predictable and flexible resources needed for this purpose. However, the payment must be higher for a patient with chronic disease and even higher for a patient with social risk factors, so that the practice can devote sufficient time to meeting the needs of each patient. Patients must voluntarily enroll in a primary care practice if they want to receive the services supported by these payments, rather than a payer “attribute“the patient to a primary care practice without the knowledge or consent of the patient or primary care provider.
Fees to resolve a new acute problem. When a patient has a new acute problem, primary care practice should be organized to diagnose and treat it promptly, and the clinician must have enough time to ensure accurate diagnosis and plan appropriate treatment. Patients with more frequent acute problems will require more clinician time, and payment must be sufficient to support the extra effort. Since the systems commonly used to ‘adjust the risk’ of capitation payments to not consider new acute problems and new chronic diseases, the best way to support this inherently responsive, clinician-focused service is to pay an acute care fee. The fees should allow the flexibility to provide care in the way that best suits the patient – an office visit, telehealth or a phone call. However, fees would only be paid for new types of acute problems; exacerbations of previously diagnosed chronic conditions should be treated by services funded by monthly payments.
This combination of monthly payments and fees is in line with the âhybridâ payment recommendation made at a recent national academy of science, engineering and medicine. report on primary care. However, unlike current hybrid payments who continue to pay fees for all types of visits and add a small monthly care management payment, our approach rewards primary care practice for reducing chronic disease exacerbations and responding quickly to emerging acute problems.
Making primary care affordable for patients
In addition to paying the primary care practice adequately and appropriately for its services, health insurance plans must ensure that primary care is affordable for patients. Many patients with the greatest health care needs are the least able to pay more for the extra help they need, and financial barriers to care are one of the causes of current health disparities. Ideally there should be no patient cost sharing (i.e. co-payments, coinsurance or deductibles) for monthly payments for wellness care and chronic disease management, since these services can avoid the need for more expensive care in the future. If cost sharing is required, the cost sharing amount for acute care services should be set so that it is affordable for patients, to encourage them to seek early diagnosis and appropriate treatment of problems through primary care practice.
Ensuring the quality of patient care
We recommend abandoning the use of quality measures and payment incentives like the merit-based incentive payment system (MIPS) in Medicare and the payment-for-performance (P4P) systems used by other payers. . In addition to being administratively burdensome, current quality measures penalize physicians when they tailor care to the needs of each patient. This can make it more difficult for disadvantaged patients access to appropriate services and is likely to increase inequalities in outcomes rather than reduce them. In addition, there are no quality measures for many aspects of care and many types of patient needs.
Instead, we recommend a more robust, efficient, and patient-centered approach – asking primary care practices to proactively identify patient needs and provide evidence-based care to meet those needs. :
Regularly assess patient needs and outcomes. Good primary care requires knowing whether patients are having problems and whether their treatments are working. Free technologies, like that of Dartmouth HowsYourHealth.org, allow primary care practices to regularly ask each patient some standard questions on the health issues that concern them most. Many small practices have been successfully use these tools to improve patient care, but current payment systems do not reward it.
Use evidence-based clinical practice guidelines. Provide the services recommended by evidence-based clinical practice guidelines is the most appropriate way to achieve good results for most patients. However, the clinician should be able to deviate from guidelines when the recommended services are inappropriate or unfeasible for a particular patient. If (and only if) primary care practices are adequately remunerated, it is reasonable to expect that they will use evidence-based guidelines developed without commercial influence to diagnose and treat patients and document them. reasons why deviations from the guidelines are necessary.
The quality assurance mechanism should be simple and straightforward: when a practice submits an invoice to a payer for a monthly payment or acute care charge for a patient, that would attest that he regularly assessed the patient’s needs and outcomes and provided the care recommended by the appropriate guidelines (or documented the reasons for the deviation). It is not necessary for the firm to submit written documents of these things to the payer, just as current payment systems do not require a firm to submit documents proving that an office visit has been made or what was done during the visit. The documentation would be kept in the patient’s clinical file so that it could be verified if there was a problem with the quality of care.
Creating more value through a learning health system
Documenting the reasons for deviations from guidelines and evaluating service outcomes not only ensures quality care for individual patients, but also provides a mechanism to improve and expand clinical practice guidelines, especially for patients with more complex needs. This is essential to create the kind of “learning health systemThe Institute of Medicine (now the National Academy of Medicine) called over a decade ago. Small independent primary care practices have done this on their own before, and they’ve been able to provide better care to their patients accordingly.
We have to stop talking and taking action
Primary care is in great difficulty. The United States already ranks last among high-income countries in terms of access, affordability and equity of health care. The gap will only widen if we continue to lose primary care practices. We urge payers to start using a patient-centered approach to paying for primary care practices before it’s too late.
The opinions presented in this article are the sole responsibility of the authors and do not necessarily represent the opinions of the Patient-Centered Outcomes Research Institute, its Board of Directors or its Methodology Committee.
John H. Wasson, MD, is Professor Emeritus of Medicine at the Geisel School of Medicine in Dartmouth and has already spent four decades as a practicing internist and geriatrician. Harold C. Sox, MD, is a retired general internist, writer emeritus of Annals of Internal Medicine, and director of peer review at the Patient-Centered Outcomes Research Institute (PCORI). He is co-author of Medical decision making. Harold D. Miller, MS, is President and CEO of the Center for Healthcare Quality and Payment Reform, and Assistant Professor of Public Policy and Management at Carnegie Mellon University.
Last updated on August 31, 2021
Miller stated that he received personal honoraria from the American College of Allergy, Asthma, and Immunology, American College of Rheumatology, American Medical Association, American Society of Cataract and Refractive Surgery, American Society of Clinical Oncology, AsociaciÃ³n Colombiana de Empresas de Medicina Integral, Forks Community Hospital, Maine Hospital Association, New Mexico Hospital Association, North Dakota Hospital Association, Northern New England Clinical Oncology Society, Ontario Hospital Association, South Dakota Healthcare Financial Management Association, Utah Hospital Association, and Washington State Hospital Association.