But doctors need more funding and payment options to be effective
America’s health care system is in crisis. Amid the COVID-19 pandemic, we are facing a growing behavioral health and substance abuse catastrophe compounded by the unknown long-term health impacts of the virus itself. At the same time, our expensive health care system is failing to produce positive outcomes for individuals and communities with diverse health care needs—creating barriers to care for millions of Americans. However, we can change the trajectory by investing in the only part of the health care system documented to improve health and lower cost: primary care.
In its landmark report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, the National Academies of Science, Engineering and Medicine highlighted primary care as the only discipline of medicine associated with better health outcomes and lower costs. However, primary care must be sufficiently resourced and supported to play this essential role.
The value of primary care to individuals and our health care system has never enjoyed broader recognition and support, but it has also never been at greater risk. This is primarily due to a failed financing model. To truly achieve the full benefits of primary care, we must support a more comprehensive, longitudinal, multimodal, and proactive style of primary care versus the reactive, episodic, sick-focused, fee-for-service system that exists today.
While there have been many efforts to transform primary care, mostly they have focused on achieving quick results in models built on the faulty foundation of the fee-for-service model. For the past decade, we have approached innovations in primary care delivery and payment models as if they were a 100-meter dash. We line everyone up and ask them to go as hard as they can, for a short period of time, and hope that a winner emerges.
In many cases, we ask them to run this race with a 100-pound weight strapped to their backs. However, primary care physicians who engage with these innovative models assert maximum effort for a short period of time only to find themselves exhausted and likely left out of the next race. This is the wrong approach.
There are three steps that payers, including Medicare and Medicaid, should take to accelerate participation in non-fee-for-service models among primary care physicians:
Budgets often reflect what we value, and our track record shows investment in primary care isn’t a priority. The current system has failed primary care, largely due to the design of the resource-based relative value scale.
Simply put, our investment in primary care does not begin to support its true capabilities or our expectations of it as a country. Effective primary care is more than the sum of its component services. We should seek to pay primary care based on its value to individuals and populations, not just its resource costs. Furthermore, correcting historic distortions in primary care financing is critical to expanding the primary care workforce, which would enhance the value of a longitudinal relationship with a primary care physician.
2. Create additional primary care alternative payment models
For the past decade, we have engaged in a create, implement and test approach to primary care payment models, refusing to make model improvements or launch new models until evaluation of the previous model is complete. This approach prioritizes evaluation over innovation. Moving forward, we need to create multiple primary care models that are available to all physicians and include Medicaid beneficiaries, rural communities and other underserved populations.
These models should be designed to help physicians move into more advanced payment models over time, with performance metrics that increase commensurate with capabilities and reward potential. Finally, these models must be responsive to real-time learnings and innovation. If technical adjustments are needed to improve the model and the care provided to patients, we should make those adjustments. Our main objective is clear: to improve our health care system, not to focus on the evaluation process.
3. Remove barriers to entry by creating an “on-ramp” for physicians
Primary care physicians and practices are not one-size-fits-all. Instead of asking physicians to use models that may be beyond their current capabilities, we must create models that meet them where they are—allowing them to build skills and capacity. We must also invest in structural supports, such as access to timely and actionable data, technical assistance programs and learning collaboratives that help practices build capabilities whether they are in a model or not.
The reality is that front-end investments are needed to position physicians for success in value-based payment models. By creating “on-ramps” we can eliminate the current trend of primary care physicians not engaging in innovative models because of their complexity and cost.
Strengthened investment in primary care, creating more alternative payment models and removing barriers for physicians will improve our health care system. But primary care physicians can’t do this alone. We need the help of our nation’s lawmakers, employers, health plans and health care leaders to design, implement and evaluate innovations in primary care financing. Only then can we recognize the true value of primary care and achieve our shared goal of ensuring equitable, affordable and accessible care for Americans.
R. Shawn Martin is executive vice president and CEO of the American Academy of Family Physicians.