U.S. primary care is hurting, but Medicare could be the prescription

The future of primary care is at risk and The Commonwealth Fund has proposed options Congress could consider to strengthen primary care through Medicare payment reform.

Amongst a few recommendations, Commonweath is encouraging how and how much we as payers, providers and consumers pay for primary care.

Primary care, critical for improving health and addressing patient needs, is on a decline for many reported reasons. According to a Commonweath report, the percent of people reporting a usual source of care is falling. This could be due to increased lack of patient access, the increase in physician burnout, fewer physicians choosing to go into primary care and physicians retiring in rural areas.

In relation to the investment aspect of primary care, there are two factors contributing to the fall of primary care as reported in 2021 by the National Academies of Sciences, Engineering, and Medicine (NASEM). These two factors result in decades of underinvestment and issues related to how we pay for care.

The portion of healthcare dollars going to primary care is small and decreasing over time across payers. According to Commwealth, the U.S. spends an estimated 4% to 6% of total healthcare dollars on primary care. For Medicare, primary care represents roughly 3% of spending.

Low reimbursement for primary care services play into what accounts for the underinvestment in primary care. In addition, reliance on fee-for-service payment leaves clinicians maximizing volume and rushing visits.

Medicare can have a profound impact in addressing these issues and revitalizing primary care in the U.S., according to Commonwealth.

"Primary care payment reform in Medicare can help restore balance to a health care financing system that is badly misaligned," a passage in the report said. "As a long-term investment, restructuring primary care can address the workforce shortage, improve the health of the population, and create greater equity."

Based on ideas generated by NASEM and the Medicare Payment Advisory Commission (MedPAC), below are options encouraged by Commonwealth that Congress could consider to strengthen primary care through Medicare payment reform:

1. Increase payment for primary care services.
   To address the undervaluation of primary care services, Congress could create two fee schedules: one for the evaluation and management of patients — everyday diagnosis, treatment, counseling, and patient or family support (known as E&M services) — and one for everything else. A dedicated E&M fee schedule would protect against payment for primary care–related services being decreased to accommodate fee increases for other specialty services, which is required to keep the overall fee schedule budget-neutral.
2. Develop a partial capitated per-member per-month payment model. Per-member per-month payments would provide clinicians a fixed amount per patient paid in advance, allowing clinicians to innovate, budget, and more easily integrate others kinds of care like behavioral health or telehealth. To ensure the payments address current undercompensation, they should represent a 30% to 50% increase in current revenues.
   
   For this to work, Medicare will need data from patients about who they consider to be their primary care provider. As an incentive for patients to designate a primary care clinician, Congress could waive any cost sharing for office visits when patients indicate their primary care clinician on an annual basis.
3. Modernize the Medicare Physician Fee Schedule.
   Create a new expert panel that simplifies the Medicare Physician Fee Schedule, collapsing the current 8,000 service codes into “clusters” of related services. Congress also can task the experts with identifying ways the Centers for Medicare and Medicaid Services (CMS) can determine rates using objective, empirical data rather than the current process, which relies on flawed estimates of clinician time and work.
4. Increase overall spend on primary care.
   Congress could direct CMS to require its payers and plans to measure and annually report the portion of total spending going to primary care, with the goal of increasing that proportion over time.