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From volume to value: Primary care delivers


There are numerous models for primary care delivery successfully saving money while also improving patient outcomes.

Editor's Note: Welcome to Medical Economics' blog section which features contributions from members of the medical community. These blogs are an opportunity for bloggers to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform.

Innovative payment models are changing the way healthcare is paid for and delivered in the United States-for the better. The transition to a value-based healthcare system, one where physicians, other health professionals, and health systems are rewarded for high-quality services that improve patient outcomes, is underway. Evidence shows that primary care can help us live longer, healthier lives and can save our healthcare system $13 for every $1 spent. As the healthcare sector shifts toward rewarding value over volume, primary care should be at the heart of our efforts to promote simplicity, coordination, and affordability.

Now is the time to examine the many successful models for primary care delivery that save money as they improve patient outcomes and determine how we can accelerate these programs to reach even more patients. These include both pilot projects that should be expanded, as well as long-standing programs that strengthen the foundation of America’s healthcare system.


Home-Based Primary Care and Medical Homes Deliver on the Triple Aim

One example of a successful model for primary care is the CMS Innovation Center’s Independence at Home Demonstration, which offers home-based primary care to patients with multiple chronic conditions. The program saved Medicare over $7 million in 2017-an average of $746 in savings per Medicare beneficiary. As the program’s latest progress report says, home-based primary care “allows healthcare providers to spend more time with their patients, perform assessments in a patient’s home environment and assume greater accountability for all aspects of the patient’s care.” This successful initiative was extended by two years, and expanded slightly in the Bipartisan Budget Act, but its enrollment remains limited to 15,000 beneficiaries.

Advanced Primary Care Medical Homes, which focus on care coordination and team-based practice, have also been shown to transform healthcare delivery and improve the quality and experience of care for patients. In this setting, healthcare providers are able to work together as “partners in care,” placing patients at the center of their care and ensuring that additional services, like behavioral health screenings and treatments, are readily accessible.

Initiatives like the Centers for Medicare and Medicaid Services’ Comprehensive Primary Care Plus (CPC+) program, a five-year, multi-payer program, are expanding the medical home model across the country by encouraging team-based approaches to caring for patients.

The Independence at Home and CPC+ programs are just two examples of innovative payment models that not only reward quality but offer real benefits for patients. These initiatives reiterate the value of primary care and its ability to improve the overall quality of care and life for patients served while reducing costs. As we look to pay for value and outcomes rather than volume, we need to make programs like these available to practices across the country.


Continued Success from Community Health Centers and Workforce Programs

Together with these programs, we should also look to expand and sustain long-standing initiatives that have consistently delivered primary care to communities that face high rates of costly chronic disease and lack access to the same broad range of physicians and hospitals enjoyed elsewhere.

For 50 years, community health centers (CHCs) have delivered affordable, accessible and quality primary care to patients, regardless of their ability to pay. Funded largely by the Community Health Center Fund (CHCF), CHCs care for the whole person by providing both medical and behavioral healthcare as well as pharmacy services to more than 27 million individuals in almost 10,000 urban and rural communities.

While the latest federal spending bill provides two years of health center funding, CHCs face an uncertain future if so-called “funding cliffs” are not resolved by sustained CHCF appropriations. Lapses in CHC funding jeopardize the care of some of our nation’s most vulnerable citizens and destabilizes thousands of communities. This should be the last year that health centers get caught up in Capitol Hill’s wrangling. Well before the next deadline, a long-term funding solution for these invaluable services must be found.

Similarly, if we want to ensure primary care is an increasingly attractive career path to students-and incentivize them to practice in these underserved rural and urban communities-we have to invest in training more primary care professionals. Fortunately, we already know how.

The National Health Service Corps (NHSC) provides scholarships and loan forgiveness to nearly 10,500 primary care, dental, mental, and behavioral health practitioners serving in rural, urban and frontier communities. The Teaching Health Center Graduate Medical Education Program also trains primary care residents in federally qualified health centers, rural health clinics and tribal health centers. Seventy-seven percent of these residency slots are in medically underserved communities. After the end of their service, more than 60 percent of NHSC-trained primary care professionals remain in areas experiencing health professional shortages for an average of 10 years.

From these programs, we have learned that when physicians, nurses and others are trained in a community, they stay in these communities, filling crucial gaps in our primary care workforce. Working together, Congress and the administration should increase the federal commitment to the NHSC and Teaching Health Center programs as well as support other successful primary care workforce initiatives.

Together, we can accelerate existing models and programs that make primary care accessible to all while innovating a new generation of advanced payment models that reduce costs and improve outcomes.

Glen R. Stream is a family physician in La Quinta, Calif., and president of Family Medicine for America’s Health, which sponsors the Health is Primary campaign. John Rother is president and CEO of the National Coalition on Healthcare.


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