This disconnect stems from how we spend our money. Research confirms that advanced primary care, such as patient-centered medical homes and other accountable care models, help fulfill the “quadruple aim”: high-quality care, better health, lower costs, and improved experience for clinicians and staff in the delivery of care.
Despite this understanding, the best available estimates indicate that the percentage of health care spending devoted to primary care in the US is an anemic 5 percent to 7 percent. In a recent study, RAND Corporation researchers estimated that just 2.12 percent to 4.88 percent of total Medicare fee-for-service medical and prescription drug spending goes toward primary care. High-performing health care systems in other countries spend double or triple that amount.
One way to bridge this gap, which Anthem and the Patient-Centered Primary Care Collaborative (PCPCC) both support, is to promote new approaches to delivering primary care, such as value-based payment models. The Center for Medicare and Medicaid Innovation’s April 22 announcement about five new voluntary primary care payment models is a significant step toward paying for value rather than volume.
Anthem has found that these value-based arrangements can lower costs and improve quality. They enable advanced primary care practices to provide integrated, patient-centered, team-based care, and to begin to get off the fee-for-service treadmill by receiving compensation for work they do between office visits, such as care coordination and care planning. Anthem’s next generation of value-based care models will also reward population health management and prevention while incentivizing coordination between primary care providers and medical specialists, expanding value-based care across the medical neighborhood.
A key focus of the PCPCC’s advocacy agenda is helping to facilitate state efforts to invest more in advanced primary care models. In conjunction with the Graham Center, the PCPCC recently issued its 2019 Evidence Report, an initial look at state spending on primary care by both commercial and public payers. This report, which also shows an association between increased primary care spending and reduced hospitalizations and emergency department visits, provides important information for state leaders as they prioritize spending and focus on both improving population health and keeping costs in check.
Measuring Primary Care Investment
While the US is underinvesting in primary care, the exact degree of that underinvestment is difficult to calculate because a standard definition of “primary care spending” does not exist. Without an agreed-on measure, we cannot draw definitive comparisons, but we can see that the US lags behind other industrialized, wealthy countries whose health outcomes are better than ours are.
A standard, publicly reported measure of primary care for the US would not only allow us to make comparisons among states, health plans, and accountable care organizations but would catalyze research quantifying the value of primary care. Ultimately, a measure could help public and private payers prioritize their allocation of health care spending and resources. And it would help us to better evaluate new value-based payment models across payers and payer types.
Choosing the right process to create this measure will ensure its relevance and durability. First and foremost, it must be a consensus-based approach driven by a broad group of stakeholders. It’s important that multiple voices are included, encompassing not only physicians and other health care providers but also patient advocates, health plans, and other purchasers, including employers and state Medicaid agencies.
This multistakeholder group should be guided by a trusted, independent third party such as the Health Care Payment Learning and Action Network (LAN), the National Academy of Medicine, or a similar public-private partnership. The LAN, for instance, could take on the job of defining “primary care spending” in much the same way it set a national standard framework for defining alternative payment models.
While other efforts to define primary care already exist, such as those that have grown out of state initiatives or legislation, our proposed approach for a national standard would be preferable; even the best rules and metrics would be difficult to implement and follow if there were 50 versions with different nuances. Nevertheless, the process should be informed by existing work, including the groundbreaking work supported by the Milbank Memorial Fund.
The group that takes on this work should leverage its members’ multiple perspectives and think broadly about how to define primary care services, particularly in light of value-based payment models. Defining primary care spending will mean answering some weighty questions:
- Should primary care spending include spending beyond direct reimbursements, such as infrastructure payments to patient-centered medical homes or accountable care organizations?
- Should capitated payments to provider organizations be differentiated into the dollars that flow to primary care versus non-primary care services?
- Should primary care spending include only payments that flow to a narrowly defined set of primary care clinicians, or should payments to a broader range of team members be included in the primary care spend measure?
- Should primary care spending be defined solely by the specialty of the rendering provider or also by the specific types of services delivered?
While we believe the answers to these questions are best left to a consensus-driven group, our hope is that they will lead to a measure that helps the US more effectively identify where greater primary care resources are needed.
A Cooperative Primary Care Strategy
All Americans deserve a health system that delivers the best possible health and health care in the most efficient way possible. All of us in health care—patients, insurers, clinicians, employers, hospitals, and government—can work cooperatively to bring balance to our country’s health care system, shifting spending to primary care and prevention. As a first step, we must prioritize and reward high-quality primary care services.
Date: August 07, 2019
Source: Health Affairs