Pandemic Shines Spotlight on Need for Comprehensive Primary Care
The pandemic has given us an opportunity to see both how valuable and how vulnerable our primary care system is. As a percentage of total cost of care, primary care spending has been going down over the last decade, even with the coverage expansion through the Affordable Care Act. Many small practices were hit hard by the pandemic. But there are efforts across the country to bolster primary care, integrate it with behavioral health, and pay for it differently. Can they be scaled up on a national level?
“If you look at different measures of the orientation of our healthcare system toward primary care, they’re going in the wrong direction,” says Ann Greiner, president and CEO of the Primary Care Collaborative (PCC), where she leads efforts to define an agenda that furthers comprehensive, team-based and patient-centered primary care.
One of the problems the pandemic highlighted, she says, is that the vast majority of practices are still paid in fee-for-service. “We haven’t actually seen much of a change over the last several years in terms of the proportion of physician practices that are paid by capitation or even more broadly in value-based arrangements,” she says. “I think those practices in value-based payment arrangements fared better during the pandemic.”
Several years ago, Rhode Island was the first state to require increases in primary care spending over a five-year period. Now an additional four states have committed to increasing primary care spending to achieve the outcomes they are seeking. “Many of them urge that these dollars go into value-based payment arrangements and help to fund more comprehensive primary care,” Greiner says.
In addition, 12 states are now reporting on primary care spending as a percentage of overall spending. “I think that’s a very important first step,” Greiner says. “European countries, as a matter of course, report primary care expenditures, and I think we need to do that. We need standardized national measures so that we can compare one state to the next and one year to the next and have a way to understand what’s happening within our system. States are looking across health plans, and it’s an opportunity to ask the question: are our expenditures reflective of the goals we’re trying to achieve? Are we being strategic with our investment if we want a healthier population? We want to address the inequities that were always there, but that have become much more intense with COVID,” she says. “Primary care is very well-situated to work with others to help address health inequities. If we partner with patients to provide good chronic care management and prevention and health promotion, we’re going to have not only a healthier population, but we won’t have the same number of downstream expensive interventions that are needed because people’s health will be better.”
Christopher Koller is president of the Milbank Memorial Fund, which funds research and collaborative work focused on primary care and health system transformation. He stresses that it is important to study whether people with better access to comprehensive primary care were in better shape to weather the pandemic. Those patients would have had a reliable source of information from their primary care provider; they were getting information sooner about prevention; those providers were more likely to switch to telehealth sooner and more likely to be paid in a non-fee-for-service way, so they could maintain operations at the beginning when everything was shutting down, he says. “That would put the patients in good stead, but not everyone had access to that kind of primary care. It is the minority of primary care practices that are paid in a way that can provide comprehensive care; most are still stuck in fee-for-service medicine.”
Moving to comprehensive primary care
Koller says speeding up the transition to comprehensive primary care must start with Medicare. “Alignment is important, and until Medicare moves, other payers are not going to align. In a multi-payer world, if every payer is coming to a primary care practice with a different model, that is not going to help the practice very much. If Medicare moves first, it starts to set the standard for the commercial payers.”
Koller, who led the reforms in Rhode Island as its health insurance commissioner, says many other states are making progress on primary care improvement, including Maryland, Oregon and Minnesota. “In Minnesota, clinics are not a dirty word,” he says. “People go to their clinics. They think in terms of multispecialty, primary care-oriented practices.”
He says there is a logical order of battle in moving to comprehensive primary care. “First states make this commitment to primary care,” Koller notes. “Then they start to explore other things. Oregon has created a standard for comprehensive primary care. Vermont has shared resources for primary care practices to use. That is a natural second stage after you make a policy commitment. It leads into issues like community health teams and greater integration of behavioral health,” he adds. “Those are all capacities we need to fight the pandemic. It is of grave concern that the money appropriated under the CARES Act has subsequently gone to bail out hospitals. It hasn’t gone to build up primary care. I think we who are concerned about this are doing our best to raise awareness about the fact that if you want to have a pandemic-resilient delivery system, you have to have strong primary care.”
Maryland’s approach
For several years, the State of Maryland has been working with the Center for Medicare & Medicaid Innovation to move all the hospitals in the state from fee-for-service to a globally budgeted system. Both the federal government and the state soon recognized that they couldn’t achieve a balance and effectively reduce the hospital and emergency department high cost and unnecessary utilization without engaging with ambulatory providers at the same time. That led to the creation of the Maryland Primary Care Program, a voluntary program open to all Maryland primary care practices and modeled after the CMMI’s national Comprehensive Primary Care Plus (CPC+) program. More than 560 practices —about two-thirds of the practices in Maryland — are participating in the network. In the first year of the program, Medicare was the only payer. CareFirst BlueCross BlueShield, the state’s largest commercial payer, joined in 2020. Several of Maryland’s federally qualified health centers joined in January 2021.
“What we really want to do is change the way we deliver healthcare in the state to make it equitable, and we provide sufficient resources, particularly for those previously under-resourced Medicare fee-for-service beneficiaries by making strategic investment in primary care,” explains Howard Haft, M.D., the program’s director. “We knew there was insufficient care management in primary care, insufficient access, and insufficient data management across the continuum of care. We knew there was virtually no behavioral health integration into primary care — and that was a big issue.” One of the things the Maryland team saw when looking at the CPC+ program was that for small and medium-sized practices, it was hard to access care management, pharmacists, and social workers. “We created care transformation organizations around the state that can use economies of scale and serve these practices with a simplified contractual design to provide a pro-rated amount of pharmacist or LCSW (licensed clinical social worker) or care manager,” Haft explains. “We have 24 of those across the state, and 70 percent of the practices choose to contract with those to one degree or another. In addition, 96 percent of practices had integrated behavioral health to some degree by the end of the first year.”
One ingredient of the “secret sauce” making the program work involves feeding data back to practices in individualized dashboards through the state health information exchange, CRISP. “We provide meaningful, actionable data to everyone in the program,” Haft says, “as well as the resources that allow them to understand how to use that data in their work flow. We engage a team of practice coaches and we do ongoing education.”
The federal Primary Care First alternative payment model is enrolling practices now. It is intended for practices that are willing to accept a small amount of downside risk for the total cost of care in exchange for upside benefits. “Think of it as more than CPC+ but less than an ACO [accountable care organization],” Koller explains. “It is meant for primary care practices that have transformed and are ready to take on risk. I think there needs to be a focus on the primary care practices that are still being paid in fee-for-service. There are practices ready to do the complex and comprehensive payment mechanisms, but the majority of doctors are still on fee-for-service and we have to get them off of that. That left us very poorly prepared for the pandemic, and I think that should be a policy goal.”
Haft stresses that other nations around the world that have better health outcomes and lower costs are largely characterized by making more investment in primary care and having larger, more effective primary care programs. “We can’t fix the vexing problem of higher per capita expense and mediocre results with the same tools that created it,” he says. “We need different tools.”
