At the Value-Based Care Summit on Jan. 24, several innovators and stakeholders advocated for primary care as the cornerstone of value-based care’s future as the CMS Innovation Center works on revising accountable care initiatives.
Primary care often serves as the quarterback in assuring care throughout the system, said Stephanie Quinn, senior vice president for advocacy, practice advancement and policy for the American Academy of Family Physicians. “Instead of looking at value-based care through this narrow lens of just extracting savings from the system, we need to think about resourcing primary care on the front end. Fee for service is actually hostile to prevention and wellness. It puts physicians in a mode where they're waiting until people need care until they access it, whereas if you look toward value-based care and proactively and prospectively resourcing them, they're able to actually manage a population. And I think population health is what we're after.”
Quinn added that we really need not look further than COVID-19 if we were to look for the use case for why the transition is needed. “Those that were in largely fee-for-service practices were unable to meet their patients’ needs, and those who were being more prospectively paid were and I think that we really should take notice of that.”
Rushika Fernandopulle, M.D., chief medical officer at One Medical, a membership-based primary care practice, said that if we don't change the payment model, primary care cannot do the job it can do. “Fee for service is the wrong way to pay for primary care, and we should stop doing it,” he said. “Primary care is about relationships, not transactions.” Also, we need to actually double down on primary care, he added. It is 4 or 5 percent of total healthcare spending, and that number ought to be 12, or maybe 15 percent, and that would lead to better outcomes and actually lower total costs, he said.
“It would allow us to do a lot of things via omnichannel delivery models — email, text and video — to be proactive, and not just reactive,” Fernandopulle said. “In the end, if we don't actually make actual people healthier, this is all a waste of time, right? It's just a shell game. I think it's very clear that the sort of primary care models we're talking about that allow you to give people health coaches and navigators and engage with them in a variety of ways, is much better for patients,” he added. “I think we all can point to lots better outcomes, and by the way, we lower healthcare costs. But that's a side effect of doing this. It is clearly better for patients. When doctors start working on these models, they realize this is better for them; it is a much better way to practice. It might be some doctors don't like that. But, you know, we shouldn't design the system around that. We should design the system around improving outcomes. And by the way, the physicians end up liking it better.”
Steven Sell, M.B.A., CEO of Agilon Health, which partners with primary care on transforming to value-based care, noted that to achieve CMMI’s stated goals, you're talking about 30 million senior patients moving incrementally into accountable care. To do that, you're going to have to move a lot of communities that are 100 percent fee for service today into value-based care for the first time, he said. “You're going to have to create kind of an ecosystem within a community to enable that. We're focused on being a partner to these groups and allowing them to do that for the first time. That takes capital; that takes team-based support in which in the office they've got social workers and care managers, and nurse practitioners, so that primary care physician can practice at the top of their license. That's important. This year we are going to work with 22 payers, and the majority of them had never done this before, so many of the health plans are moving into this for the first time as well.”
Farzad Mostashari, M.D., co-founder and CEO of Aledade Inc., recalled that the conventional wisdom when they started Aledade seven or eight years ago was that value-based care was all about hospitals and health systems. “That never made sense to me, because not only is primary care the best situated to get all the relationships to be able to access the data throughout the ecosystem, but from a financial alignment point of view, they have the most to gain and the least to lose from moving away from fee for service. And I think that's why primary care is that Archimedes lever in moving the world.”
From a policy standpoint, the important thing is inevitability of moving to value. He compared it to his time as the national coordinator for health IT during the Meaningful Use era, and getting provider organizations on electronic health records. “We were able to get basically every hospital, almost 90 percent of physician practices in America off of using paper and pen to electronic health records, a much bigger transformation in their daily workflow than anything we had ever done before. The way that happened wasn't the size of the checks; it wasn't even that there were huge penalties. There was the sense of inevitability that this is going to happen, so you may as well do it sooner rather than later. More than anything else, we need the federal government as well as the private sector as well as purchasers saying this is going to happen —fee for service is not going to be the way that you are going to be a thriving practice in the future.”
Another recommendation Mostashari makes is that if you're in a hole, stop digging. There are some regulatory tweaks that have to be made where we're disadvantaging rural providers, he said. “Why would we disadvantage rural providers?”
As CMMI mulls its next moves, Mostashari said we don’t more models. “There are models that we know work — and that is giving primary care global accountability for total cost of care. So let's use the Medicare Shared Savings Program as the platform. Maybe we need Direct Contracting for groups that don't have pre-existing relationships with patients so there can be new entrants into this market. But we don't need new models. We need to really supercharge the models we have.”