Can Primary Care Be Saved?

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This is a good Health Affairs piece from last month. If you get a chance, check it out!

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In a nutshell, we pay primary care physicians too little compared to specialists, their jobs can’t be done in even an extended workday, and there are too few of them.

We have to pay PCPs more and pay them differently if we want to change health outcomes for the population of the United States.

You must be getting tired of hearing me say this by now, but we NEED to pump more resources into accountable, team-based primary care. (This is more than physicians!)

Primary Care Matters:

• Primary care serves as the first point of contact for most patients’ healthcare and is the quarterback of healthcare. When well-funded and resourced, it provides comprehensive and longitudinal care.

• It plays a crucial role in prevention, early detection, and management of chronic conditions.

• Effective primary care can reduce the need for more expensive specialist and hospital care.

Who We Mean When We Say “Primary Care”:

• Physicians (generally internal medicine, family medicine, geriatrics, pediatrics)

• Advanced practice providers (others who can bill Evaluation and Management codes, prescribe, and serve as physician “extenders”): nurse practitioners, physician assistants, clinical nurse specialists

• Increasingly: behavioral health providers, pharmacists, registered nurses

• Emerging: medical social workers, community health workers

• Also belongs: physical therapists (and others)

The Current Challenge:

• Medicare's underinvestment in primary care has created a domino effect throughout the healthcare system.

• This has led to a shortage of primary care physicians and increased burnout among existing providers.

• Access to care and patient engagement are suffering.

The Path Forward:

We talk a lot about “fixing the physician fee schedule conversion factor,” but that will increase funding to specialists even more than primary care and other providers that bill the physician fee schedule and primary care related codes. It also requires major funding, which isn’t so easy to come by.

From the Health Affairs article:

Three consensus recommendations from the authors’ review of expert opinions:

1. Pay primary care differently

2. Increase primary care spending rates within current Medicare spending limits

3. Improve the effectiveness of the processes by which physician services are valued

   The relative value scale update committee is made up 80% by specialists. It’s failing primary care. The article includes this 2018 MedPAC report and recommendations. However, it will take strong political willpower and funding to create meaningful change here.

From Health Management Association (HMA):

Pages 15 and 16 provide recommendations by type of provider. Here’s a summary of how to address physician pay from the VBC perspective. The other three suggestion types are also worth reading.

And from page 32:

There are many ways Congress and the Administration could improve payment to primary care and improve patient outcomes.

To truly transform primary care, we need to embrace a team-based approach that leverages the skills of various healthcare professionals. Advanced primary care teams should include:

• Pharmacists

• Behavioral Health Providers

• Physical Therapists

• Nurses

• Social Workers

• Community Health Workers

If you are one of the above provider types or others who could be more closely aligned with primary care, are you familiar with the issues and solutions?

For these advanced primary care teams to be effective, it's crucial that each member understands their role in care transformation.

I wrote about the physician fee schedule earlier this year:

Here’s what I’m personally hoping for, as a healthcare provider and health policy expert:

MACRA reform and major physician fee schedule updates happen at the same time. Congress adds stronger financial and “flexibility” incentives to MACRA’s statute, and through meaningful participation, those who bill the physician fee schedule will earn more.

Also, advanced primary care services are weighted more heavily and additional services are named and valued to pay for work already being done by primary care teams. To access higher funding levels, primary care provider teams must accept accountability for their patients’ outcomes.

I’m glad you tuned in today!