Primary care plays a central role in health care and provides comprehensive, patient-centered care across a patient’s lifespan. Primary care helps patients focus on wellness, manage complex medical conditions, and navigate an ever changing and complex healthcare system. Access to primary care has been shown to improve patient outcomes and lower cost.1 Yet, primary care in the United States is in a crisis.2 Compensation models based solely on fee for service no longer align with all the demands placed on our primary care practices.3 What does primary care look like when it is highly functioning and how can our country support this critical mission?
Primary care has changed dramatically in recent years. Traditionally a primary care practitioner (PCP) would see patients scheduled in clinic, with minimal work outside of these visits, no population management, and no way for a patient to directly contact a clinician. The staff in clinic were there to support a PCP’s ability to see patients. Payment was solely by billing of discrete patient visits through fee for service.
We have evolved into a new standard called comprehensive primary care which provides acute care, chronic disease management, preventative care, coordination of care across the medical spectrum, and outreach to at risk populations. As practices advance in their ability to deliver this care, they address mental health, social determinants of health, nutrition, transitions of care and longitudinal care management. Population based care and the change in patients’ access to clinicians due to advances in technology are leading to new demands on clinicians and practices. Access standards, utilization rates, and cost of care are new metrics for our practices.
Unfortunately, current payment models neither adequately fund this new model nor support the work required of PCPs to meet these goals. A fee for a service payment model, as is currently prevalent, focuses compensation incentives solely on visit volume. This creates an incentive to see patients for visits when a visit may not be necessary and also provides a disincentive to more creatively addressing patient concerns through messaging or using ancillary staff, when appropriate. Instead, compensation needs to align with this new care model and create incentives to provide the appropriate level of care in the correct setting at the correct time adding value rather than volume.
The key to developing a new payment model is understanding the work that is accomplished in a clinic and tying funding directly to those activities. Medical assistants need to effectively room and move patients through the clinic (or virtually in telehealth visits), administer vaccinations, and provide ancillary testing. While these tasks can fit into a fee for service model, medical assistants also gather patient information, assess and pend orders to close gaps in health maintenance, and are key contributors in managing the flow of information with patients outside of office visits. Such work is clearly not tied to in clinic visit volume and fee for service billing.
Comprehensive primary care also relies heavily on nurses to manage the increasingly complex flow of asynchronous patient communications. Nurses using protocols can manage routine clinical issues avoiding patient visits, a practice clearly discouraged by current fee for service models. Nurses are able to assist with completing paperwork and collect necessary records to authorize a myriad of patient services. Nurses also play a critical role in responding back to patients with results and coordinating scheduling of the care plan for needed follow up of results. None of this work is adequately accounted for in a fee for service model.
Wrap around support services expanded significantly in clinics successfully providing comprehensive primary care. Alternative payment models, such as Comprehensive Primary Care Plus, already demonstrated a successful approach to funding these critical roles through prospective payments, recognizing that myriad services provided by pharmacists, mental health providers, dietitians, nurse care coordinators, and social workers in the primary care setting cannot be covered through fee for service reimbursement. This is mainly due to reimbursement rates too low to support the salary of these providers or are not currently billable services.
There are more complicated issues affecting the PCPs:
- Appropriately compensating the work of physicians and advance practice providers is the most pressing issue.
- Current fee for service payment models is unable to address the changing demands being put on clinicians.
- This handcuffs a practice’s ability to provide this level of care.
- Small private practices need to ensure that revenue projections cover expenses and large salaried practices set wRVU targets to measure production.
- These currently remain closely aligned with the work done traditionally by clinicians and paid for through fee for service billing.
- This requires templates to be weighted heavily to patient visits.
It is not sustainable to ask clinicians to continue to keep a traditional schedule and absorb the exponential increase in asynchronous work. PCPs are exposed to increased patient access through telephone and especially patient portal messages creating demand for care outside of scheduled in person or virtual visits. Home oxygen orders, home health orders, FMLA forms, medication refills, prior authorization requests, durable medical equipment orders, and any number of future demands not tied to a clinic visit require time to complete. A new payment model needs to better align with the work being asked of our clinicians, prospectively paying for the critical asynchronous work that comprehensive primary care demands and allowing time to be reallocated appropriately. A key to successfully implementing a new payment model is quantifying the balance of time required between patient visits and asynchronous work and negotiating appropriate compensation for the asynchronous work with payers.
Comprehensive primary care requires a hybrid payment model combining fee for service with prospective payment for asynchronous services considering the changes needed to support the staff and physician work demands. Different clinics may be able to provide different levels of services and there may not be a one-size-fits-all ratio of fee for service and prospective payments. A practice starting to take on comprehensive primary care should have a payment ratio more weighted to fee for service while a mature comprehensive primary care practice able to provide more wrap around services should have a payment ratio more evenly balancing fee for service and prospective payments. This hybrid model would be able to avoid some of the problems that developed in prior fully capitated HMO type payment models by not overly incentivizing limiting scheduled patient visits and care, keeping a reasonable percent of payments tied to fee for service.
The model would have to also allow for risk adjustment based on the complexity of populations of patients being seen in practices. There is a clear correlation with more complex populations requiring more resources. Comprehensive Primary Care Plus used a payment model that adjusted based on patient complexity level. This creates an appropriate incentive for clinics to provide care for complex patients. Practices need to deliver on quality measures that need to be clearly defined and should be aligned between payers; practices should also take on some level of risk in payments tied to delivering quality care and living up to the value component promised with comprehensive primary care.
The final issue that needs to be addressed is the amount a payer should pay for comprehensive primary care. It has been noted that primary care is chronically underfunded and the country is looking at a crisis in PCPs. More clinicians will be needed to provide comprehensive primary care with current physician employment trends moving away from primary care. The United States currently allocates far less than 10% of healthcare spending on primary care. Moving this target to 10% of spending would allow for competitive compensation and support comprehensive primary care.4 The proposed hybrid payment model would financially support the value promised by comprehensive primary care and ensure that the benefits of comprehensive primary care are realized by patients, clinicians, staff, and payers, while providing appropriate controls to ensure quality measures are met.
- Friedberg MW, Hussey PS, Schneider EC. Primary care: A critical review of the evidence on quality and costs of health care. Health Aff. 2010;29(5):766-772.
- McMahon LF, Rize K, Irby-Johnson N, et al. Designed to fail? The future of primary care. J Gen Intern Med. 2021 Feb;36(2):515-517. doi: 10.1007/s11606-020-06077-6. Epub 2020 Jul 29.
- Berenson RA, Rich EC. US approaches to physician payment: The deconstruction of primary care. J Gen Intern Med. 2010 Jun;25(6):613-8. doi: 10.1007/s11606-010-1295-z.
- Bodenheimer T, Grumbach K. Understanding Health Policy: A Clinical Approach, Eighth Ed. San Francisco: McGraw Hill; 2020.
Clinical Practice, Health Policy & Advocacy, Leadership, Administration, & Career Planning, Medical Education, SGIM, Wellness
Dr. Doolan (Robert.Doolan@CUAnschutz.edu) is an associate professor of clinical practice in the Department of Medicine at the University of Colorado School of Medicine and medical director of primary care for the Division of General Internal Medicine
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