Does MA change what PCPs do?

If you haven’t seen it yet, a few days ago, The Commonwealth Fund posted an analysis of their 2022 International?Health Policy Survey of Primary Care Physicians to try and ascertain if the care delivered by Primary Care Physicians (PCPs) who primarily care for Medicare Advantage (MA) patients differs from that provided by PCPs who primarily see Traditional Medicare patients. Now, given my background, I applaud the line of inquiry because I think it is really important to understand if the payment structure impacts how care is delivered, but I think there is a huge fly (or two) in the ointment that impacted their analysis and conclusions.

The first big issue is that in their categorization of these PCPs, they don’t appear to have distinguished between MA where the plan has the risk and simply pays the PCPs FFS (with or without incentive payments) from MA that is delegated to the provider organization which is typically sub-capitated and ultimately directly responsible for patient outcomes. Those capitated payments enable managed care provider organizations to implement infrastructure that supports the PCP in the provision of patient care. Around half of MA in this country is still paid on a FFS basis to providers using the Medicare physician fee schedule, so effectively, there frequently is no real difference to the PCP between MA patients and Traditional Medicare patients. By blending these doctors with those that are part of a capitated entity, you aren’t truly distinguishing between two different payment structures that may impact the way care is delivered.?

This becomes important, especially when it comes to activities such as development of treatment plans, provision of home-care instructions and connecting with patients between visits, where a delegated, capitated group will develop internal supportive infrastructure that supplements the work being done by the PCP. In true, holistic, interdisciplinary, team-based care, while the PCP may still be focused on evaluating and treating the patient sitting in front of her, there are others that are identifying patients with rising risk, doing outreach, educating, connecting with social services, having pharmacists assess medication risks and numerous other tasks. The PCP may have regular meetings with this team to help guide the care plan, add clinical perspectives and follow up on discussions with the patient during visits, but the burden of the work doesn’t (and shouldn’t) fall on the PCP’s shoulders. Nearly half the time in MA it is the health plan that is trying to perform these activities, but their “care team” is completely disconnected from the people that are actually providing the care.

Seeing that PCPs who primarily saw MA patients were more likely to be informed when their patients were seen for after-hours care, in an ED or admitted to the hospital shouldn’t come as a surprise. Regardless of the structure, attempts at coordination of care are a minimum expectation for managed care. What subsequent actions occur because of those notifications is where I’d expect to see a difference between that health plan MA paid FFS vs MA that is delegated and capitated. In the latter case, there is a care team that can help do that outreach to identify further care needs and facilitate follow up or future access. In the former, it is less likely there’s an integrated care team and there aren’t direct incentives for the PCP to outreach to the patient.

This flawed thinking is reflected in the questions around PCPs screening for social needs. The assumption is that the PCP is the one who would be expected to perform such screening. That’s like assuming it should be the PCP injecting the vaccine she just ordered or calling the patient the day after notification of an ED visit to see how they’re doing. That isn’t the most efficient use of a physician’s time, but those are services that should be provided. When the PCP is part of a care team, they should be able to rely on that team to perform essential tasks without needing to be involved at every step.

This leads me to the second issue I have with this analysis. The assumption behind the line of survey questions is that the payment structure (MA vs Traditional FFS) will directly impact the PCP’s activities. The value in managed care and the increased percentage of payments attributable to primary care services do not mean that the PCP is doing more or even getting paid more. Managing a population of patients is a team sport and much of the work is performed by the interdisciplinary team. In this type of arrangement, there is someone working on care plans, providing self-management education, entering self-management goals, contacting patients between visits, assessing and addressing social determinants and closing care gaps, but it typically isn’t the PCP. The questions posed appear to assume that the onus is on the PCP to do these tasks. Ultimately, if there is an impact on patient care from the different payment methodologies, the questions should be centered around whether certain types of services are being provided and how they impact patient outcomes and experience.

There is a fair amount of data demonstrating better outcomes and lower utilization for patients in managed care arrangements (e.g. see https://atlas.iha.org/ ), but I understand that many people still aren’t convinced. I’m looking forward to more robust studies demonstrating the accuracy or fallacy of this premise, but unfortunately, I’m not sure this particular one brings us closer to that day.

https://www.commonwealthfund.org/publications/issue-briefs/2024/mar/does-medicare-advantage-affect-primary-care-practices