Healthcare Payers: You have the Power to lift the Primary Care Physician to Center Stage

In a prior blog, I emphasized the importance of moving “the primary care physician to center stage.” I also articulated that rationale behind my plea.

Ultimately, as noted in a recent article in Health Affairs, “Primary care clinicians are uniquely trained to diagnose and treat the vast majority of medical ailments and chronic diseases, to reduce over-treatment, and to care for the whole patient. Primary care’s value in cutting costs, preventing disease, improving patient satisfaction, and enabling individualized care based on shared decision making has been well established.”

As noted in my prior blog, while the value and strength of primary care physicians are well established, they are also under-valued in their current and potential role in our society.

That under-valued role of the primary care physician has translated to lower pay, especially vs. other physician specialties and a less than satisfying contribution to the overall health of their patient. 

While not universal, primary care physicians who are part of major hospitals can become nothing more than referral centers to the vast array of specialists and technology within their health systems.

Independent primary care physician practices face different, but no less satisfying, challenges on a daily basis as they race to find ways to see as many patients as possible to keep their practice afloat financially.

Ultimately, this combination of lower pay and the large amount of student loans along with a less than satisfying role in caring for their patient, has resulted in fewer medical students selecting primary care.

Why the primary care physician needs to move to center stage

As noted in my prior blog, the following factors have created the societal necessity of moving “the primary care physician to center stage” and enhancing their role in the healthcare continuum:

·        The transition from “fee-for-service” to “value-based” care

·        Reimbursement methodologies that are more risk-based and rely on patient compliance

·        Evolving from a “sick-care” system to a true “health” system

·        The overall focus on population health (outside the walls of the hospital)

·        The recognition of the importance of integrated wellness and prevention in healthcare as well as nutrition, diabetes education and patient and caregiver engagement

·        The recognition of the importance of addressing the “social determinants of health” (see blog) along with the importance of linking patients with needed community services to remove gaps of care

·        The recognition of the importance of the linkages between clinical, behavioral/mental health and chronic disease management as well as the importance of a team-based approach in healthcare

·        Finally, the concern of the escalating costs of healthcare from a societal perspective

Healthcare payers: your passivity was a major factor in creating the “sick care” system that exists today, which devalues primary care

As noted in my prior blog that focused on employer disruption, the major financiers of our healthcare system are the government, through Medicare and Medicaid, and employers (insurance companies work for employers). As I have discussed in prior blogs, historically both the government and employers have taken a passive role when it comes to our healthcare system.

I define “passive” as sitting on the sidelines (or on a bench) and observing escalating healthcare costs and inconsistent quality and accepting it as a norm rather than proactively addressing the root causes (fee-for-service payment methodologies, lack of cost and quality transparency, and a less than competitive marketplace, etc.) in a sustainable manner. This passivity would apply on a societal basis to Medicare (as result of lobbying by healthcare stakeholders wanting to protect their slice of the pie) (see blog), and especially to employers on both a national and community level.

Passivity also applies to employers when they hire third parties, i.e., health insurance companies, employee benefit consultants and brokers, and they do not hold them accountable for performance.

This passivity also created an environment that placed the primary care physician in a second class role in the healthcare continuum especially as it related to their level of pay vs. specialists.  

The reliance on a fee-for-service payment methodology (“the more you do the more you make”) primarily benefited specialists and was the growth engine for hospitals and all to the detriment of primary care physicians.

The primary care physician was further penalized when Medicare developed the Resource Based Relative Value Scale (RBRVS) as a basis for calculating reimbursement for physicians. This coding system does not adequately account for the work performed by primary care physicians in that it rewards procedural work over cognitive work. 

Health insurance companies also played “follow the leader” in cloning Medicare RBRVS fee schedule as their own base for determining payment levels for the physicians and the related services. This again was done to the detriment of the primary care physician, and most health insurance companies were not interested in disrupting the status quo.

Finally, these same Passive Purchasers (Traditional Medicare & health insurance companies) also did not differentiate providers of care from a value perspective as it impacted the overall health of the patient, which was also detrimental to the primary care physician.   

Passive purchasers of healthcare services are now transitioning to active purchasers who are “demanding” better value for their healthcare dollar

As a result of escalating healthcare costs Passive Purchasers of healthcare services are now transitioning to Active Purchasers who are demanding better value for their healthcare dollar.

Medicare Advantage Plans, Medicaid Managed Care, Self-insured employers, enlightened health insurance companies, and consumers who are more financially engaged with their healthcare purchasing decisions (Health Savings Accounts, etc.) are all examples of Active Purchasers. 

Each of these Active Purchasers can play a key role in moving the primary care physician to “center stage.” These Active Purchasers finance healthcare and, as I have stated repeatedly in prior blogs such as a “walk down memory lane”, a healthcare system is shaped by “what you pay for and how you pay for it.”

The “what” and “how” (and the “how much”) especially with regard to the major payers (Medicare, Medicaid, self-insured employers and health insurance companies) are the life-blood of the “supply” side (healthcare providers).

The Active Purchasers of healthcare services need to recognize and put into action the power they have to shape the healthcare system at a community and national level to make it more primary care-focused.

Primary Care Capitation

Time to look at Capitation, not Decapitation, ... Sorry!

If we recognize the value of the enhanced role of primary care physicians and their teams, then we need to support these efforts by paying for their services in a more holistic fashion. In the ideal world this would be in some form of per member capitation.

In 2016, the Urban Institute published a thoughtful study that focused on primary care capitation. That report stated the following: “The theoretical virtue of primary care capitation is that it permits primary care physicians themselves to decide what mix of activities best serves each patient, rather than rely on third-party payers to approve payment codes and payment levels to influence how clinicians spend their time.”

“Primary care capitation places decision-making in the hands of health professionals who may be in a better position than distant insurers to act in patients’ best interests. In addition, in direct contrast to fee schedules, primary care capitation in effect establishes spending limits for the patients a physician is responsible for, thereby creating financial incentives in favor of activities that reduce spending.”

As further stated in the Urban Institute report, “A hybrid of primary care capitation and fee schedule payment, as well as incremental payments such as shared savings and Pay for Performance , are all compatible—and in some contexts, probably desirable.”

Additional initiatives that will both financially benefit the primary care physician and also cause positive disruption in the healthcare marketplace

Primary care capitated models may not be realistic in all cases, ultimately, there can be innovative approaches to reward and incent the primary care physician to expand their societal role in the healthcare continuum. There can also be creative partnerships developed between the primary care physician practice and payers including direct contracting with self-insured employers or coalitions as well as Medicare Advantage Plans. 

Finally, there are multiple new and innovative entrepreneurial organizations of all types that are partnering with self-insured employers and third-party administrators to develop creative approaches to developing benefit designs and other vehicles to further the search for value. 

Many of these entrepreneurial organizations recognize the true value of the primary care physician and they are moving it to center stage. These disruptive organizations a long with organizations like Amazon are also sending a message to traditional insurance companies who hold on to the past, that is do something or get out of the way.

Medicare is causing their own disruption that could have a very positive impact on Primary Care Physicians as it ripples through the payer community

The disruption continues. As noted below, CMS will be introducing a new model for paying for primary care. The message within this statement is that CMS finally gets it when it comes to the potential value of primary care.

Also, this program can provide a very positive domino effect, since as noted in this blog, commercial insurance companies and other payers play “follow the leader” when it comes to Medicare’s payment methodologies.

Per an article in Modern Health Care: “Health & Human Services (HHS) on Monday, April 29, 2019,  launched an ambitious, double-pronged strategy to shift primary care from fee-for-service payments to a global fee model where clinicians and hospitals could assume varying amounts of risk.”

“Per HHS Secretary Alex Azar, the Center for Medicare & Medicaid (CMS) projects the new voluntary programs will shift at least a quarter of people in traditional Medicare out of fee-for-service.”

“The first model aims at small primary-care practices, offering two options with a flat monthly fee per patient. Bonuses or penalties will depend on their ability to keep their patients "healthy and at home," said Adam Boehler, director of the CMS' Center for Medicare and Medicaid Innovation, or CMMI.”

“Larger practices and health systems would have additional choices, which could be very lucrative but pose steeper risks. Under the first "professional option," providers would assume 50% of the risk, including savings and losses. Under the "global option," providers would take on full risk. Most of the newly announced Innovation Center models will launch in January 2020.”

The role of the consumer of healthcare services

Consumers also have a role in moving primary care physicians to center stage. The more consumers value the role of the primary care physician and partner with them in achieving better health and quality of life, the greater the likelihood that primary care physicians would be moved to center stage.

Consumers also need to demand that their specialists provide their primary care physician with all information related to their visits. 

Active Purchasers, you also need to “demand” the Interoperability of Electronic Medical Records

Electronic Medical Record (EMR) connectivity is critical to the hub and the multiple roles of the primary care physician.

The primary care physician is also in the best position to play a key role in managing risk and the provision of value-based care throughout the continuum, but this is contingent upon receiving timely data from all caregivers.

Too many times, and we all know as consumers of healthcare services, our primary care physician does not have access to this timely data.

The technology is there for seamless interoperability, but stakeholder greed is preventing it from occurring in a timely manner. It is time that the government steps in and break down these artificial barriers.

THE SUPPLY SIDE

The following are initiatives that can be implemented to both increase the number of primary care physicians and expand their effectiveness and financial stability:

·        Debt of students who pick primary care. Same as public service.

As noted in a recent article in Health Affairs, “The large amount of debt that medical students incur often dissuades them from entering primary care. The government should either cover the cost of medical school for students who remain in primary care for at least 10 years after certification or incentivize individual institutions to offer loan forgiveness programs.”

“According to a report from the Congressional Research Service, in 2014, the federal government spent $11.3 billion on graduate medical education (physician residencies and fellowships). The Centers for Medicare and Medicaid Services (CMS) currently spends about $10 billion a year on physician residencies. It would cost a fraction of that amount to pay for medical school for any student going into primary care. The AAMC supports such a program.”

·        Residencies

As again noted in a recent article in Health Affairs, “CMS has the power to determine how many of those residency slots are committed to training primary care physicians, yet it currently exerts little control over promoting training programs with an eye toward increasing the number of primary care residency slots.”

·        Use of technology, Telemedicine

I am a believer in the increased use of technology to allow us to better leverage our primary care resources in an economical manner. 

Digital health solutions, such as telehealth, provide greater access to primary care and can encourage patients to take a more active role in their health.

While technology can be used to increase the number of primary care visits (telehealth), it cannot short-change the value of primary care and the personal relationship between the primary care physician and their patient. It should not just be used as an entry point for increased specialist referrals.

·        Independent primary care physician practices struggle to pay for expensive Electronic Medical Records systems (EMRs) as well as increased governmental regulations

Adding to the financial challenges of primary care physicians, most independent primary care practices must pay for expensive electronic medical record systems and tech support, staff to contend with increased regulations and fee collection, and sometimes scribes and nurses to satisfy regulatory demands.

The federal government needs to play an expanded role in assisting independent primary care physician practices in addressing their administrative costs in implementing expensive EMR systems. I am not a believer in government control and I am definitely not an EMR expert, but this is one area where the government may need to step in with their own solution to this issue. One solution would be to find a way to commercialize their own EMR (or sub-contract with a third-party) that would then be made available to primary care physician practices. This EMR would enable a primary care physician practice to load social determinants of health onto the system.

Finally, the government needs to be sensitive to over-regulating independent physician practices, especially primary care practices, to the point where it is not financially feasible to stay in existence.

Leadership training

As noted in my prior blog on the primary care physician, all of this also does not mean that the primary care physician is ready for this expanded and necessary role. As clearly noted in this blog, to achieve this new enhanced role primary care physicians will need to develop leadership skills that do not always come naturally for physicians.

The primary care physician needs to be both a team player and a team leader. See blog on physician leadership.  

CONCLUDING COMMENTS

The enhancement of the role of the primary care physician along with increased income (and less financial educational loans) will attract more medical students to this needed specialty.

Another advantage for medical students selecting primary care as their area of specialty is the increased career options (or career doors) that will be available to them in this risk/value based world ahead.

As discussed in my blog titled, “Physicians, Your future is in Your hands,” physicians have options and they can control their own future. This is especially true for primary care physicians. 

Some options for primary care physicians include the following and this is expanding:

·        Working in an independent physician practice (local, regional or national). This risk/value-based world of healthcare will pump new energy into independent physician practices.

·        Working for a hospital system, ideally an enlightened hospital system, that allows them to play an enhanced role in the healthcare continuum

·        Being employed or owning a worksite or near-site employer clinic.

·        Becoming a medical director for self-insured employers or a health insurance company

·        Working for or starting an entrepreneurial company that is focused on providing better healthcare

·        Working in the public and population health arena

·        Starting a Direct Primary Care (DPC) model that gives individuals unlimited access to a primary care doctor for a monthly fee without insurance being billed (see the following two articles for additional information on DPC : “Direct Primary Care” and “The future of employee care.”

Primary care physicians, it is your time to shine.

Thomas Campanella is the director of the Health Care MBA and an associate professor of health economics at Baldwin Wallace University near Cleveland, Ohio.

If you are interested in receiving a monthly summary of all of my healthcare blogs, you can respond to me on LinkedIn or e-mail Tom Campanella ([email protected] ) with your contact information.

Source of pictures: pixabay.com & pexels.com