TEN TRANSFORMATIVE TRENDS 2021
Pandemic Shines Spotlight on Need for Comprehensive Primary Care
A pandemic-resilient delivery system requires stronger primary care and a faster move away from fee for service, experts say By David Raths
T
he pandemic has given us an oppor- tunity to see both how valuable and how vulnerable our primary care
system is. As a percentage of total cost of care, primary care spending has been going down over the last decade, even with the coverage expansion through the Affordable Care Act. Many small practices were hit hard by the pandemic. But there are efforts across the country to bolster primary care, integrate it with behavioral health, and pay for it differently. Can they be scaled up on a national level? “If you look at different measures of the orientation of our healthcare system toward primary care, they’re going in the wrong direction,” says Ann Greiner, president and CEO of the Primary Care Collaborative (PCC), where she leads efforts to defi ne an agenda that furthers comprehensive, team-based and patient- centered primary care. One of the problems the pandemic highlighted, she says, is that the vast majority of practices are still paid in fee- for-service. “We haven’t actually seen much of a change over the last several years in terms of the proportion of physi- cian practices that are paid by capitation or even more broadly in value-based
period. Now an additional four states have committed to increasing primary care spending to achieve the outcomes they are seeking. “Many of them urge that these dollars go into value-based payment arrangements and help to fund more com- prehensive primary care,” Greiner says. In addition, 12 states are now reporting
on primary care spending as a percent- age of overall spending. “I think that’s a very important fi rst step,” Greiner says. “European countries, as a matter of course, report primary care expenditures, and I think we need to do that. We need standardized national measures so that we can compare one state to the next and one year to the next and have a way to understand what’s happening within our system. States are looking across health plans, and it’s an opportunity to ask the question: are our expenditures refl ective of the goals we’re trying to achieve? Are we being strategic with our investment if we want a healthier population? We want to address the inequities that were always there, but that have become much more intense with COVID,” she says. “Primary care is very well-situated to work with others to help address health inequities. If we partner with patients to provide good chronic care management and preven- tion and health promotion, we’re going to have not only a healthier population, but we won’t have the same number of downstream expensive interventions that are needed because people’s health will be better.”
Christopher Koller is president of the Ann Greiner
arrangements,” she says. “I think those practices in value-based payment arrange- ments fared better during the pandemic.” Several years ago, Rhode Island was
the fi rst state to require increases in primary care spending over a fi ve-year
Milbank Memorial Fund, which funds research and collaborative work focused on primary care and health system trans- formation. He stresses that it is important to study whether people with better access to comprehensive primary care were in better shape to weather the pandemic. Those patients would have had a reliable source of information from their primary care provider; they were getting infor- mation sooner about prevention; those providers were more likely to switch to telehealth sooner and more likely to be paid in a non-fee-for-service way, so they could maintain operations at the begin- ning when everything was shutting down,
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he says. “That would put the patients in good stead, but not everyone had access to that kind of primary care. It is the minority of primary care practices that are paid in a way that can provide comprehensive care; most are still stuck in fee-for-service medicine.”
Moving to comprehensive primary care
Koller says speeding up the transition to comprehensive primary care must start with Medicare. “Alignment is important, and until Medicare moves, other payers are not going to align. In a multi-payer world, if every payer is coming to a pri- mary care practice with a different model, that is not going to help the practice very much. If Medicare moves fi rst, it starts to set the standard for the commercial payers.” Koller, who led the reforms in Rhode Island as its health insurance commis- sioner, says many other states are mak- ing progress on primary care improve- ment, including Maryland, Oregon and Minnesota. “In Minnesota, clinics are not a dirty word,” he says. “People go to their clinics. They think in terms of multispe- cialty, primary care-oriented practices.” He says there is a logical order of battle in moving to comprehensive primary care. “First states make this commitment to primary care,” Koller notes. “Then they start to explore other things. Oregon has created a standard for comprehensive pri- mary care. Vermont has shared resources
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