Enhancing Primary Care

Primary care is a vital part of a well-functioning healthcare system. Decades of research have highlighted its crucial role in maximizing patient and population health, improving efficiency, and ensuring equity in healthcare delivery. Patients consistently value access to an ongoing relationship with a trusted primary care practitioner (PCP), which correlates with better health outcomes. However, despite these benefits, primary care in the United States remains chronically underfunded. The current payment structures often incentivize visit volume over quality, contributing to a decline in the patient-PCP relationship, even among those with robust insurance coverage.

To address these issues, state and federal policymakers have introduced various value-based payment (VBP) models aimed at strengthening primary care. These models, which often involve collaborations between Medicare, Medicaid, and commercial health plans, seek to provide more sustainable and supportive funding mechanisms for PCPs. Despite these efforts, fewer than half of PCPs are engaged in VBP models, and participation is often limited to practices with more resources. This limited engagement means that many practitioners and patients who could benefit most are not seeing the advantages intended by these policies. This article explores the challenges PCPs face in participating in VBP models and proposes potential solutions to improve primary care funding and measurement.

Increasing Funding for Primary Care

One of the most significant barriers to effective primary care is underfunding. Despite the goals of VBP models, the financial support available often falls short. Several factors contribute to this issue:

Misalignment with Fee-for-Service Payments: Most primary care practices operate under fee-for-service payment structures, which incentivize the volume of patient visits rather than the quality of care. This misalignment pressures PCPs to increase visit numbers rather than focusing on comprehensive, coordinated, and patient-centered care. Reducing reliance on fee-for-service payments and adjusting payment rates to better reflect the value of primary care services compared to other specialties could help shift the focus toward quality.

Insufficient Engagement of Commercial Payers: While Medicare and Medicaid are key players in VBP models, the involvement of commercial payers is often minimal. When commercial payers do participate, their enhanced payments for primary care are relatively small. Additionally, as Medicare Advantage plans gain market share, there is a risk of these plans engaging in practices like patient selection and enhanced coding, which could undermine the effectiveness of VBP models. Policymakers need to ensure that commercial payers contribute adequately and that safeguards are in place to prevent gaming of the system.

Challenges for Small and Rural Practices: Independent and rural practices face particularly steep financial challenges. With fewer resources and narrower profit margins than larger practices, these smaller entities are more vulnerable to financial strain. Offering upfront payments at the start of model participation and avoiding downside risk exposure would help these practices invest in necessary resources and remain financially viable.

Underinvestment by Health Systems: Many PC-VBP participants are affiliated with large health systems that may use these models to drive more referrals to their specialty and hospital services, rather than focusing on improving primary care delivery. To address this, health systems should be incentivized to invest meaningfully in primary care. Models should ensure that resources are directed to support primary care practices effectively, rather than being diverted to other areas.

Decreasing and Refocusing Primary Care Measurement

Another significant challenge for PCPs participating in VBP models is the burden of measurement and reporting requirements. Current quality measures and documentation demands often detract from patient care. Key issues include:

Over-Simplistic Measures: Existing quality measures frequently rely on binary or simplistic metrics for specific conditions or screenings. These measures can be reductive and do not adequately capture the complexity of patient care. PCPs prefer measures that reflect access to and continuity of care rather than those focusing on isolated conditions. Metrics should prioritize the four Cs of primary care: accessible, continuous, coordinated, and comprehensive care.

Burden of Documentation: PCPs often face pressure to maximize the number of diagnoses recorded in electronic health records to increase patients’ Hierarchical Condition Category risk scores. This documentation burden can distract from delivering quality care and may incentivize practices that do not align with patient-centered goals.

Focus on Total Cost of Care: Total cost of care measures in VBP models often fail to account for the influence of specialists and hospitalists on overall costs. PCPs argue that these measures should be applied primarily to large organizations such as health systems or accountable care organizations (ACOs), rather than individual PCPs. This would help focus efforts on reducing costs in areas where PCPs have more influence.

Need for Better Metrics: PCPs and experts suggest replacing numerous, overly simplistic condition-specific measures with fewer, more meaningful metrics. These should capture aspects of primary care that are directly linked to patient outcomes, such as appointment availability, continuity of care, and patient communication.

The current landscape of primary care payment models presents opportunities and challenges. While VBP models have the potential to enhance primary care delivery, significant reforms are necessary to address underfunding and measurement issues. Increasing financial support for primary care practices, aligning payment structures with the goals of VBP models, and reducing the burden of reporting and documentation are critical steps in making these models more effective.

Policymakers should ensure that new value-based payment models, such as Making Care Primary and ACO Primary Care Flex, address the concerns of PCPs and incorporate the necessary changes. Enhancing primary care funding and refining measurement practices will lead to a healthcare system where more people have access to a PCP who can comprehensively address their health needs and contribute to better health outcomes.