The Changing Face of Primary Care

IN 2019, FEDERAL health officials unveiled a new primary care experiment that proposed to pay doctors for providing an elevated level of service designed to keep patients healthy and reduce hospital visits. Proponents of the value-based care model believe the efforts could transform the way medical services are delivered for millions of Americans. The Centers for Medicare and Medicaid Services (CMS) Primary Cares Initiative includes five payment options for both small and large providers, allowing them to take varying levels of financial responsibility for improving care and lowering costs. The core of the initiative seeks to overhaul how primary care is delivered by rewarding physicians for improving care for patients, especially those with chronic illnesses such as high blood pressure and diabetes. “This initiative will radically elevate the importance of primary care in American medicine,” said Health and Human Services Secretary Alex Azar.¹ He went on to note that creating a system that rewards providers for outcomes rather than procedures has the potential to free up doctors to focus on the patients in front of them, rather than the subsequent paperwork.

An Incentivized Approach

For many patients, the primary care physician is their first point of contact with the healthcare system. Research indicates that when incentives for primary care providers are structured to reward high-caliber care, the quality and cost effectiveness of patient care improves. “As we seek to unleash innovation in our healthcare system, we recognize that the road to value must have as many lanes as possible,” said CMS Administrator Seema Verma. “Our Primary Cares Initiative is designed to give clinicians different options that advance our goal to deliver better care at a lower cost, while allowing clinicians to focus on what they do best: treating patients.”²

Accountability is also a factor; value-based reimbursements are calculated by using numerous measures of quality and determining the overall health of populations. Unlike the traditional model, value-based care is driven by data because providers must report to payers on specific metrics and demonstrate improvement. Providers may have to track and report on hospital readmissions, adverse events, population health, patient engagement and more.

Because value-based care reimbursement ties payments for care delivery to the quality of care provided and rewards providers for both efficiency and effectiveness, it may offer an alternative — and potential replacement — for fee-for-service reimbursement, which pays providers retrospectively for services delivered based on bill charges or annual fee schedules. Fee-for-service encourages many providers to order more tests and procedures, as well as manage more patients to get paid more.

Additionally, under fee-for-service models, cost variations for procedures and tests increased and the healthcare industry was spending more to treat patients even though patient outcomes were not necessarily improving. The model also challenged provider workflows because physicians were seeing more patients and each claim had to be processed in a fragmented network.

A State Health Care Cost Containment Committee report sums it up this way: “The opportunity exists to transform how healthcare is delivered. The goal is straightforward but ambitious: Replace the nation’s reliance on fragmented, fee-for-service care with comprehensive, coordinated care using payment models that hold organizations accountable for cost control and quality gains.”³

Advantages of Collaborative Care

Another care model altering the delivery of primary care is the integrated approach. Essentially, integrated care combines primary healthcare and mental healthcare in one setting. Over the past decade, the integration of behavioral health and general medical services has been shown to improve patient outcomes, save money and reduce stigma related to mental health.

Significant research spanning three decades has identified the collaborative care model as being effective and efficient in delivering integrated care. A report titled Dissemination of Integrated Care Within Adult Primary Care Settings: The Collaborative Care Model, developed jointly by the American Psychiatric Association and Academy of Psychosomatic Medicine, offers insights into this approach, including recommendations for how to advance its use to better meet the whole health needs of people with mental health conditions. “Bringing mental health services to primary care normalizes and destigmatizes treatment for behavioral health disorders, simultaneously increasing access for patients by making evidence-based mental health services available in their regular primary care clinics,” the report states. “The delivery of primary care services to mental health settings also can overcome barriers to receiving medical and preventive care, offering increased convenience and familiarity with services. Merging mental health services within primary care services is more studied than the reverse; the science around effective health services delivery is greater for these models.”⁴

According to the National Institutes of Health,⁵ the integrated model is valuable because:

• Primary care settings, like doctor offices, provide about half of all mental healthcare for common psychiatric disorders.
• Adults with serious mental illnesses and substance use disorders also have higher rates of chronic physical illnesses and die earlier than the general population.
• People with common physical health conditions also have higher rates of mental health issues.

This approach is unique in that it addresses the whole person with the belief that a patient’s physical and behavioral health are both essential for the achievement of lasting, positive outcomes and cost-effective care.

Historically, it has been difficult for a primary care provider to offer effective, high-quality mental healthcare when working alone, and although most primary care providers can treat mental disorders, particularly through medication, that may not be the most effective, long-term treatment plan for a patient. Integrated care is structured to meet all of a patient’s health needs in one setting, and it can be delivered in multiple ways depending on who is providing the care, what type of care is being provided, where the care is taking place and how services are being coordinated. Options for integrated care include a behavioral health setting, a primary care office, a specialty clinic or a home health setting.

Identifying the appropriate type of integrated care is often determined using a system called the Four Quadrant model that prescribes integration levels based on diagnosis complexity and risk. Basically, the location, types of providers and services vary depending on the complexity of a patient’s condition. For instance, individuals with mild-to-moderate physical and/or behavioral health issues may be best cared for in a primary care setting with integrated behavioral health providers. Likewise, patients with complex general medical conditions coupled with mild-to-moderate behavioral health disorders may benefit from a medical specialty setting with integrated behavioral health providers. Finally, patients with severe behavioral problems, as well as medical conditions, may receive the most comprehensive care in a specialty behavioral health center with integrated general medical providers, or in a health home.⁵

Primary Care in the Age of Millennials

Behavioral trends and generational preferences are also influencing the future of primary healthcare. A recent poll of 1,200 adults conducted by the Kaiser Family Foundation found 45 percent of 18- to 29-year-olds had no primary care physician compared with 28 percent of those aged 30 years to 49 years. The study’s authors state, “Millennials are foregoing the time-bound model of office-based primary care in favor of more convenient care such as urgent care centers, telemedicine and drugstore retail clinics.”⁶

Another factor influencing millennial healthcare choices is that most young people have been on their parents’ insurance plans since birth. That means as they transition to their own insurance plans, they are suddenly responsible for their own health at a time when they are managing student loans, first jobs and becoming independent. All of that coupled with a tendency to feel healthy and invincible can result in letting primary medical care fall by the wayside.

In an attempt to capture this demographic, physicians are increasingly looking to technology to make everything from scheduling appointments to asking questions both quicker and easier for patients. “We’re all relying on smartphones,” says Susanne Madden, MBA, PCMH CCE, CEO of The Verden Group, a consulting firm for healthcare providers. “The difference is that the older generations are a lot more tolerant of not having that technology. Millennials, because they’re the connected generation, they’ve directed that change. There really is a groundswell demanding this, but millennials are just leading the charge.”⁷

And, it’s not just millennials who are shifting their focus away from primary care. A study by the nonpartisan Health Care Cost Institute found fewer adults are seeing their primary care physicians and opting more often to see a nurse practitioner or physician assistant. In fact, visits to primary care physicians have been declining since 2012, and the trend has not abated. The message seems to be that convenience and ready access are the desired qualities younger Americans value in engaging the health system.⁸

Team-Based Care Alleviates Burnout

Physician burnout in the primary care setting has also been an issue for a number of years, and it is fueling a desire to change the model of primary care delivery. According to a new study by InCrowd, some 79 percent of primary care physicians say they have experienced symptoms of burnout, compared to 68 percent among all physicians surveyed.⁹ “The alarming persistence of physician burnout over the years and across multiple studies, unfortunately, demonstrates that we have not yet turned the tide on this problematic issue,” said Diane Hayes, PhD, co-founder and president of InCrowd. Dr. Hayes notes that since InCrowd last surveyed physician burnout in 2016, there have been no noticeable improvements. “The healthcare industry would benefit from refining and expanding current initiatives to assure adequate staffing levels needed to deliver the quality care patients deserve,” she says.

Team-based care has become a popular healthcare goal in the wake of the industry’s move toward value-based care models, and it may be a viable means of reducing physician burnout. Because valuebased care models are cost-cutting and outcomes-based, industry experts believe teamwork between various providers is essential for long-range success. For example, value-based care puts a heavy emphasis on patients with chronic illness or other complex health needs. These patients typically see a number of providers, including primary care physicians, specialists, pharmacists, nurse practitioners and physician assistants who may all be practicing in those facilities. A team-based model can improve the quality of healthcare, minimize incongruities in care and potentially reduce physician burnout.¹⁰

According to the National Academy of Medicine (NAM), “The existing evidence demonstrates a generally positive association between team-based care and clinician well-being.” Reducing physician burnout can improve the quality of care patients receive because their physicians will be less tired, more attuned to patient needs and able to create better relationships with patients.¹¹

Although evidence is currently limited, researchers at NAM say team-based care may be one key solution to physician burnout. Team-based care can also positively impact the patient experience. Research has shown that patients who believe their medical team works well together also perceive they have received a higher level of care.

As the primary healthcare industry continues to adapt to changing fee structures, adjust delivery methods to meet patient preferences and seek new ways of reducing costs and improving outcomes, it will be essential for organizations to embrace innovation and reinvention. While advances in technology and the shift toward value-based care may permanently alter the primary care delivery landscape, the future depends on collaboration between the many industry stakeholders, including PCPs, specialists, politicians, Medicare, Medicaid, commercial insurers and healthcare systems. Now more than ever, healthcare providers must rethink the primary care paradigm and introduce new, innovative ways to deliver care and, ultimately, improve the patient experience.