WASHINGTON — Primary care needs an overhaul if it is going to work the way that it should in the U.S., according to a report from the National Academies of Sciences, Engineering, and Medicine.
“High-quality primary care is the foundation of a high-functioning healthcare system and is critical for achieving healthcare’s quadruple aim (enhancing patient experience, improving population health, reducing costs, and improving the healthcare team experience),” noted the 449-page report. “Yet, 25 years since the Institute of Medicine (IOM) report Primary Care: America’s Health in a New Era, this foundation remains weak and under-resourced, accounting for 35% of healthcare visits while receiving only about 5% of healthcare expenditures. Moreover, the foundation is crumbling: visits to primary care clinicians are declining, and the workforce pipeline is shrinking, with clinicians opting to specialize in more lucrative healthcare fields.”
In addition, “unequal access to primary care remains a concern, and the COVID-19 pandemic amplified pervasive economic, mental health, and social health disparities that ubiquitous high-quality primary care might have reduced,” the authors wrote. “The pandemic also pushed many primary care practices to the brink of insolvency, with most practices uncertain about their financial viability.”
Five Major Steps
To solve some of these problems, the authors listed several steps that should be taken:
- Pay for primary care teams to care for people, not doctors to deliver services.
- Ensure that high-quality primary care is available to every individual and family in every community.
- Train primary care teams where people live and work.
- Design information technology that serves the patient, family, and interprofessional care team.
- Ensure that high-quality primary care is implemented in the U.S.
For each step, the 20-member committee that developed the report lists several actions to take. For instance, in terms of paying for care rather than services, the report recommends that Medicaid, Medicare, commercial insurers, and self-insured employers who are currently using a fee-for-service (FFS) payment model for primary care should shift primary care payment toward hybrid models that are part FFS and part capitated, “making them the default method for paying for primary care teams over time.”
The authors also recommend that CMS “should increase the overall portion of spending going to primary care” by improving the Medicare physician fee schedule’s accuracy, including “developing better data collection and valuation tools to identify overpriced services, with the goal of increasing payment rates for primary care evaluation and management services by 50% and reducing other service rates to maintain budget neutrality.”
Reforming the RUC
The report also suggests restoring the Relative Value Scale Update Committee (RUC) “to the advisory nature as originally intended by developing and relying on additional independent expert panels and evidence derived directly from practices.” To make the recommendations stick, the committee recommended that the Department of Health and Human Services (HHS) establish a “Secretary’s Council on Primary Care” to help make the report a reality.
Such a council is needed “because there really is no federal champion for primary care” when it comes to formulating health policy, said Robert Phillips Jr., MD, co-chair of the committee, during a briefing Tuesday. Council members should include the CMS administrator; the directors of the Center for Medicare and Medicaid Innovation, the Health Resources and Services Administration (HRSA), and the Agency for Healthcare Research and Quality; the Assistant Secretary for Planning and Evaluation at HHS; and the National Coordinator for Health Information Technology, said Phillips, who is also founding executive director of the Center for Professionalism and Value in Health Care at the American Board of Family Medicine.
The council should coordinate primary care policy across all of HHS, with attention to areas such as ensuring sufficient primary care funding, monitoring primary care workforce sufficiency, assessing the adequacy of government funding for primary care research, addressing primary care’s technology needs, and establishing meaningful metrics for assessing the quality of primary care, he continued. The council would report annually to Congress and the public on the progress of its implementation plan.
Increasing the Primary Care Workforce
The report also looked at the primary care workforce with an emphasis on rural and underserved areas. One of its recommendations was that HHS, with Congress’s help when needed, “should redesign the graduate medical education [GME] payment to support training primary care clinicians in community settings and expand the distribution of training sites to better meet the needs of communities and populations, particularly in rural and underserved areas. Effective HRSA models (e.g., Teaching Health Centers, Rural Training Tracks) should be prioritized for existing GME funding redistribution and sustained discretionary funding.”
“Part of it is how we prime the pipeline,” said Phillips. “We know that bringing rural-born people into the health professions training pipeline means you’re more likely to have a rural workforce on the other end. And that’s really important. We looked at a lot of evidence that also shows that training people in those rural settings — rural health clinics, critical access hospitals — means you’re much more likely to wind up in one of those settings again.”
The 1996 report did not get a lot of traction, but committee members think things will be different this time around. “The 1996 report was really conceived when the country was looking at healthcare reform,” including First Lady Hillary Clinton’s healthcare plan and the Republican response to it — “there were more than 20 proposals at the time,” said Phillips. “So there was a great deal of enthusiasm that the report might land when health reform was richly underway; that didn’t happen.” At about the same time, capitation payments for primary care were trending, but those also largely failed, “so two key opportunities for primary care to thrive kind of dissipated at the moment when these recommendations landed,” he noted.
The 1996 report also did not include the recommendation for a Secretary’s Council on Primary Care, said report committee member Alex Krist, MD, MPH, professor of family medicine and population health at Virginia Commonwealth University in Richmond. “We’re trying to designate a group that is nationally overlooking and making sure this is implemented, that primary care becomes the common good we say that it should be,” he said. The report also includes “measures on a national level we can look at to make sure that elements are being held accountable. If that step is implemented, it goes a long way toward making sure this can move forward.”
There is another way that 2021 is different from 1996, said report committee member Christopher Koller, president of the Milbank Memorial Fund in New York City. “In the last year we’ve gone through a pandemic and struggled with that,” he said. “We’ve realized the depth and the cost of the inequities that are existing in our social system, and we’ve watched life expectancy actually decline, even pre-pandemic. None of those were present in 1996 … Primary care can help address all of those items.”