Primary care physicians are the key to providing value-based care and population health.
As we transition to a world of risk/value-based healthcare and overall population health, the role of the primary care physician needs to take center stage. The role of the primary care physician should not be subservient to all the other specialties.
In fact, the role of the primary care physician should be more like the conductor of the orchestra. Conductors need not know how to play each instrument, but they know enough to bring them all together to make beautiful music. Likewise, the primary care physician can help orchestrate the care from the other providers to bring forth a better health status for the patient.
Also, just like the conductor, the primary care physician needs to have a holistic approach in that they are responsible for the entire ensemble or the overall health of the patient.
The important role of the primary care physician:
- The primary care physician can and should be a trusted patient advisor and advocate. Sadly, not all primary care physicians play the role as patient advisor and advocate. In some cases, the primary care physician acts as more of an entry point for the patient to receive access to specialists and sub-specialists. As a non-clinician, while I may not be an expert, I do know that I am made up of more than organs and body parts. I need a physician advocate who can look at me from a holistic perspective. I also know as a non-clinician, I need someone in my corner to guide me through the often-confusing maze we call healthcare.
- As a trusted patient advisor and advocate, the primary care physician can play a key role in engaging patients in their own health. Poor lifestyles and a lack of patient compliance will negate to different degrees the best and most expensive healthcare services provided.
- Primary care physicians play a key role in transitioning our healthcare system to be value-based. As noted in an 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 we are evolving to reimbursement methodologies that are more risk-based and rely on patient compliance, the role of the primary care physician needs to be enhanced. The key to profitability for providers in a risk/value-based world will be keeping patients healthy, which is the focus of the primary care physician.
- The primary care physician plays an important role in positively impacting population health and social determinants. The primary care physician can and should be linking patients with needed community services to remove gaps of care.
- As the conductor, the primary care physician needs to have a holistic approach in that they are responsible for the entire ensemble or the overall health of the patient. In this holistic role, the primary care physician links clinical, behavioral/mental health and chronic disease management in a team-based approach to better serve their patients.
The need for timely and appropriate data
A key ingredient to unleashing the real power of the primary care physician is timely and appropriate data. The primary care physician cannot be a real advocate of the patient without the necessary data from the other caregivers. 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, again, they need timely data from all caregivers.
Too often (as we all know as consumers of healthcare services) our primary care physician does not have access to timely and appropriate patient data. Electronic Medical Record (EMR) connectivity is critical to unleashing the real power of the multiple roles of the primary care physician. The EMR, ideally, also needs to have critical social determinants factors identified that are integral to the patient’s health status. We need to strengthen interoperability of the EMR through enhanced data management and collaboration with provider, payers, and community partners.
Not enough docs
We do not have enough primary care physicians to meet today’s needs, let alone our future needs. We will need many more primary care physicians, given their increased role in our new risk/value-based world, who are focused on improving the health status of our population.
Approximately 30% of physicians are in primary care which stands in stark contrast to other high-income countries, where the ratio of primary care providers to specialists is generally 70:30.
I am an advocate of increasing the number of NP and PA programs, but it should not be a substitute for the needed growth in numbers of primary care physicians.
I am also a believer in the increased use of technology, including telehealth, to allow us to better leverage our primary care resources in an economical manner. But this does not mean we reduce primary care to sound bite answers, with little or no personal interaction. Ultimately, the value of the primary care physician-patient relationship is based on trust.
If we identify the expansion of NPs/PAs programs and the growth of virtual office visits as the answer to this physician shortage, then we are downgrading the potential value that primary care physicians can bring to the table.
Healthcare payers can help
Ultimately, the combination of lower pay and the large amount of student debt along with a less than satisfying role in caring for their patient, has resulted in fewer medical students selecting primary care as their area of practice.
Healthcare payers’ passivity was a major factor in creating the “sick care” system that exists today, which devalues primary care. I define “passive” as sitting on the sidelines and observing escalating healthcare costs and inconsistent quality and accepting it as a norm rather than proactively addressing the root causes. This passivity also created an environment that placed the primary care physician in a second-class role in the healthcare continuum, especially with regard 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.
Active Purchasers
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 or potential 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 a healthcare system is shaped by “what you pay and how you pay for it.”
Payers, as well as innovative organizations, are also collaborating or creating physician practice management service organizations. These organizations provide administrative infrastructure and support services to independent primary care practices transitioning to value-based care models.
Payers, such as United’s Optum, are also buying primary care practices or hiring primary care physicians directly.
Innovators such as Privia Health hire and collaborate with primary care physicians and practices to better serve patients, self-insured employers, health systems and payers. Organizations such as Agilon Health have partnered with independent primary care physician groups such as Central Ohio Primary Care to allow the practice to embrace risk/value-based payment methodologies such as capitation.
Enlightened consultant and brokers are partnering with self-insured employers and third-party administrators in developing value-based benefit designs as well as incorporating Direct Primary Care and other vehicles to further the search for value. These disruptive organizations are also sending a message to traditional insurance companies who do not value the role of the primary care physician in the value equation.
Transitioning to payment methodologies that incent
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, and as it relates to health systems, global 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.”
The Center for Medicare & Medicaid Innovation Center (CMI) plays a key role in transitioning payment systems, including for primary care physicians, to be value-based. If appropriate, CMI hopes that private payers will clone these payment systems to both enhance their effectiveness as well as to cut down the administrative burden of providers of care.
Finally, the 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.
Enhancing their role
The enhancement of the role of the primary care physician along with increased income (and less financial educational debt) 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.
I am a strong believer in the Direct Primary Care (DPC) model since it plays a key role in both patient health as well as addressing employee health and related productivity which positively impacts employers’ profitability.
Even though I am an advocate of increasing the role of primary care physicians, I am not under-valuing the role of specialists and sub-specialty physicians. I am not suggesting that a primary care physician has the expertise of these specialists, nor would any primary care physician make such an assertion. Patient care should be a team approach, and the primary care physician does play a necessary and increasingly important role in our new world of healthcare.
Primary care physicians, the future is yours.
Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry – particularly the health insurance, physician and hospital sectors – he’s focused on strategic advising and community outreach. For more information, visit Tom on LinkedIn at: linkedin.com/in/thomascampanella or Baldwin Wallace University at www.bw.edu.