What work is being done at the national level to promote more access to primary care?
By Graham Garrison
Editor’s note: The following is part 3 in a series examining the future of primary care. For previous stories, see the January 2025 and February 2025 issues of Repertoire Magazine.
For many patients today trying to find and maintain a primary care clinician, the struggle is real.
Ann Greiner, President and CEO of the Primary Care Collaborative (PCC) said their struggles can be attributed to several factors, including shortages of primary care clinicians, historically in rural or underserved areas but increasingly now in major metropolitan and higher income areas, patient financial barriers including high deductible health plans and the rising complexity of insurance networks that make it difficult to identify in-network primary care providers.
The PCC, a national nonprofit organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care, has several initiatives underway to better connect patients with clinicians.
For example, in the spring of 2022, the PCC launched the Better Health – NOW (BHN) campaign, a broad-based effort that focuses on advocating for more equitable, accessible and patient-centered primary care. There are seven Shared Principles of Primary Care, PCC said, endorsed by more than 380 diverse organizations:
Comprehensive and Equitable. Primary care addresses the whole person with appropriate clinical and supportive services that include acute, chronic and preventive care, behavioral and mental health, oral health, health promotion and more.
Accessible. Primary care is readily accessible, both in person and virtually for all individuals regardless of linguistic, literacy, socioeconomic, cognitive or physical barriers.
Person and Family-Centered. Primary care is focused on the whole person – their physical, emotional, psychological and spiritual well-being, as well as cultural, linguistic and social needs.
Team-Based and Collaborative. Interdisciplinary teams, including individuals and families, work collaboratively and dynamically toward a common goal. The services they provide and the coordinated manner in which they work together are synergistic to better health.
High-Value. Primary care achieves excellent, equitable outcomes for individuals and families, including using health care resources wisely and considering costs to patients, payers and the system.
Continuous. Dynamic, trusted, respectful and enduring relationships between individuals, families and their clinical team members are hallmarks of primary care.
Coordinated and Integrated. Primary care integrates the activities of those involved in an individual’s care, across settings and services. Primary care proactively communicates across the spectrum of care and collaborators, including individuals and their families/care partners.
Campaign participants range from associations to payers and providers, including the American Academy of Family Physicians, American Academy of Pediatrics, Blue Cross Blue Shield of Michigan and Blue Shield of California, Humana, the National Rural Health Association, Oak Street Health, UCSF Center for Excellence in Primary Care, VillageMD and Waymark.
Greiner said some accomplishments already achieved by the BHN initiative include CMS announcing the ACO Primary Care Flex model, finalizing a Streamlining Coverage Rule in Medicaid that will reduce coverage disruptions caused by red tape and administrative barriers, and a bundled prospective payment for primary care in the Medicare physician fee schedule.
How primary care performs in CMS models
Primary care’s performance in government physician reimbursement models bears particular attention in the coming years. Primary care already excels in the MSSP due to its focus on prevention, chronic disease management and accessibility, which reduce emergency and acute care costs and improves outcomes, Greiner said. And after evaluating primary care in Medicare Accountable Care organizations, PCC released a 2024 Evidence Report touting primary care as the “MVP of MSSP.”
The report noted that primary care-centric ACOs consistently achieve higher savings – 2.4 times more than others from 2017 to 2022 – by leveraging wellness visits, care coordination and data-driven interventions. “This approach minimizes unnecessary hospital use and ensures effective management of high-risk patients, aligning closely with MSSP goals,” Greiner said.
Key findings for the years from 2017 to 2022 include:
- MSSP ACOs in the highest quintiles of primary care centricity were consistently more likely to generate savings and generate savings above the median rate, as compared to ACOs with a lower measure of primary care centricity.
- Primary care centric ACOs outperformed most other ACOs. Concurrently, the median level of shared savings of all MSSP ACOs increased modestly, from 1.1 percent to 3.4 percent.
- High primary care centric ACOs generated 2.4 times the savings as low primary care centric ACOs between 2017–2022.
- By two different measures examined, MSSP ACOs did not appear to achieve these savings by targeting beneficiaries that have fewer social and economic vulnerabilities, although more research is needed at a smaller geographic level to confirm this encouraging finding.
Despite the strong performance of primary care centric ACOs, PCC noted the percentage of beneficiaries in those ACOs is dropping. In 2017, about 27.5% of beneficiaries were enrolled in primary care centric ACOs; in 2022, only 24% of beneficiaries were enrolled in such ACOs.
What can be done to reverse that trend? PCC said policymakers can take steps to promote the growth of primary care centric ACOs, such as considering waiving Part B cost-sharing requirements for beneficiaries who obtain care from their chosen source of primary care within the MSSP ACOs, or creating a create a new pathway within the MSSP that allows for primary care capitation, providing new and existing ACOs an opportunity to take on more risk and potentially more reward. They could also look at incentivizing more comprehensive primary care in the MSSP, starting with behavioral health integration.
Aligning motivations
Incentivize is a key word – perhaps the key word – when it comes to successfully adopting models of care that prioritize value over volume.
Both in the academic and professional settings, Thomas Campanella has listened to discussions about the need for more value-based health care for years. Unfortunately, when accounting for industry stakeholders and their various motivations, it’s been more aspirational than realistic.
“As long as you have a fee for service payment system, which is the predominant payment system in the United States, which basically pays providers on the basis of the more you do, the more you make – if that’s the overriding payment system, all you’re doing is focusing on doing more services and seeing more specialists,” he said. “We just wind up with escalating costs.”
It’s not rocket science; it’s inertia, Campanella said, and changing the status quo means going against “powerful players that are making lots and lots of money from a broken-down health system. At one end, you can see what needs to be done, but on the other end, the roadblocks from doing it are pretty big.”
For example, a number of years ago Congress passed a budget neutrality law in regard to physician increases. The idea was to control healthcare costs, but the model made the mistake of dumping primary care in with specialists and sub-specialists. So, if more money was given to primary care, then less money would be available for specialists and sub-specialists. That dynamic creates too much friction, Campanella said.
“What I think needs to happen, if primary care is considered a key ingredient to keeping people healthy and lowering healthcare costs, then maybe we should carve them out of this budget neutrality formula and give them whatever increases they need, but not at the expense of other specialties and subspecialties,” he said.
When push comes to shove, there needs to be a national strategic plan for primary care, something with teeth, Campanella said, and akin to the Marshall plan following World War II that provided structured support and economic aid to help rebuild Western Europe. “People get excited about these things, but then they jump to something else. We need to have more of a sustainable effort at a national level.”
Campanella said he is hopeful that the PCC can be one such catalyst for our nation’s health care system.
Whole-person care
Along with Better Health NOW, the PCC has also launched a new multi-year initiative on whole-person care and lifestyle medicine. Whole-person primary care promotes the full health of individuals and their communities by not only treating disease but by promoting wellbeing, PCC said. It approaches people holistically –supporting their physical, mental, social and spiritual needs – and as partners at the center of their own care.
Integrating behavioral health into primary care is particularly crucial. Mental health and physical health are, at their core, deeply interconnected, Greiner said. “Many patients with chronic physical health conditions also face mental health challenges, and vice versa,” she said. “By integrating behavioral health, primary care clinicians can offer more holistic care, improving early identification and treatment of mental health conditions such as depression, anxiety and substance use disorders.”
This integration leads to better overall outcomes, improved patient satisfaction and reduced stigma around seeking mental health care. This ensures that both physical and mental health needs are addressed concurrently.
PCC said whole-person primary care uses an array of approaches to promote health, from conventional medicine to lifestyle coaching, community connection, self-care and complementary therapies like acupuncture and mindfulness. It relies on a diverse team of professionals to help individuals reach their own health goals.
This model aims to strengthen the patient-clinician relationship, improve care coordination and ensure that patients’ diverse needs are met in an integrated manner, “leading to better health outcomes and more effective use of health care resources,” Greiner said.
Indeed, improved access to primary care is linked to better health outcomes for patient populations. The National Academy of Science, Engineering and Medicine (NASEM) reported that primary care is the only part of the healthcare system where more investment leads to better health. And there is plenty of evidence indicating that people who have access to high-quality primary care lead healthier lives and those with chronic conditions in particular benefit from strong primary care, Greiner said.
“Underinvestment in primary care leads to shortages of the professional teams needed to address rising rates of chronic conditions, mental health needs and other challenges faced by an aging, diverse population and falling life expectancy.”
Flexing with primary care
The ACO Primary Care Flex Model (ACO PC Flex Model) is a voluntary model focusing on primary care delivery in the Medicare Shared Savings Program (Shared Savings Program). It will test how prospective payments and increased funding for primary care in Accountable Care Organizations (ACOs) impact health outcomes, quality, and costs of care. The flexible payment design will empower participating ACOs and their primary care providers to use more innovative, team-based, person-centered and proactive approaches to care, CMS said.
It could certainly provide a boost to primary care physicians, who cover nearly half of all physician office visits, but typically don’t receive as much reimbursement as their specialist counterparts.
“The reimbursement rates for primary care services are significantly lower than those for specialists, with the current way that services are valued under the fee-for-service payment model not fully reflecting the true value of primary care,” Greiner said. “And, despite being responsible for a significant portion of physician office visits, primary care focuses primarily on preventive and chronic care management rather than high-cost interventions like surgeries or specialty care.”
Better Health – NOW tenets
Key tenets of the BHN campaign include:
- Shift primary care payment from volume-based to value-based models that reward quality and cost-effective care, offering clinicians more flexibility and patients personalized, comprehensive services.
- Increase health care spending on primary care.
- Fund diverse primary care teams to deliver a comprehensive set of services that better meets the needs of all populations.
- Ensure patients have a consistent primary care clinician and encourage long-term relationships.
- Support rural and underserved primary care practices with upfront investments, fair payments and additional resources.