A Vision for the Future of Primary Care
Primary care is at a crossroads. In the fall of 2019, after Governor Baker proposed an unprecedented increase of investment in primary care and behavioral health in Massachusetts, MHQP convened a panel of experts and stakeholders focused on addressing threats to the sustainability of traditional primary care practices.
Then the COVID-19 pandemic hit and many primary care practices found themselves struggling to survive amid substantial uncertainty. During these unsettling circumstances, MHQP convened a Roundtable including the panel of experts and stakeholders mentioned above (see list of participants here) to discuss a vision of primary care. We focused on two specific topic areas – access and payment systems –believing these to be the most critical and highly leverageable elements for the future of the primary care system. While COVID-19 created many challenges for the healthcare system, it also established a unique opportunity and an even greater urgency for payment and care delivery redesign changes that lead to a sustainable and equitable primary care system.
Achieving real, sustainable change in the post-pandemic world will require that we begin with a clear vision of the desired direction and destination. This is especially important with a challenge as complex as the primary care system. We believe the vision that emerged from the Roundtable meetings may be helpful in this regard. That vision, which is detailed below, coalesces around five themes. (You can click on each theme to reveal more detail.)
We seek a primary care system in which:
- Behavioral health providers, social workers, health coaches, community health workers, persons with lived experience and others are integrated as members of the primary care team. This will increase continuity of care for patients, improve care access and enable care and services to be tailored to specific patient segments. This will require reimbursement that supports care and services offered by the extended primary care team, education about the value of team care, and the development of a more diverse workforce.
- The administrative and service tasks currently performed by primary care providers are minimized to reduce provider burnout and increase provider retention. This will require elimination of unnecessary tasks, automation of some tasks, and delegation of work to others, when appropriate.
- Primary care practices have tools, resources and meaningful data to identify and address health inequities. This will require that practices and the larger system in which providers work make health equity a priority and invest more to ensure the equitable treatment of all patients. This will also require incentivizing investments that make primary care more accessible to underserved populations (e.g., offering interpreter services, telephone telehealth visits), prioritizing recruitment and retention of primary care clinicians/team members from underrepresented minority groups (race/ethnicity, sexuality), addressing payment inequities, health literacy and discrimination for non-white, non-male clinicians/team members, and investing in research to identify and understand the relationship between healthcare disparities, patient factors, organizational factors and payment structures.
- Telehealth platforms and patient-provider communication systems are used to improve care and patient access. This will require that we adequately reimburse providers for telephone and video visits, as well as for asynchronous communication (e.g., secure texting, secure email, e-visits). We must also recognize that a wide range of communication technologies and visit modes offer a continuum of services that improve care and better meet patients’ needs.
- Technology is leveraged to promote wellness and to support the care of individuals with chronic health problems. This will require lowering the cost and logistical burden of using internet tools such as internet-based Cognitive Behavioral Therapy, and that patients have access to secure internet-based health tools, evidence-based treatment apps and remote patient monitoring equipment (e.g. blood pressure cuffs, pulse oxygen meters).
- Behavioral health is integrated into primary care to better meet the behavioral health needs of primary care patients. This will require that behavioral health services that can be successfully managed in primary care are financed through primary care or through healthcare systems that own primary care practices, not through a separate behavioral health financing system. Having a separate behavioral health financing system creates barriers to behavioral health integration into primary care.
- Payment incentives encourage shared decision making in primary care, defined as making non-urgent health care decisions in a manner that is consistent with medical evidence and tailored to each individual patient’s risks, benefits, values and preferences. This will require transitioning from current guideline-based measures of quality for preventive and chronic disease care (which do not account for individual patient risks, benefits, values or preferences) to shared decision making-based measures of quality.
- The system addresses social determinants of health (SDOH). This will require financing that recognizes the breadth of services that practices provide for their patients and that allows for the reimbursement of SDOH screening, and services and support staff to help address individual patient SDOH needs.
- Provider organizations are rewarded for improving coordination/integration of care and patient-provider relationships. This will require rethinking how information is managed in health care, including but not limited to, the content and format of medical documentation, governance and access rules for medical information, and how we collect data and use technology to collect and/or measure these concepts. New forms of measurement should offer practices information about how care is delivered across a continuum of services. This will also require that incentives encourage: appropriate, non-traditional care (e.g., telemedicine, care delivered by the extended primary care team); coordination and integration between community based organizations, specialists, hospitals and PCPs (e.g., holding specialists accountable for how well the care they provide integrates with primary care and around the patient; holding hospitals accountable for how successfully discharged patients are re-integrated into primary care; and assessing how well patients have community based services re-established once they are discharged); and strengthening the patient-provider relationship (e.g., including the patient voice in care, improving patient-provider trust). re coordination/integration efforts will only be effective if they make appropriate use of technology (e.g., care coordination communications are integrated into the EHR rather than being faxed to primary care offices) and are accompanied by collaboration in more than name only (e.g., building on trusting relationships between PCPs and specialists).
- Health plans, employers and large healthcare systems preferentially invest in primary care to improve access and primary care capabilities. This will require a shift in reimbursement to rebalance what we pay non-primary care clinicians compared to primary care; and necessitate that large systems, payers and others realign incentives to encourage more investment in primary care and behavioral health services that are integrated into primary care (e.g., team- and evidence-based models of collaborative care that address mood and anxiety, trauma related disorders, substance use disorders, dementia and pediatric behavioral health services). This requires that health plans and employers communicate the essential nature of primary care to members and employees, and to change benefit designs to encourage members/patients to use primary care effectively (e.g. PPO plans do not support patients having a primary care clinician.)
- The payment system allows practices to move beyond the fee-for-service construct that ties payment to in-person visits and makes practices susceptible to shocks in volume such as those experienced with the COVID-19 pandemic. Powerful inertia exists to maintain the status quo. Change will require leadership at all levels and organizations (state and federal government, health plans, employers, provider systems, and individual providers) to move to global payment on a large enough scale to “move the market.” In part because of the way they were implemented (limited risk, delays in payment reconciliation), current global payments at the system level (e.g., Medicare and Medicaid programs, Blue Cross Blue Shield’s Alternative Quality Contract) have not had the desired effects of changing health care; changes resulted in moving site of service to lower cost sites and improving some measures of quality, but they did not create change on a large enough scale. This argues for a per member per month primary care global reimbursement model.
- The payment system empowers practices to be more creative and flexible in the services they provide to better tailor services to their patient populations. This will require that practices understand and address patient preferences and needs, including appropriately expanding access to current services (e.g., after hours care) or offer access to new services (e.g., health coaches). This will also require rewarding innovation and looking to best practices outside of Massachusetts.
- The payment system fairly reflects the patient population of each individual practice. This will require an updating and rethinking of current risk adjustment models as well as required coding.
We hope this vision offers important guidance to practitioners and policymakers alike regarding the priorities we must address to strengthen and sustain primary care in the Commonwealth. While the COVID-19 pandemic has highlighted key vulnerabilities in primary care related to access and payment systems, it has also created a receptive environment and impetus to make significant changes to how primary care does its work and how it is paid. These changes will not be easy, but if pursued with care and creativity, they can lead to a more resilient, sustainable and equitable primary care system.
For MHQP’s part, our Board of Directors has endorsed this vision as a “north star” guidance for our continued work on primary care. We are currently exploring two possible paths forward as ways that MHQP can uniquely contribute to this effort:
- Convene payers and other stakeholders, including patients, to discuss basic alignment on capitation in order to advance primary care capitation in Massachusetts.
- Build a primary care dashboard for Massachusetts to create a more favorable environment for primary care and monitor progress in the state.
We welcome your feedback on these ideas and any other suggestions you might have for what MHQP can uniquely do to help strengthen and sustain primary care in Massachusetts.