Payment Reform, Telehealth Expansion, State and Federal Policy Changes Recommended
Ensuring access to high-quality primary care for all people in the United States will require reforming payment models, expanding telehealth services, and supporting integrated, team-based care, says a new report from the National Academies of Sciences, Engineering, and Medicine. No federal agency currently has oversight of primary care, and no dedicated research funding is available. The report recommends the U.S. Department of Health and Human Services (HHS) establish a Secretary’s Council on Primary Care and make it the accountable entity for primary care, as well as an Office of Primary Care Research at the National Institutes of Health (NIH).
Building on the recommendations of a 1996 report by the Institute of Medicine, the new report, Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, provides an implementation plan for high-quality primary care in the U.S.
All individuals should have the opportunity to have a consistent source of primary care, regardless of insurance status, says the report. Health insurance providers should ask all covered individuals to declare that source of primary care annually, so they can track this information and use it for accountability measures. Community health centers, hospitals, and primary care practices should assume an ongoing clinical relationship with the uninsured individuals they treat.
A strong foundation of primary care is critical to the health system. Yet visits to primary care clinicians are declining, the workforce pipeline is shrinking, and many practices have struggled to remain open. Primary care is the only part of health care where an increased supply is associated with better population health and more equitable outcomes. For this reason, the report emphasizes that primary care should be a common good, made available to all individuals in the U.S., promoted by responsible public policy, and supported with the resources to achieve health equity.
Declining primary care workforce capacity is associated with a loss of 85 lives per day overall, the report finds. It recommends opportunities to diversify the primary care workforce; equalize compensation with that of specialty care, to make primary care a more attractive choice for medical graduates; and incentivize trainees to work in rural, underserved areas and primary care “deserts.”
Despite accounting for a third of health care visits — and for many individuals, the only place they seek care — primary care practices were denied COVID-19 relief funds in the initial relief packages. Furthermore, primary care teams have been untapped as partners in addressing health disparities and supporting COVID-19 testing, tracing, and vaccination efforts. Several COVID-era policy changes should be made permanent, the report adds. The Centers for Medicare & Medicaid Services (CMS) should enable beneficiaries to continue telehealth and virtual visits, ease physician documentation requirements, and eliminate other barriers to high-quality primary care.
“The strength and quality of primary care need to be a public priority. Primary care serves people throughout their lives, for everything from school-mandated health checkups to managing multiple chronic conditions, but it remains inaccessible to far too many,” said Bob Phillips, director of the Center for Professionalism and Value in Health Care, American Board of Family Medicine, and co-chair of the committee that wrote the report. “If we increase the supply of primary care, more people and communities will be healthier — and no other part of health care can make this claim. For this reason, similar to public education, primary care should be a common good, not a commodity service that needs to compete in the marketplace.”
The report also recommends several policy changes to strengthen care delivery and payment. Current payment models will need to move away from fee-for-service in favor of payment models that better support independent practices, enable team-based care, and address the social determinants of health. As the largest payer in the country, Medicare should be prioritized for payment reform, since its payment policies set the tone for other public and commercial payers.
“It’s time we invest in health care as a lifelong relationship, rather than as a series of transactions. Primary care has the potential to improve health and health equity for all of society, and the way we pay for it should reflect that,” said Linda McCauley, dean of the Neil Hodgson Woodruff School of Nursing at Emory University and co-chair of the committee that wrote the report.“If we are to recognize high-quality primary care as a common good, it requires accountability structures, which this report clearly outlines.”
To achieve its vision for high-quality primary care in the U.S., the committee recommended several actions:
- Reform payment models: Public and private payers should shift from a fee-for-service (FFS) payment model to hybrid models (part FFS, part capitated, in which clinicians are rewarded for better outcomes and paid per patient, rather than per visit or procedure), making them the default payment method over time. CMS should aim to increase physician payment rates for primary care services by 50 percent, and identify overpriced health care services and reduce their rates to accomplish this.
- Increase access points: HHS should invest in the creation of new health centers, particularly in areas that are underserved or have a physician shortage. These may include federally qualified health centers, school-based health centers, rural health clinics, and Indian Health Service facilities.
- Design interprofessional care teams: Primarycare teams should fit the needs of communities, work to the top of their skills, and coordinate care across multiple settings, says the report. The field needs to consider how to meaningfully engage the full range of primary care professions, including physician assistants, nurse practitioners, medical assistants, community health workers, behavioral health specialists, and others. In addition, the report describes opportunities for integration between primary care and public health, behavioral health, oral health, and pharmacy.
- Support community-based training programs: Training primary care clinicians individually in inpatient settings will not adequately prepare them to deliver high-quality primary care, says the report. HHS should support training opportunities in community settings and in rural and underserved areas, and provide economic incentives such as loan forgiveness and salary supplements. Trainees should also receive opportunities to work alongside non-physician care providers and extended care team members.
- Make health information technology user-friendly: Digital health technology can make the primary care experience more efficient, higher quality, and more convenient. In the next phase of electronic health record certification standards, theOffice of the National Coordinator for Health Information Technology and CMS should account for the user experience of clinicians and patients (time spent using the system, ease of data transfer, and ability to make sense of data).
- Establish accountability and effective measurement: Senior secretary-level coordination at HHS is necessary because of the various agency-level activities that affect primary care, including workforce training, safety-net funding, payment and benefits policy, health information technology, and research. The proposed Secretary’s Council should be tasked with defining measures for high-quality primary care. There are currently too many metrics, which are burdensome and measuring the wrong things. Measures should be pared down and focus on overall health and well-being and equity, rather than disease-specific outcomes or payment.
- Create a primary care research agenda: Primary care still largely depends on evidence derived from research on subspecialty care, hospital settings, or single-disease cohorts. Moreover, primary care research is routinely less than 0.4 percent of NIH’s budget. Creating a research arm for primary care at NIH would build an evidence base to guide improvements in care quality, experience, and cost. Further, the report recommends prioritizing funding of primary care research at the existing National Center for Excellence in Primary Care Research office at the Agency for Healthcare Research and Quality.
While universal health insurance or a single payer system would help to make primary care a common good, says the report, the committee’s recommendations and implementation plan are intended to work within the current realities of the U.S. insurance marketplace.
“As the United States contends with the effects of the COVID-19 pandemic, health inequity, and a long-overdue reckoning of institutional racism, transforming primary care is essential to meet the moment,” said Victor J. Dzau, president of the National Academy of Medicine. “This report presents an opportunity to reimagine primary care so it reflects people’s needs and values, is supported with the right clinical and financial resources, and remains grounded in equity and social justice.”
The study — undertaken by the Committee on Implementing High-Quality Primary Care — was sponsored by: Agency for Healthcare Research and Quality, American Academy of Family Physicians, American Academy of Pediatrics, American Board of Pediatrics, American College of Physicians, American Geriatrics Society, Academic Pediatric Association, Alliance for Academic Internal Medicine, Blue Shield of California, the Commonwealth Fund, U.S. Department of Veterans Affairs, Family Medicine for America’s Health, Health Resources and Services Administration, New York State Health Foundation, Patient-Centered Outcomes Research Institute, Samueli Foundation, and Society of General Internal Medicine.
The National Academies are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln.