Expanding primary care capacity through adequate payments and technology
Updated 11 months ago on February 04, 2023
Nina, the mother of an autistic teenager, had never experienced panic attacks until Covid-19 closed her son's school in March 2020. Then they began to occur with frightening regularity. The single parenting of a disoriented child she couldn't leave unsupervised resulted in her having to quit her job and finding herself confined to the house with no one to help with such necessary tasks as grocery shopping.
In desperation, Nina (that's not her real name) called a local clinic, and she was lucky enough to find one with doctors, counselors and social workers who use a primary care model that combines services to support physical, mental and social well-being. They quickly assessed her condition and home situation using telemedicine, explained and normalized her symptoms, prescribed medications and referred her to mental health counselors. They also arranged food deliveries from local food banks and helped her apply for unemployment benefits. The clinic became her lifeline, providing Nina and her son with vital physical, mental and social support for a year of isolation before schools resumed.
For years, many primary care physicians have been helping to address the many health crises plaguing communities across America--the surge in mental illnesses that mental health providers cannot handle, the rise of substance abuse, the constant strain on rural health care, and the effects of social stresses, especially on people of color, low-income people, or people with disabilities. Covid has exacerbated these interrelated crises. Economic stress contributes to higher rates of anxiety, depression, suicidality, substance abuse and addiction. As rural hospitals and clinics close, the lack of access to reliable health care providers deprives these and other disadvantaged communities of another important link in the social safety net and increases the risk of poor health and life consequences. The pandemic has demonstrated more clearly than ever the vital role that primary care plays.
The sustainability of primary care cannot be taken for granted. There are many indications that many practices are struggling greatly under current funding and payment arrangements. In 2020, primary care lost an estimated $15 billion, and a year later, one-third of practices said they had not regained their financial footing. As a result, a growing number of once-independent practices have been acquired by hospitals or private equity firms.
But even before the pandemic, primary care was already struggling under the fee-for-service system. In order to truly solve a patient's problem, the clinical team needs time to provide psychological support, understand the person's social context, and organize work with relevant community groups and institutions. The time required to fully understand the patient's problems and to act to solve those problems are "uneven" and unpredictable requirements in the physician's workday, which is contrary to the fee-for-service system. America's dependence on and expectations of primary care continue to grow, but the nation's investment in it has not kept pace.
A meaningful step forward would be to empower primary care with flexible, appropriate payments and technology so that all practices can integrate physical, mental and social supports and collaborate with other service sectors. The integrated care model that Nina was lucky enough to find is not widely available precisely because current payment structures and chronic underpayment for primary care create insurmountable barriers to including behavioral health and social supports for most practices. Federal skilled nursing facilities that can offer integrated care often rely on reimbursement to build this infrastructure. The Veterans Administration's integrated health care model also relies on predictable annual budgets and hired staff. Paying for shared mental health care, as Medicare currently does, is just the beginning. A better way would be to convert much of the payment for primary care into periodic and predictable lump sum payments. This would free the practice from the pursuit of more visits and more billing and allow it to focus on the patients in front of it.
A multidisciplinary team, telehealth, electronic consultations, home monitoring tools, connections and relationships with community service partners, and peer specialist support can form the chassis that gives primary care providers the resources and capabilities they need. But few practices, especially those serving rural, minority, or low-income communities, can afford to make these investments on their own. A national investment in teams and tools, whether by public or private insurers, can be a much more efficient expense than paying for the subsequent costs and health burdens of neglecting to provide truly comprehensive care.
Restore this essential foundation of the U.S. healthcare system with a combination of these upfront investments, and then offer primary care providers a sustainable business model through value-based payment programs that have already demonstrated success by rewarding high quality and containing costs.
Based on experiences in other countries and comparisons across U.S. communities, investments in primary care will pay off over time by reducing overall health care costs through fewer specialty and hospital services and by reducing the health care burden that leads to lost productivity and lost years of life. A broad and growing coalition of stakeholders is coming together to advance a policy agenda for primary care payment reform based on recommendations from the National Academy of Sciences, Engineering and Medicine (NASEM). Rural providers, mental health advocates, safety net clinics and health systems, primary care practices, payers, employers, and consumer advocates all understand that they cannot afford to do nothing. The Centers for Medicare & Medicaid Services has offered various primary care payment pilot programs, but none are as long or as invested as those recommended by NASEM, and none can be expanded nationwide.
The Biden administration and Congress should support what the facts show: primary care is the only part of the U.S. health care system that, with additional investment, will improve health in all communities.
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