New Possibilities in Primary Care and Reimbursement

For diabetes patients, care in the primary care setting extends beyond the office visit to “between visit” care that includes community-based care, home-based care, and social support. Moreover, primary care includes nutritionists, health coaches, and diabetes educators as well as physicians. How can practices—and patients—afford all this?

Speakers in “Building a Stronger, High-Quality Primary Care System: The Key to Diabetes Prevention and Management” took on the issue at Diabetes Innovation 2013, the annual conference of the Joslin Diabetes Center in Washington, DC. The group discussed the future role of primary care as the legislative landscape changes and reimbursement models rely less on traditional fee-for-service.

Panelists were Lisa Whittemore, MSW, MPH, vice president, network performance improvement, BlueCross BlueShield of Massachusetts; Kavita Patel, MD, MS, fellow in economic studies and managing director for clinical transformation and delivery, Engelberg Center for Health Care Reform, Brookings Institution; Susan Manzi, MD, MPH, chair, department of medicine, Allegheny Health Network and vice chair and professor of medicine, Temple University School of Medicine; Bruce Goldberg, MD, director, Oregon Health Authority; and Rushika Fernandopulle, MD, MPP, chief executive officer, Iora Health. Robert Gabbay, MD, chief medical officer, Joslin Diabetes Center, moderated the session.

What’s the Right Role for Primary Care?

Panelists agreed that improving the quality and continuity of care, while decreasing costs, are goals that can best be achieved through a more substantial reliance on primary care. It is the best setting for prevention and early intervention, Goldberg said. Primary care also extends beyond the physician office visit. “There needs to be more resources and more focus on primary care to keep people out of high-cost situations, with more care being delivered at home and in the communities,” he said. Manzi agreed, adding that the current model of care misses entire populations of at-risk patients.

Fernandopulle, chief executive officer, Iora Health, noted that his organization relies on flat fees rather than a claims-based system. Employers pay a monthly fee per employee that joins an Iora practice. The term “primary care” extends beyond the primary care physician. For example, health coaches play a large role in patient care at Iora, particularly between office visits. Many patients have multiple comorbidities, and are best cared for in a primary care setting, Fernandopulle said.

Patel said a key issue with increasing reliance on primary care is the capacity. Physicians typically spend very little time with patients and do not feel they have much control over what their patients ultimately do outside of their visits.

Where Are the Opportunities?

A number of new reimbursement models are on the table, Gabbay said. What are the opportunities for reimbursement changes to drive improvements? Whittemore stated that the key to healthcare improvements is aligning incentives. The panel agreed with this perspective, and supported the notion that the fee-for-service model is detrimental to healthcare. Overall, the consensus among panel members was that real improvements would be impossible without a reimbursement model that rewards quality rather than quantity.

Manzi noted that making these changes is “easier said than done.” She added that meaningful system improvements require providers and payers to work together to drive the change.

Goldberg agreed with Whittemore and Manzi that payment models will drive change. “We have been locked in a fee-for-service model,” he said. “We have to have the flexibility to spend dollars for coordination of care—when patients aren’t present.” Goldberg explained that this would require a move toward outcomes-based reimbursement that covers care outside of the physician’s office,

such as home-based care.

Fernandopulle chimed in, agreeing for the most part, with this caveat: “The one thing I don’t agree with is that this is complicated. It’s really simple. Throw the fee-for-service model out. We know it doesn’t work.” He said that primary care is vastly underutilized, averaging approximately 4% to 5% of healthcare spending. He advocated for a flat-fee system similar to what his practice uses. With an emphasis on primary care, his organization has been able to improve outcomes. “We have 90% of hypertension and 90% of diabetes under control and have cut our hospital visits in half,” he said.

Patel said that part of the problem with the move toward new reimbursement models is that a large percentage of business still relies on fee-for-service, which complicates the incentives and diminishes the effect of the changes. Even the Accountable Care Organizations (ACOs), she said, still rely heavily on fee-for-service. It is because of this reliance on fee-for-service that some of the pioneer ACOs have switched from a 2-sided risk model to a 1-sided risk model. “They are realizing it’s too hard to innovate in a fee-for-service [environment],” she said.

The progress toward value-based care has been gradual. “It’s slow because we are not setting the goal that it is unacceptable to be slow.” Progress will continue to be modest until substantially more healthcare dollars are spent in primary care, Patel predicted. “A dermatologist can make more in 10 minutes than a primary care physician can in days,” she said. She added that it would make a big impact if a large health system refused to use fee-for-service.

She credited Iora for its innovation, and stressed that more visionary stakeholders need to make a commitment to value-based care. “We have a huge failure of leadership,” she said. “We need to be able to try new things and not be afraid of it.”

Golberg agreed that the focus should be on leadership, and on getting payers and purchasers on board. Getting the payment model right is necessary to making real improvements, he explained.

Fee-for-service is not working. “We are all purchasers,” he said. “We need to stand up and say, ‘We are not going to take it anymore.’ ” Whittemore noted that adding other caregivers to the mix, such as nurses and care coordinators, helps to improve care while reducing the burden on physicians. “There is tremendous fatigue in the primary care world,” she said. “They are entrenched.” It is important to start training physicians in medical school how to think differently about patient care.

Goldberg said that under the current system, physicians who may have initially decided to practice medicine so they could heal people had to adapt and learn how to run a business. Changing the model to rely more heavily on value and quality helps physicians get back to the basics of why they became doctors in the first place. “It’s a great opportunity to get back to why we are doing this—helping make peoples’ lives better,” he said.

Fernandopulle said that at Iora the physicians are essentially “system architects” responsible for running a team. “A lot of our day is spent working with health coaches, running groups, calling patients, spending time with specialists. It’s a fundamentally different job,” Fernandopulle said.

Role of Specialists

“The role of the specialist is not the role they have now,” Fernandopulle said. Primary care physicians should manage the patient’s care. They should integrate with a small group of specialists who are available to help with more complex cases. “The vast majority of type 2s I can manage,” he said. Endocrinologists can help answer questions and provide expertise with high-risk patients who have type 2 diabetes and with all patients who have type 1 diabetes.

Patel agreed that specialists should work with the sickest, highest risk patients. She added that the knowledge transfer from the specialist back to the primary care physician is key. “If we talk about being innovative—specialists should be a productive part of that spend.”

Managing a Busy Practice

Panelists were asked how to propel change while running a busy practice. Goldberg was the first to answer. “It has to become part of what the primary care physician does. It’s not an afterthought,” he said. “Where I’ve seen primary care be most effective is when there’s true integration with specialists. I think it’s very possible, but there’s got to be about a whole different model of care.”

Whittemore said her health plan “put a social worker on every single team. We turned the paradigm on its head.” A high-risk nurse care manager is used for really complex patients, she said.

Manzi said that behavioral health needs to be translated beyond the primary care setting into communities and homes to make a difference. “What’s really critical is the risk stratification idea,” she said. While doing all this, Fernandopulle warned that stakeholders need to be rigorous and careful how they measure cost savings to avoid unintended consequences. Compliant patients cost more initially, but overall care improves and costs go down. “Every time people try to save money in healthcare, bad things happen. In the beginning you may see costs go up, but if you do the right thing you will save money in the long run,” he said.