Considering Different Payment Models for Primary Care

By | November 11, 2021

As we continue to focus on value-based care, how we design our value-based payment models continues to be critical. Historically, we have oversimplified the polarity by placing a fee-for-service on one end of the spectrum and global capitation payments on the opposite side. Thus, creating the idea that these two payment mechanisms are counter to each other, and a service fee is the antithesis of a price for value. As with all dualities, we must consider it more as an “and” versus an “or,” thereby creating hybrid models that genuinely fit the services. Therefore, adjusting payments to align with delivering value is significant, regardless of whether the reimbursement design is a global payment or a fee for the service provided.

Three completely different scenarios currently challenge primary care; chronic condition management, health and wellness (including prevention), and episodic care. Each of these situations has a value component and differing service levels, thus requiring different strategies and support. We must think about the payment for each separately and the measurement of outcomes that demonstrates value. For example, chronic disease management might fit better under a management fee structure with metrics aligned with the improvement or stabilization of the disease process. Treating an acute event may require payment for that event, with the outcome being the resolution of the situation, i.e., fee-for-service. Health and wellness, including prevention, is better delivered in a team-based model, and reimbursed under a management structure with outcomes consistent with patient-reported results.

Thus, a hybrid approach to payments might be the most appropriate mechanism. This model would consist of a monthly management fee based on an individual’s conditions accompanied by a health and wellness management fee. Additionally, certain services would be “carved out” and paid for on a fee-for-service basis within a management fee structure. Even items under health and wellness might be better covered on a fee-for-service model, such as immunizations, to deter the incentive of avoidance if covered under a flat management fee.

None of these concepts shared here are new or creative, but what is new, and needed, is an approach where we create a model that fits the needs of the individual while simultaneously providing the correct incentives. The key is tying the right metrics to each component including, patient-reported outcomes, not just their satisfaction with the service. Unfortunately, we are in a situation where a person might disagree with the treatment and thus believe they are receiving poor service, and thus “score” accordingly.

Whole person care within the context of their changing needs with situational components creates a complex environment for Primary Care. Our payment models must consider this complexity while also being easy to understand for those we serve. Since there is an abundant amount in the value chain, we must continuously live in the polarity and innovate how we deliver needed services and the payment models that will support the outcomes desired.