Considering Redefining Primary Care

By | December 16, 2022

As we continue our journey of value-based care, we still struggle to find models that significantly move the needle on improving quality and outcomes while also lowering costs. Central to this movement, has been a focus on primary care clinicians delivering services that focus on the holistic needs of individuals they serve, which includes prevention, lifestyle modification, healthy living education, social drivers of health and several others. However, the results have been underwhelming.

An evaluation of the Comprehensive Primary Care Plus (CPC+) model implemented by the Center for Medicare and Medicaid Innovation (CMMI) was recently undertaken and reported on by Markovitz et al. in Health Affairs. Their findings concluded that CPC+ did not lower spending or improve quality for private-plan enrollees in Michigan, even before accounting for payouts to clinicians. The CPC+ model was a multiplayer reform that incents primary care practices to lower spending and improve quality performance.

When we step back and query why our hypothesis is proving wrong, it’s also critical to examine the situation without bias. For one, do payment models need to differ based on the segmented population by payer type? For instance, commercial lives are very different from governmental lives in Medicaid and Medicare. In comparison, Commercial lives are younger, have more acute issues that eventually resolve, and do not remain with a single payer for an extended period due to job mobility. Therefore, incentives that take years to show benefit due to the nature of the slow progression of disease states cannot be tested in a short time within this segment of the healthcare ecosystem. Studying math of the study may be a confounding factor.

Additionally, it’s essential to consider what we refer to as Primary Care in two separate buckets. For instance, Primary Care Services encompass health and wellness, prevention, and a focus on the social determinants of health as drivers of cost and quality. And we have Primary Care Clinicians who specialize in diagnosing and treating acute illnesses and chronic disease management. To date, we have lumped both these functions together under the umbrella of Primary Care. We need to embrace the possibility that we need to “decouple” these functions and think about them separately. We try to accomplish keeping them coupled by providing a team-based approach within the Primary Care Physician’s office. However, if we think about each component separately, Primary Care Services may be better delivered by a completely different population-based approach. Maybe instead, we should call them population-based services, to help us consider them differently. That would allow us to create separate models for population-based services and primary-care clinician services. Population-based services could fall into much more of a public health model while clinician services would continue to be handled as done today. Undoubtedly, there would be coordination of information.

The CMMI program’s purpose is to help us learn what is successful and what isn’t. When we encounter one that shows no benefit, it’s crucial to step back and evaluate the why, including if the model is incorrect or just poorly implemented. Concerning primary care clinician-centric models, we might slowly realize that our underlying premises need to be adjusted. Let us embrace our learnings with positivity; knowing what doesn’t work does is as important as learning what does.