Recent strains on primary care, including the COVID-19 pandemic, have inspired many practicing clinicians, administrators, and payers to examine its sustainability, reimbursement, and develop solutions to save practices.
Primary care needs help. Reeling under lost revenue caused by the ongoing COVID-19 pandemic and the disruption in clinic visits due to people’s fear of infection, many physician practices are struggling to stay open. Although telehealth has helped, reimbursement is often lower than for in-person care.
“Primary care is under significant threat, and for some their survival is in question,” said Russell S Phillips, MD, director, Center for Primary Care, Harvard Medical School, Boston, MA, who said that up to 20% of practices report being in danger of closing.
A 2020 survey published in August by The Physicians Foundation, an organization that represents primary care physicians and specialists nationwide, shows the toll COVID-19 is having on physician practices: 8% of physicians have closed their practice, 43% have reduced their staff, 72% have experienced income reduction, and 37% saw volume decreases in their practices of up to 25% while 41% saw volume decreases of 26% or more. According to the report, this last number represents the percentage volume loss that makes it difficult to impossible to sustain practices longer than a few months for most practices.
But COVID-19 is not the sole or even main strain on the sustainability of primary care as currently practiced. For many years, a chorus of voices have called for a rethinking of primary care practice using words like revolutionize and transform to indicate the dramatic change needed.
In a 2017 article titled, “The Coming Primary Care Revolution,” Dr Phillips along with Andrew L Ellner, MD, laid out the daunting challenges facing primary care, among them challenges to work-life balance, high rates of physician and staff burnout, poor quality of care, and lower salaries and prestige from other specialties.
“While all of the world’s health care systems struggle to achieve these aims, and experience different trade-offs between health care cost, quality, access, and equity, the United States has the most expensive, technologically advanced, and sub-specialized health care, with worse population health outcomes and measures of equity than any other high-income country,” explained Drs Phillips and Ellner in the paper.
“Change is never easy, and dramatic change to something as personal as health care is likely to be accompanied by considerable distress for all involved, particularly for those whose livelihood is at stake,” they continued. “Nonetheless, we believe that physicians, particularly those early in training or practice, should view this revolution with considerable optimism and excitement, for it holds the promise not only of considerable improvement in the experience of our daily clinical work, but also of our profession drawing closer to its highest ideals of humanism and scientific rigor.”
More recently, investigators at Michigan Medicine—the University of Michigan’s academic medical center—dug deeper into some of these issues by looking at specific daily tasks within primary care practice that are taxing the ability of practitioners to deliver high quality care and avoid burnout. Ironically, some of the challenges to delivering high quality primary care seem to come from evolving practices and expectations in primary care initiated to streamline care and become more patient focused. The switch to an electronic medical record (EMR) system, for example, has placed extraordinary time demands on providers to document diagnoses, orders, and treatment authorizations. Expectations that primary care providers act as gatekeepers to specialty care, engage in shared-decision making with patients on all aspects of care, and be available through online patient portals to rapidly respond to lab results and messages all add up to hours that extend well beyond even a long work day. In their study addressing what they describe as a need to reset expectations on primary care, Laurence F McMahon, Jr, MD, MPH, professor, department of internal medicine and department of health management and policy, school of public health, University of Michigan, Ann Arbor, MI, and colleagues reported on a survey of general internists at the University of Michigan who said that managing EMR tasks alone added 20 hours a week on average to their weekly duties.
Demands on Time
A clear concern for the health and viability of primary care is the demand on provider time. “We know from data on primary care physicians that if they practice in the usual way it takes about 17 hours a day, and there is no way to run a practice practicing that long every day,” said Dr Phillips.
Among the solutions suggested by Drs Phillips and Ellner in their 2017 article is the need to redesign practices to alleviate some of this daily burden on primary care physicians. They suggest the need to triage and redistribute tasks to primary care teams for management of many primary care needs, free up generalist physicians to focus on high acuity and high-complexity cases, and using technology for more routine care (ie, using algorithms to standardize care handled by nonphysicians).
Dr McMahon also highlighted the need to rethink primary care delivery by focusing on the different levels of expertise, skill, and resources needed to manage the multiple interactions between the patient and health care system from disease prevention through treatment and management.
“The challenge is to reimagine the spectrum of services and reallocate the services to differing professions, organizational resources, and systems within the health system with the focus on the patient or population,” he said.
Within these broader, more structural changes to ease the time constraints on primary care providers are more specific changes that can be done in daily practice. Dr McMahon and colleagues suggest the need to redefine the clinical time needed for face-to-face visits to reflect reality, citing evidence to suggest that a full-time primary care physician should have 24 hours a week allocated to face-to-face clinical time with 20 hours for administrative, quality assurance, and nonsynchronous patient interaction duties. They also suggest managing expectations on how rapidly primary care physicians and others in the care team need to respond to online messaging to patients, such as lab results.
In a second commentary, Tanner J Caverly, MD, MPH, and Rodney A Hayward, MD, from the VA Center for Clinical Management Research, Ann Arbor, MI, suggest another change in practice to ease the time burden on primary care providers—to modify the expectations of engaging in SDM within all primary care patients.
“An emphasis in recent years has been on improving discussions between the physician and patient—about medical evidence, personal preference and overall goals,” said Dr Caverly in a press release.
The focus on detailed SDM is time consuming and Dr Caverly claims, not a good fit for primary care where most decisions are not high stakes. “Primary care providers most often guide patients about lower-stake decisions such as whether and when to get screened for different diseases and only have a minute or two within a clinical visit to make those decisions,” he added.
Drs Caverly and Hayward suggest that instead of expecting primary care physicians to engage in what they describe as detailed SDM, they adopt an everyday SDM that better reflects the substantive everyday decisions encountered in primary care practice. In their study, they lay out several steps to implementing the use of everyday SDM in practice. Among them is the information physicians will need to gather prior to the clinical visit with the patient, as well as the items needing discussion during the patient visit.
“We have years of using this everyday approach personally and it is very feasible in a time-constrained primary care environment,” said Dr Caverly, who said that he and his colleagues are in the process of systematically gathering feedback from patients on this approach to formally study its feasibility and effectiveness.
For Dr Phillips, changing the payment system for primary care from traditional fee-for-service (FFS) to a global capitation or sub-capitation is critical. “Primary care needs to be able to count on a level of support that is sustaining,” he said. One way, is for primary care providers to receive an agreed upon payment (sub-capitation) by the larger health care system that distributes monies negotiated through global payment contracts with insurance companies. Currently, Dr Phillips explained, the monies distributed remain FFS.
As a member of a task force in Massachusetts advocating for global payment or capitation for primary care providers, he said that this type of payment structure enables practices to invest in innovation to improve quality of care and lower cost instead of focusing on what FFS pays of which often does not adequately address the overall health issues—such as the well-established social and behavioral issues linked to poor health and chronic diseases.
“For example, fee-for-service doesn’t pay for community health workers or health couches and practices may want to have these to address behavioral change (which health coaches can do) or address social determinants of health (which community health workers can do),” said Dr Phillips.
Payment reform is one of the solutions Drs Phillips and Ellner lay out in their 2017 article to address the crisis in primary care. Specifically, they call for payment reform that moves away from rewarding volume or visits to value, including expanding to services traditionally not reimbursed in primary care but critical for preventive and overall health —such as dental and eye care, behavioral health management, and social services to address social determinants of health.
“More resources are needed to provide the services that primary care should be providing,” said Dr Phillips.
Questioning the true value of value-based reimbursement, Dr McMahon pointed out that many value-based payment and associated incentives tend to be disease-specific and often target expensive areas of service rather than having the hoped-for effect of breaking down barriers with organizations to enhance patient outcomes.
“A more fruitful mechanism might be to reward organizations based on the degree to which they are integrated across the professions with incentives shared amongst the professions and providers delivering care to groups of patients, rather than focusing on discreet outcomes or the cost of treating individual diseases,” he said.
Ensuring adequate and appropriate reimbursement for primary care, and redesigning practices to ease the substantial and unsustainable work load on practitioners are among the many issues under discussion to address the critical needs of primary care.
“By redesigning our care, embracing more professionals, integrating nonprimary care specialties into a managed-care paradigm, primary care will be enhanced, valued, and successful in improving the health of our patients and populations,” said Dr McMahon.
However, “If organizations view primary care as the only locus in the patient-centered care model and that the primary care provider is the only responsible professional within the organization tasked with the multitude of steps necessary to realize that model, primary care and managed care are in jeopardy,” he said.