Physicians

Focusing on Primary Care for Better Health

Screen Shot 2016-07-07 at 2.30.28 PMIn the United States, we have historically invested far more in treating sickness than we do in maintaining health. The result of this imbalance is not only poorer health, but more money spent in institutions, hospitals, and nursing homes.

The road to a better health care system means correcting this imbalance. We should reinvest in what we value — primary care — as a practice, as a profession, and as an abundant resource for patients. In recent years, we have begun taking a number of meaningful steps to begin this reinvestment process. Today, we are proposing significant actions to improve how we pay primary care physicians, mental health specialists, geriatricians, and other clinicians. By better valuing primary care and care coordination, we help beneficiaries access the services they need to stay well. In addition to keeping people healthy, health care costs are lower when people have a primary care provider and team of doctors and clinicians overseeing and coordinating their care.

There are four parts to our strategy to emphasize primary care:

  1. We are improving how we pay for care that we value. Today, through the Medicare physician fee schedule proposed rule, we are announcing an important set of changes that would improve how Medicare pays for primary care, care coordination, and mental health care. We conservatively estimate that these changes would result in approximately $900 million in additional funding in 2017 to physicians and practitioners providing these services. Over time, if the practitioners qualified to provide these services were to fully provide these services to all eligible beneficiaries, the increase could be as much as $5 billion in additional funding for care coordination and patient-centered care. These changes build on the work we’ve done to improve access to care in Medicaid by finalizing long-anticipatedrules that help support state delivery system reform efforts, and strengthening new policies to align payment with better, more cost-effective care and ensure that access to care is sufficient in key specialties.
  1. We are providing more opportunities for primary care providers to practice the way they think is best. Medicare is transitioning to policies that reduce burden on both patients and clinicians by better rewarding coordinated, quality care. We’ve recently launched a new advanced primary care Medical Home model called CPC+, which will be broadly available across the country and will support primary care doctors’ and clinicians’ efforts to spend more time with patients, serve patients’ needs outside of the office visit, and better coordinate care with specialists.
  1. We are finding ways to reduce practice expenses associated with operating a primary care or other small practice. We have been convening meetings with physician practices across the country to find ways to reduce reporting and compliance burdens, while at the same time increasing support to their practices. This spring, we proposed to streamline how Medicare pays for quality and value through the new Quality Payment Program, which includes features intended to reduce the reporting burden for clinicians. Through this new program, we’ve moved beyond meaningful use to the new Advancing Care Informationcategory, which supports the vision of providers leveraging health IT to promote efficiency and clinical effectiveness based on their unique needs. In addition, the Transforming Clinical Practice Initiative supports more than 140,000 clinicians in sharing, adapting, and further developing their comprehensive quality improvement strategies.
  1. We are exploring and encouraging far-reaching innovations to connect people with primary care in new ways. We have included telemedicine in a number of care models. TheRural Health Council is also helping to promote a strategic focus on access, economics, and innovation issues across rural America.

Today’s Proposals for Primary Care Payments in the Physician Fee Schedule

With today’s primary care payment proposals, Medicare continues to move toward a health care system that encourages teams of doctors to work together and collaborate in order to provide more personalized care for their patients.  Doctors will be compensated for spending more time with their patients, serving their patients’ needs outside of the office visit, and better coordinating care. These changes will deliver improved health outcomes that matter to the patient. Some examples of today’s proposals include:

  • Increasing payments for routine office visits for treating patients with mobility-related disabilities. Currently, Medicare pays approximately $73 for these visits, even though the patient might need to spend more time with the physician or require more physical and staff support during the visit. Under today’s proposal, Medicare would pay approximately $119 for the visit.
  • Increasing payments to geriatricians or family practice physicians – specialists who provide core services for the Medicare program. Under our conservative assumptions, we anticipate that these clinicians could receive a two percent increase in their payments for providing the care we propose to recognize under the Physician Fee Schedule.  Over time, if all of the practitioners that can provide these services provide them to all eligible patients, we estimate that the payment increase could be as much as 30 and 37 percent respectively to these specialties.
  • Proposing to pay for care using the behavioral health Collaborative Care Model. The Collaborative Care model supports mental and behavioral health through a team-based, coordinated approach involving a psychiatric consultant, a behavioral health care manager, and the primary care clinician and which extends beyond the scope of an office visit. Payment for care using this model will help address access issues for behavioral health and improve care for patients. This model, increasingly used by primary care practices, has demonstrated benefits in a variety of settings to improve patient outcomes. CMS is also proposing to pay for other approaches to behavioral health integration.

Strengthening Primary Care Beyond Medicare

As more people age into the Medicare program, we know that access to primary care is an essential tool for their health and wellbeing. We know that effective primary care, care coordination and planning, mental health care, substance use disorder treatment, and care for patients with cognitive and functional impairments can improve outcomes and result in smarter spending. Today’s efforts aim to better value primary care to ensure continued – and strengthened – beneficiary access to these valuable services.

We expect to see the impact of this proposal far beyond Medicare beneficiaries and hope that it will help strengthen the fabric of primary care throughout the country.

For more information, please visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-07-2.html.

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20 replies »

  1. Thanks. The government is unable to manage so many micro-healthcare economies so they pick one type and make all of America suffer from their failures. They have no faith in individual Americans that could create the needed micro-healthcare economies and make the necessary decisions in their own behalf.

  2. I know you are right. If this were about improving healthcare for Americans, CMS would do time out in the field. This is about money, plain and simple. Andy has a degree in English and Economics, then an MBA; of course we are widgets. That is all he knows. What a shame. It is wishful thinking, but this physician in the trench was hoping he would take my words (and invitation) to heart. My father and I have 65 years of medical experience between us. Our practice has been around since 1971 like so many others. What a loss for small communities across the country.

  3. Niran, regardless of reality, it appears that CMS wishes the independent practitioner, especially primary care, to become as populous as the unicorn. CMS would like all physicians to be treated like widgets. They have no interest in discovering what the physician in the trenches needs really are. That interferes with the dreams created in ivory towers by those who are rewarded with promotions for bad ideas while physicians would be prosecuted.

  4. Andy, the MOST important thing is for you to spend one day, two, or even a week out in the field at my office or another small primary care physicians office. You need to see what we do on a daily basis and actually understand the viewpoint of a physician in a small practice. This LACK of understanding and knowledge is at the core of CMS’ problem.

    Once you understand what we are capable of doing, how we do it, and how it actually SAVES money in the long run, while providing good quality care, then you are ready to tackle Focusing on Primary Care for Better Health.

    I agree with others this is a good start. I hope you are serious. You must pay us more for what we are doing if you want to increase our overhead expenses. Have you even thought about the fact that my county with a population of 260,000 has NO psychiatrist? Not one. We did have a consulting psychiatrist from Seattle who saw Medicaid patients only one day per month, but she just left the area. We are back to square one.

    Have you not realized small practices provide urgent, acute, and chronic care (comprehensive as you would say), plus care coordination, plus winging it when there is NO specialist to refer to at all in certain specialties? That deserves reward. Period. It is value at its best. You cannot get anything more out of us. There is nothing more to give.

    At the very least, please spend a day with one primary care physician in a small community. It will open your eyes to all the can be good with health care. It will open your eyes to what you are about to destroy with your outlandish EHR requirement with which we could never afford to comply.

    Thank you Dr. Holm for your compliment regarding my post. It is good to know I am not alone.

  5. Thank you Dr. Holm for your compliment regarding my post. It is good to know I am not alone.

  6. Good post, I agree. The entire EHR mandate/subsidies has been a huge disaster….and one that has been costly in terms of dollars as well as the patient-doctor relationship, and began to turn the profession of medicine into a sort of indentured servitude unlike any other profession (law, architecture) …..and, as you point out, likely prevented the development of a truly compelling EHR that made sense to doctors and patients (kind of like mandating Blackberrys and thereby blocking any room for an innovator like the Apple Iphone from coming into being).

  7. Great post….what a breath of fresh air, especially contrasted with the latest concoction of the central planners whose plans never work and always have unintended consequences…..and always lead to calls for more rules and regulations and centralization of power with the bureaucrats.

  8. I generally like the direction that it’s going (CPC+ track 1 emulating DPC) to allow support delivery models that involve more patient access and time with encounters. The big elephant in the room, at least for me, is the contradiction that he makes about trying help reduce practice expenses when they don’t address the largest non-staffing/salary practice expense which is the certified EHR. Nowhere does the Advancing Care Information proposal mention anything about doing away with the costly, unnecessary mandate that EHRs have to be certified. It killed innovation and killed solo practices (like mine) that were already electronically fitted to begin with. By not addressing this, no solo practice will ever survive in the future.

  9. Well-intentioned effort to be sure, but the solution takes the form of the problem, by trying to treat a sick primary care model rather than focus on upstream prevention via true reinvention that will make a difference in primary care access, outcomes, and cost. What’s the problem? Patients simply don’t have primary physicians who can provide easy access (same or next day appointments & virtual visits) + time and attention (30+ minute appointments, practicing at the top of licensure). Why? Fee-for-service, inflated patient panels (3,000-5,000 patients per physician!), and health care systems that use primary care as a triage to specialists and ER/urgent care (average patient time with a primary care doctor is about 7 minutes!).

    The Answer? Pay for direct primary care with a fixed per patient per month fee which removes (nearly all of) the fee-for-service and insurance paperwork distraction (physician offices spend nearly half their time chasing payments and running insurance company gauntlets). This does away with a focus on revenue generation and allows physicians to focus on, and be incentivized for, the only three things that matter (and are fulfilling to them): engaging, satisfying, and improving the health of their patients. Cap physician patient panels at ~900 patients (maybe more or less, depending on patient panel health status), so that physicians can actually provide access and time. This is not managed care, patients choose to have a direct primary care physician as their main doctor, and can still access specialists and facility services via their insurance.

    In this model physicians provide patients with their cell phone number (yes, really), and patients call their doctor rather than run to the ER or urgent care (no, patients don’t abuse this). You can imagine what happens to ER and urgent care costs–they plummet. Physicians have the time to direct patients to high value lower cost specialists, facility-based procedures, and ancillary services (endoscopy, imaging, and blood work)–and to make the appointments for their patients–and to call specialties before and after a patient visit–and, frankly, simply ensure that the patient actually sees the specialist. Physicians can take the time to have real conversations with their patients about family, work, mental and emotional states and much more. They don’t have to worry about how they will get paid to help someone improve lifestyle habits, lose weight or quit smoking. They can take emails, do phone consults, coordinate specialist care, work through polypharmacy issues with patients, visit patients in the hospital–and make a house call from time to time (yes, really). Importantly, these physicians can be their patients’ 24/7 health care warrior and advocate, practicing health “care” the way their hearts and minds envisioned when they went to medical school.

    This direct primary care model is radically reducing total health care costs for employers right now, while giving patients an amazingly wonderful relationship and care experience with their doctors. It can work in the Medicare space as well, and probably better given the greater care needs of many Medicare patients. The primary care tail can wag the whole health care dog.

  10. Being a specialist, I may get jabbed here, but I think that the more CMS tries to “do better”, the more they are making a mess. Honestly primary care MDs need straight up better reimbursement. Forget making them count more clicks, numerators, denominators, unpaid participants in setting up ACOs, homes, etc. CMS seems to forget or ignore the costs of setting up and maintaining these “value based care” models. I would also be wary of pitting primary care against specialists. We all work together, and when you look at what bankers, IT, consultants, insurance execs are paid, all of us in medicine are grossly underpaid. No doubt, we could use some parity in pay between specialists and primary care, but not at the expense of each other. That is one reason I hate MIPS/MACRA, it says someone must lose if someone wins in the payment scheme. Thats ridiculous. I really do not know of anyone left out here that is not busting their butt trying to take the best care of their patients and making their way through these complicated regulatory actions. There is no doubt in my mind that physicians are now more overburdened, despondent, and waking up daily trying to figure out how to get out of this profession. Its MUCH worse over the past 5 years, and no one seems to be listening. We are hearing stuff from Andy S, but his proposal is EXACTLY the same stuff, its not simpler, its more of the same. Its some nightmarish calculation that they think tells that some physician is doing “better” than another, because that one physician can click better, or count better. Its really sad. I’m very sad to see the damage that has occurred to us a profession. I’m not sure it will ever recover. If Andy S had some real bravery, he would say, lets stop ALL this madness. Lets get out of the way. Or at least say lets try to see if what CMS thinks is good does better than the “get out of the way” option. For the past 5 years CMS has spent many billions on EHRs that has not improved safety security efficiency usability nor patient satisfaction nor physician satisfaction. They keep firing out more complex schemes that seems to be the definition of insanity, of keep doing the same thing, thinking they are going to get a different result. Andy, if you read these comments, be brave. CMS should PROVE that what they are doing is an improvement, not making things worse. MACRA appears to be EXACTLY the same stuff, if not making things even worse. You want to add in Clinical Practice Improvement? Why? Who ever said that improves anything? Has MU now ACI ever shown to improve anything about care? Has PQRS now Quality shown to improve any outcome? I would think we would see numerous studies by now since its been ongoing for over 5 years now. I have yet to see one. What is happening with all this data collection? PROVE to me its done one thing to improve care, or reduce cost. So before you pile on a bunch of complicated programs to supposedly improve primary care reimbursement, think how much more burden you are placing on them.

  11. “far more in treating sickness than we do in maintaining health. … The road to a better health care system means correcting this imbalance. ”

    Without discussing the merits of your plan I wonder if you can offer clarification of the above comment. It sounds as if you believe we should be spending more on preventative care in order to prevent people from becoming sick. Aside from vaccinations and early diagnosis, I am not really aware of what one would expect from a physician. What do you expect the physician to do to correct “this imbalance”?

  12. All great stuff Andy and I agree with your work to shift to primary. But how do you/we stop the juggernaut of hospital acquired primary practice and associated services that explode costs in the community?

  13. Mr. Slavitt I hope you understand that giving primary care more administrative stuff to do to earn more money is not the same as supporting us or paying us better. I agree with Dr Holm’s post below especially point number 4.

    Jim Nordal MD

  14. There are really only two ways to bring prices down. You can try for a free market–see canonical problems below–or you can have very large purchasers who are the main purchasers in town. Take your pick. Price controls work for a few months and they work in the minds of politicians, but not elsewhere.

    With the rapid acceleration of co-payments and deductions in the ACA, we are on a price cliff to oblivion…where the system stops. All these little triffles like MU and MACRA and “value” and ACOs are like flowers on the grave stone. Everyone is going to rather pay the tax penalty than get 6000$ deductible with actuarial values of 50% (you pay 50% OOP: Ridiculous pseudo-health insurance is what this amounts to. It is a product that is not useful or helping the folks.

  15. Thank you for this post. I hope it moves forward. Primary Care has been waiting too long for the tide to turn, but there are many things that leave us wondering:

    1) After all the effort setting up PCMHs, the reward for accelerating overhead and doing an incredible amount of work: a whopping 1.50 pmpm. This will not even support an FTE+benefits for most small practices, and will not begin to cover the massive expenses of sustaining such a model. Perhaps CMS has done this in it’s wisdom, actually not valuing a bloated process driven certification machine being used as a buy-out from MACRA. I’m sure there are many ways to perceive it.

    2) The effort to reward CCM is extremely difficult to claim for the simple reason: Lots of extra work + something we do anyway in the interest of patient care + trivial reimbursement = Forget it!. PCPs are just shaking their heads at this one.

    3)The move to value based care is a process, I am sure. But it is simply an overlay on the Relative Value system which is rife with problems for PCPs. I view it like FFSPlus or something like that. I don’t think there is a viable way forward using a system that got Primary Care into the dire situation it is in today. CMS should abandon the misinformation they have been receiving form the Relative Value Committee and tap in to what patients truly value.

    4) If CMS had a type of “value detector”, what would it have honed in on? Perhaps a rural Primary Care Physician, providing urgent and acute and chronic care, spending extra time with their sicker patients, reducing specialist referrals (because there are not many around), keeping health care costs low (because we treat resource limited people), and providing comprehensive care. Why not start there? Why not reward that?

    Please read the recent post by Dr.Niran Al-Agba. It captures the way a lot of us in Rural Primary Care are feeling.

  16. To get the hospital’s charges to come down takes an agent of the patient who is also a monopsonic purchaser! Very important. You don’t want to reduce the docs’ fee–they always take 20% of the health care dollar–you want to affect the prices of the hospital, the specialists and the drugs.You want the doc to have “market power”…the ability to affect prices. And leave the patient ultimately in charge. You either have to trust the patient and pass all the dough through him/her via indemnity or you trust the doc and let powerful groups of docs buy everything and compete by way of monopsony.

    Groups of patients COULD get together and act as powerful purchasers, but this seems very difficult.
    Prices are everthing right now because producer surplus* is going to come to a vanishing point and the system will grind to a halt…..just as no one would buy main-frame computers for 15,000$.

    A totally free market would bring the prices down but forget it, because there is no way to have the insurance mechanism extant PLUS the “many-buyers; many sellers” dictum of a free market.

    *Producer surplus is essentially the ability to sell your goods or services at any margin above your costs.

  17. This is pretty much where we’re headed Dr. Palmer, except that it’s the hospitals that own the practices and are in the driver’s seat. Private primary care is a dying breed.

  18. Try large groups of primary care docs who are large enough so that they are monopsonic purchasers of specialty and hospital and pharmacy services in a given service area….i.e. they can affect the prices of these local providers. Give them superb salaries and purchasing budgets and overload them with patients so that extreme motivation for innovative care occurs. Put them on big capitation–they pay for hospitalization, rehab and specialty care and run a pharmacy–but allow patients to demand services, CTs, MRIs, labs, so that under-treatment is not a motive. The patient is deemed to be in the same controlling position as if he were paying OOP. This arrangement would have to be shrewdly designed. The patients would feel in charge and the docs would feel in charge of their service to the patient. Allow the group to act as a bargaining oligopoly with respect to CMS. See that intense competition is allowed between these large capitated group practices. Medical students would see the controlling power of these PCP entreprenuers and be enticed to select primary care as a specialty. The main thing is that you deliberately want these groups to be large enough to be monopsonic purchasers of hospital care, rehab, pharmacy and specialty services. Hospitals would have to cooperate to survive. The ultimate power would be with the patient-boss. The mega PCP groups would have to have re-insurance to shed some of the financial risk.

  19. Andy, God is in the details, but as you describe this, it sounds like a good start. The ultimate question is who eventually becomes the quarter back of care, what does that mean, and if it’s primary care (which I believe it should be), how do we gentle them to that spot? An extender team does help. How about med school debt forgiveness? In RI, we (the local Blue Plan) funded a PCP debt forgiveness program that was popular. In any event, I like what you wrote.

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