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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Niran Al-AgbaPaul @ Pivot ConsultingLLCMichael Chen MDNeil Quinnmeltoots Recent comment authors
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Niran Al-Agba
Member

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… Read more »

Allan
Member
Allan

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.

Niran Al-Agba
Member

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… Read more »

Allan
Member
Allan

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.

Michael Chen MD
Member
Michael Chen MD

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… Read more »

Paul @ Pivot ConsultingLLC
Member

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).

Neil Quinn
Member
Neil Quinn

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… Read more »

Paul @ Pivot ConsultingLLC
Member

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.

meltoots
Member
meltoots

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… Read more »

Allan
Member
Allan

“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”?

Peter
Member
Peter

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?

ruraldoc
Member
ruraldoc

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

William Palmer MD
Member
William Palmer MD

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… Read more »

LeoHolmMD
Member
LeoHolmMD

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… Read more »

Perry
Member
Perry

Amen.

Niran Al-Agba
Member

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

William Palmer MD
Member
William Palmer MD

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… Read more »

Perry
Member
Perry

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.

William Palmer MD
Member
William Palmer MD

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… Read more »

jamesepurcell
Member

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.