News & Commentary

The necessary and the sufficient: How to right-size primary care

Wednesday, March 9, 2016
Vice President of Care Delivery Transformation, Anthem Inc.
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I started my career as a nurse in a hospital before I transitioned to the ambulatory care setting. As a nurse on the ‘front lines’ of care delivery, I witnessed events that had catastrophic consequences on patients, their families and caregivers. 

But these moments were not the end results of a neglectful or incompetent staff; in fact, the opposite was true. Rather, they were the direct result of a lack of systems and processes in place to support a well-trained, caring team of health professionals and their evidence-based approach.

These deeply rooted experiences are what drive me every day to build a stronger, better health care system that achieves the Triple Aim: (1) improving the patient experience of care (including quality and satisfaction); (2) improving the health of populations; and (3) reducing the per capita cost of health care.

The Critical Role of Primary Care

We have known for a very long time that primary care is foundational to a strong, patient-centered, coordinated, and integrated health care system. Studies since the 1990s have acknowledged that a greater emphasis on primary care can lower costs of care, improve health, and reduce health inequities. We also know that people who identify a primary care physician as their usual source of care are healthier, regardless of their initial health or various demographic background.

But our actions have yet to catch up to the research; nor has it caught up to learnings and experiences from physicians and health professionals in the field, health insurance companies that are experimenting with new payment models, or stories from patients that cite the power of patient-centered primary care. 

We know this because while primary care visits account for 55 percent of the 1 billion physician office visits each year in the United States, it represents just 6 to 8 percent of our national health care spending—approximately $200 to $250 billion annually.[1] 

What Can Be Done?

One of the most important things we can do to right-size primary care is to change the way primary care is paid. According to the Catalyst for Payment Reform, just 40 percent  of all commercial health insurance payments are value-oriented (e.g., tied to performance or designed to cut waste). 

We must also acknowledge what is necessary—but also what is sufficient—for a value-based payment model to achieve the Triple Aim through transformation of care delivery. For example, many Accountable Care Organizations are putting administrative structures in place to manage value-based contracts. However, avoiding transformation at the point of care does not support the development of a viable, long-term infrastructure that is patient-centered and focused on population health. While organizing at an administrative level is necessary, transforming delivery at the point of care is sufficient.

Anthem, as well as a number of payers in the public (Medicare, Medicaid) and the private sector are making significant investment in primary care that allows primary care physicians and their practice team to do what they can do best: manage all aspects of their patients’ care.
 
For instance, Anthem’s Enhanced Personal Health Care Program is dedicated to:

  • Providing primary care physicians with tools, resources and meaningful information that promote (1) access, (2) shared decision making, (3) proactive health management, (4) coordinated care delivery, (5) adherence to evidence based guidelines and (6) care planning built around the needs of the individual patient, leading to improved quality and affordability for our customers and their patients.
  • Help redesign the current payment model to move from volume based to value based payment, aligning financial incentives and providing financial support for activities and resources that focus on care coordination, individual patient care planning, patient outreach and quality improvement.
  • Improve the patient experience by: creating better access to a primary care physician who will not only care for their “whole person” but will become their health care champion and help them navigate through the complex health care system, making them active participants in their health care through shared decision making, and optimizing their health.

It is a step in the right direction, but it will take a concerted effort from all stakeholders in the health care industry to right-size our investment in primary care. 

 

[1] Allan H. Goroll, Robert A. Berenson, Stephen C. Schoenbaum, Laurence B. Gardner, “Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care,” Journal of General Internal Medicine, 2007, 22(3):410-415. Robert L. Phillips, Andrew Bazemore, “Primary Care and Why it Matters for US Health System Reform,” Health Affairs, 2010, 29(5):806-810. U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services, “National Health Expenditure Data Projections 2012-2022,” November 2013.

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