Primary Care Needs More Attention and Investment, CMS Officials Say

WASHINGTON — Healthcare payers, including the federal government, aren’t investing enough in primary care, said experts during a conference sponsored by the American Academy of Family Physicians (AAFP) on Tuesday.

Without that investment, there are “consequences in terms of [detecting] disease and initiating lifestyle change, and consequences in the chronic disease burden that we see in America,” including obesity, said Abe Sutton, director of the Center for Medicare and Medicaid Innovation. And yet, “the truth is, we have a great welfare system. We have wonderful resources in place. We have cutting-edge technologies,” and the chances of survival in diseases like cancer increase every year.

But despite these gains, not enough is done to get patients actively interested in disease prevention, “and that’s the consequence of the incentive structure we have,” continued Sutton, who is also deputy administrator at CMS. “We rely on a fee-for-service system, and we are tied to the RVU [relative value unit]-driven approach.” Both of those systems incentivize physicians to provide more office visits and procedures, rather than counseling and disease prevention, in order to get paid more.

Joe Albanese, director of policy at the Center for Medicare, outlined what he saw as the three biggest shortcomings in the Medicare Physician Fee Schedule. “First, there’s an undervaluing of primary care, and I think one of the ways that we addressed that … is that we introduced an ‘efficiency adjustment’ that takes non-time-based services and codes” such as those for procedures, and effectively reduced payments for them while time-based procedures such as primary care evaluation and management were not affected. Making that change led to an overall increase in the conversion factor used to calculate physician fees this year, he added.

Second, “our system is very biased towards large health systems and hospital-based care — that’s more expensive for the system, but also for the patients, and not always clinically necessary or justified,” Albanese said. “In the previous system, we had been potentially double-paying for the indirect costs at a hospital, with the assumption that [we needed to pay for] salaries and overhead … We corrected for that in order to acknowledge that those who are delivering services in modest settings, particularly in private practices, have been biased against in our payment system.”

Finally, the fee schedule calculations rely too much on outdated data sources, he said. “So we’ve been using alternative sources of data … even borrowing from our outpatient hospital system for specific services. [We want to] have less reliance on survey data or things that have small sample sizes, things that have been distorting the overall pricing that we’ve been setting.”

Also at the meeting, the AAFP and the National Association of Community Health Centers (NACHC) launched their “Triple Double” initiative, named after the phenomenon in professional basketball in which a player achieves a double-digit result in three of five primary categories (such as points, rebounds, and assists) during a single game.

Kyu Rhee, MD, NACHC’s president and CEO, introduced the Triple Double’s three goals:

• Double the nation’s investment in primary care, from 5 cents of every healthcare dollar to a dime. “It’s not just the level of spending; how we spend matters too — moving away from fee-for-service towards capitated models that support team-based, whole-person care that actually rewards the prevention of chronic disease,” Rhee said.
• Double the reach of primary care, beginning with increasing the number of patients served annually at health centers from 10% to 20%. “The infrastructure exists; the model works,” he said. “Expanding reach requires investment in the health center workforce … We’re grateful that earlier this year, the president signed the largest funding increase in a decade for the community health centers.”
• Double the next generation of primary care workforce from 20% to 40% of healthcare workers overall. “We need to recognize that only 20% of the workforce that’s graduating today, who are physicians, physician assistants, nurse practitioners, are doing primary care, and that is not sufficient for the workforce today or tomorrow,” Rhee said. “How we do that is by addressing GME [graduate medical education] reform and also [making more use of] teaching health centers.”

“The triple double is not a legislative package or a policy mandate,” he said. “It’s a unified national movement built on shared messaging and evidence organized around shared goals, and designed to catalyze a political and community will that the evidence alone cannot be sufficient to generate. It serves as a framework and a set of goals that we can all get behind and we can all track.”