Pri­mary-care prac­ti­tion­ers will be key play­ers in the value-based trans­for­ma­tion of health­care

Modern Healthcare - - COMMENT - Dr. Anand Parekh

Stud­ies con­tinue to demon­strate that a strong sup­ply of pri­mary-care physi­cians is re­lated to more ef­fec­tive de­liv­ery of pre­ven­tive care and lower rates of mor­tal­ity, emer­gency room vis­its and hos­pi­tal ad­mis­sions.

In fact, some of the best ev­i­dence of pri­mary-care medicine’s im­pact on these out­comes comes from stud­ies that high­light its role as a fre­quent source of care and the site of first pa­tient con­tact. Pri­mary-care providers are ab­so­lutely es­sen­tial to the goal of achiev­ing a value-based trans­for­ma­tion of our health­care sys­tem.

Un­for­tu­nately, it is not easy to prac­tice pri­mary-care medicine in this coun­try. Specif­i­cally, the cur­rent de­liv­ery and pay­ment land­scape does not al­low providers to spend the amount of time they need to ex­am­ine pa­tients or re­flect on their cases. This leads to many dele­te­ri­ous con­se­quences, from un­nec­es­sary con­sults and di­ag­nos­tic tests to in­creased stress, job dis­sat­is­fac­tion and burnout.

Pri­mary-care physi­cians make up less than one-third of the U.S. physi­cian work­force but pro­vide over half of all physi­cian of­fice vis­its. Ac­cord­ing to the As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges, the num­ber of pri­ma­rycare physi­cians rel­a­tive to the U.S. pop­u­la­tion has been vir­tu­ally flat for nearly the past decade—roughly 90 ac­tive pri­mary-care physi­cians per 100,000 pop­u­la­tion. How­ever, now is the time, more than ever, when we need more pri­mary-care ac­cess.

Be­yond the nearly 20 mil­lion Amer­i­cans newly in­sured un­der the Af­ford­able Care Act, more Amer­i­cans have mul­ti­ple chronic con­di­tions re­quir­ing more com­plex care. Un­for­tu­nately, a re­cent Com­mon­wealth Fund study found that al­most one-quar­ter of pri­mary-care providers said their prac­tices were not equipped to man­age care for this pop­u­la­tion.

The Pa­tient-Cen­tered Pri­mary Care Col­lab­o­ra­tive’s re­cently re­leased 201415 re­view of the im­pact of pa­tient-cen­tered med­i­cal homes on cost and qual­ity demon­strates that the vast ma­jor­ity of stud­ies on ad­vanced pri­mary care show re­duc­tions in cost or uti­liza­tion. And as more ac­count­able care or­ga­ni­za­tions are es­tab­lished, they are real­iz­ing that a key to suc­cess for pop­u­la­tion health is in­vest­ing in pri­mary-care mod­els that sup­port care co­or­di­na­tion and care man­age­ment.

For­tu­nately, there has been progress from a pol­icy per­spec­tive to sup­port pri­mary care. The bi­par­ti­san re­peal of the sus­tain­able growth-rate for­mula for physi­cian pay­ment and pas­sage of the Medi­care Ac­cess and CHIP Reau­tho­riza­tion Act of 2015 have brought greater sta­bil­ity to physi­cian pay­ments. The pres­i­dent’s fis­cal 2017 bud­get for HHS also sup­ports pri­mary care in a num­ber of ways, in­clud­ing al­low­ing the sec­re­tary to in­tro­duce pri­mary-care pay­ments in the physi­cian fee sched­ule in a bud­get-neu­tral man­ner and re-es­tab­lish­ing the Med­i­caid pri­mary-care pay­ment in­crease through the end of 2017.

Another wel­come devel­op­ment is the re­cent for­ma­tion of a bi­par­ti­san Con- gres­sional Pri­mary Care Cau­cus by Reps. David Rouzer (R-N.C.) and Joe Court­ney (D-Conn) to ed­u­cate fel­low law­mak­ers about the need to strengthen pri­mary care. Also, the Bi­par­ti­san Pol­icy Cen­ter has pre­vi­ously rec­om­mended sev­eral poli­cies to sup­port pri­mary-care physi­cian re­im­burse­ment through fee-for-ser­vice and al­ter­na­tive pay­ment mod­els and to in­crease res­i­dency slots for pri­mary-care physi­cians.

While a fo­cus on sup­port­ing and ex­pand­ing the ranks of pri­mary-care physi­cians is crit­i­cal, it is also im­por­tant to sup­port pri­mary care more broadly. Nurse prac­ti­tion­ers and physi­cian as­sis­tants pro­vide es­sen­tial pri­mary care, par­tic­u­larly in ru­ral and un­der­served ar­eas, and they must be al­lowed to prac­tice at the top of their li­cense. Un­for­tu­nately, some of the states with the low­est num­bers of pri­mary-care physi­cians in this coun­try also have the most re­stricted scope of prac­tice for nurse prac­ti­tion­ers.

In ad­di­tion, pri­mary-care physi­cians must in­creas­ingly em­brace telemedicine. Though in­ter­state li­cens­ing and re­im­burse­ment is­sues per­sist, physi­cians need to be at the fore­front of de­ter­min­ing when and how to in­cor­po­rate such tech­nol­ogy into clin­i­cal care.

Pop­u­la­tion health man­age­ment with­out pri­mary care at its core will not be pos­si­ble. Only with a strong, em­pow­ered pri­mary-care work­force can we achieve bet­ter care through im­proved ad­her­ence to ev­i­dence­based prac­tices, bet­ter health through a com­mit­ment to pre­ven­tion, and lower costs through a re­duc­tion in low-value and un­nec­es­sary health­care ser­vices. This has never been more im­por­tant than now.

Dr. Anand Parekh is se­nior ad­viser at the Bi­par­ti­san Pol­icy Cen­ter and a for­mer deputy as­sis­tant sec­re­tary for health at HHS.

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