Opinion | Making Care Primary … Again?

Early last month the Centers for Medicare & Medicaid Services (CMS) announced a new accountable care organization (ACO) model that they are planning on enrolling practices in, called Making Care Primary. From what I’ve been able to glean from a webinar last week and from information online, this is yet another attempt to build some of the important things that we think are necessary to reassert the critical importance of primary care in the healthcare system in this country.

By moving away from a fee-for-service model for primary care, it seems to seek a more capitated version of primary care, with infrastructure aimed at measuring quality, coordinating care, providing mental health resources, and helping overcome the inequities of the many social determinants of health that adversely affect so many of our patients and the health of their communities.

That all sounds good, right?

Big Paperwork Burden

Nothing they are suggesting is a bad idea, except many of us who have been looking at this program noticed that the program only seems to affect the fee-for-service nature of primary care providers, not the specialists that our patients often interact with.

The other problem would seem to be that this provides a lot of additional requirements for documentation, and for reporting and measuring quality, that puts an inordinate burden on the primary care practices themselves.

As I’ve said all along, when you put a lot of stuff in front of primary care doctors and their practices — stuff that often does not really lead to getting better care for our patients — that requires the checking of boxes, filling out of endless reports, trying to prove that you’re taking good care of patients, it feels like it’s destined to fail. Wouldn’t it be better if we just gave the primary care providers all the tools they needed to manage their patients, and helped them deliver the care to those patients that each of us would want for our own family members, as well as a little boost in their income?

Sure, in a system that increases the payment per member per month, instead of the old-fashioned fee-for-service model, there are possibilities for upside financial benefit for the practices that participate in these kinds of programs. But the amount of work that needs to go into building this — the critical infrastructure and resources in the community — seems beyond the reach of what these programs can pay for, or hope to accomplish.

It’s unlikely that providing a few extra dollars per month per patient will lead to a groundbreaking change in the way our patients live their lives in their communities, whether that’s finding a good job, finding a safe place to live, having reliable access to nutritious foods, getting equal and equitable access to subspecialty care, and so much more. Shouldn’t we instead be focusing on fixing these things where they are broken, at a societal level?

Insufficient Funds

I firmly believe that addressing our patients where they live, addressing their healthcare needs and social needs, and providing unlimited access to the right care at the right time is the way to go. But if we say to primary care practices, “We can give you a little more money, but you need to make sure that your patients come into their appointments, take their medicines, exercise, and eat healthy, and you need to address their depression and anxiety, and have all their healthcare maintenance up-to-date, and make sure they don’t suffer the devastating consequences of their poorly controlled chronic illnesses, and don’t overuse subspecialists, hospital admissions, and emergency departments,” then wouldn’t it make more sense to just fix these things at their core?

No matter how many of my patients end up enrolled in this accountable care model, the few extra dollars is not going to be enough to address the societal needs of those same patients. Sure, we can work some magic around the edges — find some ways to use additional help to get people into registries, to connect them to community-based resources, to engage them in their healthcare in the ways we and they know might work. But is that going to get us the improvement we’re looking for, that CMS is looking for, and that our patients deserve?

And if our specialist and subspecialist colleagues are still enrolled in fee-for-service healthcare — and therefore it is still in their vested interest to see more patients, to admit more patients, and to perform more procedures and more surgeries — then how are we going to get them to buy into this “less is more” model? Wouldn’t everyone be better off if we just gave those same primary care doctors all the resources they needed, all the social workers, all the mental health providers, all the access to job training programs for our patients, safe housing, clean water and nutritious food?

And wouldn’t it be an improvement if we had enough members of our team so that we could manage almost all of their medical conditions, and turn to our subspecialist colleagues only as a last resort, when things get too complicated for us?

Too Many Referrals

Right now, we primary care doctors have far too many patients seeing a gastroenterologist for their uncomplicated esophageal reflux or their irritable bowel, a cardiologist for their hypertension or their high cholesterol, or an endocrinologist for their hypothyroidism or their diabetes, when most of these bread-and-butter conditions would be better served back with us. This is what we love taking care of, and if given the time, the support, the resources, and the reimbursement, we’d be more than happy to take this on. Save the complicated cases for the specialists, when we’ve tried A, we’ve tried B, we’ve tried C, and we’ve tried D, to no avail.

The roots of this problem appear to go back to the time when the original committees got together and decided on the scales that were going to be used for physician payments, which led to the birth of the Relative Value Unit (RVU). RVUs determine how much providers are paid for each type of care they give to patients. Historically, primary care had little voice in the original setting of these levels, and nothing much has changed through the years.

As a result, neurosurgeons are paid handsomely for their surgery (which I think they deserve and are entitled to), but pediatricians, gynecologists, and internists are forced to cram as many patients in their day as they can to get the nickels and dimes from the insurance companies — amounts that will barely pay their salaries and their support staff, and keep their doors open. Those paltry payments lead to more referrals out for conditions we should be managing, as well as less satisfied patients, more unhappy doctors, and more excess and waste throughout the system.

This is also why the surgical subspecialists have plenty of people answering their phones, scribes to do their documentation, and multiple other providers helping them out in so many ways. Meanwhile, primary care doctors are left to flail at things alone, churning through their notes at night to get them done, desperately trying to get to all the messages, results, and patient questions from their in-baskets when they should be away from work spending time with their loved ones and doing self-care.

So instead of trying to re-create the wheel again, to reimagine another version of a capitated managed care program for patient care in a fee-for-service world, maybe the U.S. would just be better off if the powers that be raised the salaries of primary care doctors, and then layered on some resources, registries, and infrastructure. That would allow us to do a better job, to once again take on the management of our patients’ medical conditions and help them get to the best health possible.

Again.

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