Last week, I attended a briefing about a new policy report, issued by the influential Brookings Institution, calling for reforms to accelerate the transition to value-based physician payment. Brookings’ report builds on the framework recommended in a bipartisan, bicameral (House and Senate) SGR repeal bill that was agreed to last year by the congressional committees with jurisdiction over Medicare.
There are some very thoughtful concepts in their proposal, like improving and simplifying quality measures. Some of their ideas gave me pause, like requiring that physicians in a Patient-Centered Medical Home, or another alternative payment model (APM), accept direct “downside” financial risk for meeting quality and efficiency measures. Brookings could be setting the bar so high that few physician practices could qualify or be successful in achieving the required savings even if they were able to qualify as an APM.
Beyond the specifics of their report, though, one thought kept going through my head: as policymakers keep coming up with well-intentioned ways to “reform” physician payments, we might be at risk of killing the goose that lays the golden egg. The goose being primary care, and the egg being high quality, patient-centered, accessible, compassionate and cost-effective care, which can only come from a patient having an established relationship with a primary care physician that they know and trust.
We know from hundreds of studies that primary care is highly associated with better outcomes and lower costs. We also know that relatively few medical students are choosing to go into primary care. We know that many established primary care physicians are frustrated and discouraged, leading some of them to leave medicine altogether or downsize their patient panels by going concierge.
And we know why this is so. Primary care physicians are under-paid and over-worked relative to other physicians. Many are dejected because they feel so disrespected. Everything they do is being measured, but how often is what they do truly treasured by society? We stick them with dysfunctional electronic health records that make their lives miserable, and then penalize them with payment cuts if they don’t use their records in a way that the government considers “meaningful.” We dangle out more money to them—but only if they are willing to work ever harder and ever longer, in “alternative payment models” that involve spending more time on administrative processes (like reporting on measures) and less time with their patients. Meanwhile, many of their colleagues in other specialties that can bill for highly compensated procedures can still do quite fine under conventional fee-for-service (FFS)—and when they too have to jump through hoops to prove their value to payers, they start out with a much higher FFS compensation baseline than primary care.
Readers of this blog know that I believe that fee-for-service hasn’t been a good deal for primary care—if it was, why has primary care been so underpaid under FFS compared to other specialists? I also believe that if done rightly, new payment and delivery models, like Patient-Centered Medical Homes, offer the tantalizing possibility of valuing primary care more highly while improving patient and physician satisfaction, with better outcomes and lower costs. And just saying no to value-based payments isn’t going to be a winning strategy for primary care. It is better to mold the changes that are coming than to cling to a hope that it will all just go away.
At the same time, though, a great deal of caution is in order. When someone comes up with a new plan to change the way that primary care is going to be organized and compensated, we should ask: Will it add to the administrative burdens of primary care physicians? Take their time away from patients? Will they have to run harder just to stay in place? Will it make them feel even more beleaguered and less valued?
If the answer to any of these questions is yes, then we need to stop and re-think what we are doing to primary care, and come up with a better way.
Real value-based payments should assign the highest value to the patient-physician relationship. Everything else is secondary. Because otherwise, in our zeal to re-invent how physicians are paid and care is delivered, we will have killed the goose that laid the golden egg: the goose being primary care, and the egg being high quality, patient-centered, accessible, compassionate and cost-effective care, which can only come from a patient having an established relationship with a primary care physician that they know and trust.
Today’s questions: do you think policymakers may be at risk of killing the goose, primary care, that laid the golden egg of high quality, patient-centered care? And if so, what should be done to make them stop?