Monday, July 18, 2016

Primary Care Resurgence

By most accounts, primary care physicians are a pretty beleaguered lot these days, especially those in smaller independent practices.  Years of being undervalued and over-hassled have taken their toll, leading many established primary care physicians (PCPs) to look for an exit ramp from practice, while discouraging medical students from considering careers in primary care. burnout  is rampant. To borrow a line from the Rolling Stones, it’s enough to make a grown doctor cry.

Yet there may be reason for optimism that things will get better for primary care—even leading to its resurgence.  Writing in the New England Journal of Medicine, Dr. Bob Kocher predicts that “As health care reimbursement shifts from fee-for-service to risk-based payments, PCPs are well positioned economically and strategically. Their incomes are likely to grow substantially over the next decade, at the expense of hospitals and specialists. Specialists who fail to expand their role and develop the capabilities and relationships to drive value improvement will face a threat to their incomes and practices.”  He explains that as Medicare and other payers increasingly adopt primary care based alternative payment models (APMs) that hold clinicians accountable for achieving shared savings,  dollars will flow to primary care physicians and away from other specialists:

“These APMs assign to organizations that employ primary care physicians (PCPs) accountability for achieving quality goals and saving money relative to benchmarks. As a result, PCPs must practice differently to reduce the total cost of care and improve its quality, invest in tools such as population health management software, and often add staff such as care coordinators. PCPs assume risk and incur costs in hopes of achieving economic windfalls later from shared-savings payments or low medical costs relative to Medicare Advantage capitated payments. Many organizations, particularly large physician-led groups focusing on Medicare Advantage, have demonstrated that large and recurring savings can be achieved. Since sharing savings from beating benchmarks is predicated on reducing spending from somewhere in the health care value chain, these models create economic winners and losers. Future incomes for both PCPs and specialists depend on the “sources” and “uses” of savings: whose revenue is lost to create savings, who receives reduced expenses or proceeds, and who controls the flow of funds in these models. Early experience suggests that the sources of savings will be reducing hospital days, emergency department visits, lengths of stay in skilled nursing facilities, referrals to specialists, and the intensity of diagnostic testing by specialists. Some of the medical conditions whose costs are most modifiable are congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes, back pain, and arthritis. Reductions in volume and treatment intensity will most affect hospitals, skilled nursing facilities, and specialists — particularly emergency medicine physicians, cardiologists, pulmonologists, endocrinologists, orthopedists, and radiologists.”

This isn’t just theoretical, Kocher notes, it’s already happening. “The uses of savings will be divided between lower medical claims for payers and new revenue paid as shared savings to provider organizations that achieve savings. This potentially large magnitude of revenue gains for PCPs provides strong motivation. PCPs have an average annual income of $195,000 — significantly less than the specialist average of $284,000 — and account directly for a small percentage of health care costs. Yet they substantially influence the total cost of care through referrals and directing of their patients’ subsequent care. For example, a PCP could earn an extra $80,000 by achieving the savings rates attained in the fourth year of the Alternative Quality Contract program. This figure amounts to a 10% reduction in the total cost of care for a 1500-patient panel (assuming that payers keep half the savings and that physicians must use three fourths of their savings to pay for additional staff and tools).”

Soon, Medicare will be launching the Primary Care Plus Program that will allow up to 5,000 primary care practices (with an estimated 20,000 clinicians in those practices) in 20 states/regions--the sites will be announced later this summer--to receive risk adjusted per beneficiary per month (PBPM) care coordination payments.  Two different tracks will be offered; track one will pay these practices an average of $15 PBPM for every Medicare patient they see, track two will pay them an average of $27 PBPM.  They can also earn additional PBPB incentive payments, $2.50 in track one, $4.00 in track two for achieving savings to Medicare; these would have to be paid back to Medicare if the savings aren’t achieved.  I explained more about the program in a blog I posted in April.  And, under the proposed rule for the Medicare Access and CHIP Reauthorization Act (MACRA), Comprehensive Primary Care Plus practices will also be eligible to receive 5% Medicare fee-for-service bonus payments from 2019 through 2024, plus their PBPM payments.

But there also good news for primary care physicians in more traditional practices who aren’t quite ready to go the APM route.  Last month, Medicare published another proposed rule updating the Medicare Physician Fee Schedule, proposing a number of new codes and payment policies that will redistribute dollars from specialty care to primary care.  As ACP noted in a statement applauding  the proposed rule, Medicare proposes to:

Improve payments for Care Coordination by Primary Care Physicians: The proposed rule includes revisions to the billing requirements for the existing chronic care management (CCM) codes to address the administrative burdens of electronic access, use of certified EHRs, and documentation.  CMS is also proposing payment for two additional codes to address the amount of time patients with complex needs require for extra care management.

Increased payment for prolonged services: The Agency also proposes to recognize payment for codes related to non-face-to-face prolonged evaluation and management (E/M) services and increase payment rates for face-to-face prolonged E/M services. These codes provide a means to recognize the additional resource costs incurred by physicians when they spend significant time outside of the in-person office visit.

Integrating Mental and Behavioral Health into Team-based Primary Care: CMS is proposing to pay for specific behavioral health services furnished using the Collaborative Care Model; in this model, patients are cared for through a team approach, involving a primary care practitioner, behavioral health care manager, and psychiatric consultant. CMS is also proposing to pay more broadly for other approaches to behavioral health integration services.

Cognitive Impairment Care Assessment and Planning: CMS is proposing a new code to pay for cognitive and functional assessment and care planning for patients with cognitive impairment (e.g., for patients with Alzheimer’s). This is a major step forward in care planning for these populations.

Payment for Care of Patients with Mobility-Related Impairments: CMS is proposing to pay physicians more accurately for furnishing services to beneficiaries with mobility-related impairments. This increase in payment will improve quality and access for this vulnerable population.

Expansion of Diabetes Prevention Program (DPP) Model: The proposed rule would expand to eligible patients and physician practices in all states this CMMI model, now available in only eight states, which provides counseling and other support services to help prevent diabetes in patients that have been found to be at a greater risk of becoming diabetic.  Physicians and other clinicians who participate in the program would receive additional payments for providing such support services to their eligible patients.  ACP strongly supports CMS’s expansion of this prevention model and is pleased that it met the legal Actuarial requirements required for CMMI to expand it nationwide, and will be providing comments on the basic framework outlined in the proposed rule.

Addressing Undervaluation of Primary Care Services:  CMS notes in the proposed rule that the current set of codes for primary care evaluation and management services, like office visits, do not adequately reflect the resources involved in providing such services, and seeks comments on improving the relative value units assigned to such codes to more accurately reflect their resource costs.

These and other improvements proposed by CMS would increase aggregate payments to physicians, especially those who practice in primary care specialties including internal medicine, by approximately $900 million said Acting CMS Administrator Andy Slavitt in a blog post.

So, to our beleaguered primary care doctors, take heart, things are moving in the right direction.  It’s long been understood that patients having a relationship with a primary care physician results in better care at lower cost, the definition of high value care.  Now, finally, Medicare and other payers are beginning to put real money back into strengthening primary care; looking ahead, primary care physicians “are well positioned economically and strategically. . . Their incomes are likely to grow substantially over the next decade, at the expense of hospitals and specialists,” as Dr. Kocher predicts.

Today’s question: how does the future of primary care look to you?

4 comments :

Yasir Anzar said...

Not until I started looking residency programs as a 3rd year med-student that I realize, career as a PCP was looked down upon. It is perhaps optimistically encouraging to hear such developments.

Jay Larson MD said...

Call me a doubting Thomas, but I will believe it after it happens. Until it happens, medical students will not be drawn to primary care. I have given up on the reimbursement system and just spend time with my patients, that is my reward. I know that I am saving the system money by spending more time with patients to do an adequate history and physical, so less un-necessary tests are ordered.

PCP said...

I completed residency soon ofter Y2K and have been listening to this "help is on the way sermon" for a decade and a half now.
All I have seen is the thinning of the General Internist PCP workforce, increasing disillusionment, closure of small practices, the consolidation of larger ones into Hospital systems, the expansion of nurse oractitioner roles to fill voids, and a rising pay and prestige
gap between specialists and PCPs. So Bob I don't really know what you are talking about. You sound like the other kind that are from
from DC, you know the ones you are paid to lobby, politicans.
The primary care general IM workforce is so depleted by well over a decade of rejection by a generation of young Internists that the initiatives described will if at all benefit the armies of Nurse Practitioners graduating nowadays to enter primary care and where most states and the VA will grant autonomous practice privileges. Ultimately we will get what we deserve as a country for shoddy policy for a generation, ie shoddy care at inflated prices.
Too little too late. The ship has sailed and the workforce trajectory has been set to be what is described above. In the end this will
serve one purpose and that is to mess up the IM subspecialists the same way the PCPs endured in the past 20yrs under FFS.

Charles Carter said...

I share the skepticism of the previous respondents.
It's encouraging to see that there are evidence-based movements in law enforcement as well as governance/ policy/ legislation. It just hasn't made it healthcare policy yet.
Every time I read comments such as yours and Dr Kocher's I perceive another scheme. Maybe one better thought out than on I Love Lucy, but nevertheless a scheme.
The vast majority of us want to practice. If CMS or another agency wants to audit my care and helpfully point out perceived missed opportunities or waste, I'm all for it. What we don't want is being forced to collect data (we actually do have better things to do) and then have it lorded over us in the most threatening way possible-fines, jail, loss of income. And we don't need a 10th guideline on treating pain.
I quit the ACP for it's lack of advocacy 3 years ago, though I have immense respect for its dedication to excellent care. I'm sure your scheme would be better than the other, but we're all tired of practicing in an increasingly hostile and burdensome environment.
Your post about stop complaining and do something is all well and good. But we need a unified voice, e.g. the ACP, to say "Enough with the schemes!".