Health Rosetta: Value-based Primary Care
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What is Direct Primary Care?
In the United States, direct primary care (DPC) is primary care offered directly to the consumer, without insurance administration. It is an umbrella term, incorporating various delivery systems that involve direct financial relationships between patients and healthcare providers outside of the volume-driven insurance-based model. It can be implemented in a range of practice models from solo practitioners to organizations national in scope.
Direct Primary Care (DPC) is primary care model that offers patients, physicians and purchasers an alternate to fee-for-service (FFS) payment arrangements. In traditional arrangements primary care physicians are paid in FFS model, meaning they are reimbursed by the volume of services they provide. DPC offers a meaningful alternative as healthcare purchasing shifts from a volume to a value model.
DPC typically charge a membership fee on a monthly, quarterly or annual basis. This membership fee covers all or most of primary care services including acute and preventive care. The fee is paid for individuals out of their own pocket or via a sponsoring organization such as employers/unions or via health plans managing government programs such as Medicare Advantage. Most commonly, the practice is devoted to the particular sponsoring entity (e.g., a near site clinic for employers/unions or a Medicare Advantage-based clinic devoted to seniors).
DPC should not be confused with concierge primary care. Concierge care often adds a layer of enhanced access and amenities, paid for on a subscription basis, to a base of traditional fee-for-service primary care.
How Does It Work?
The traditional FFS payment models reimburses physicians based simply on the volume of services provided. As an alternative to fee-for-service (FFS) payment models, Direct Primary Care practices are paid a monthly, quarterly or annual membership fee. This fee covers all or most primary care services.
In addition to the reduced overhead from eliminating FFS billing, the membership fees allow DPC practices to offer a more proactive care model that can lead to significant reductions in downstream costs.
The model delivers a substantially better patient experience often in the form of more time with their provider, same day appointments, email, texting, video chats and other non-visit based interactions, 24/7 coverage by a professional with access to their electronic health record, coordinated care and little or no wait times in the office. Health outcomes are improved by shifting the focus from reactive, episodic care to a continuous care relationship, population health and care management.
Lastly, significant savings often occur through the elimination of unnecessary emergency room use, specialty visits, advanced radiology studies and surgeries, and by referring patients to highly effective and efficient specialists when needed.
Why Should You Support It?
The current fee-for-service (FFS) model in place at the primary care level reimburses physicians on volume alone; the more services a physician provides to more people, the more money you pay. The value of the services being provided is not considered. The flawed incentive structure of FFS demands very short primary care appointments that drive referrals to frequently unnecessary high margin services such as scans and specialists, and result on an over-reliance on prescriptions.
Value is defined as the ratio of quality to cost. Value increases as the quality of the care increases or the cost of care decreases. Direct Primary Care (DPC) allows a shift from volume-based rewards to value-based rewards. It allows purchasers to align interests with DPC practices to provide a better experience, better health outcomes and significantly lower costs to their employees or members.
DPC also is known to improve provider experience and professional satisfaction, which in turn has been shown to improve the quality of care.
The Diagnostic Toolbox
Many, but not all, of the following key elements are also incorporated in the goals of the “patient-centered medical home”(PCMH). PCMH better describes characteristics of a primary care practice and is not a business model.
1) Quality Reporting
Reporting should be done at 3 levels. Clinical quality measures (CQMs) should be selected from validated measures curated by national quality warehouses such as National Quality Forum and should be collected rigorously in a disciplined fashion.
- Reporting to the individual patient: Each patient should know his/her own data and how those results compare to established quality thresholds.
- Reporting to purchaser: The purchaser should be informed of the de-identified aggregated quality results for common conditions such as hypertension, diabetes, asthma and other ambulatory-care sensitive conditions. Privacy should be protected by not aggregating conditions that exist only in small numbers.
- Reporting at the community level (see below): Clinical data should be reported to a health information exchange (HIE) to assure that care both within and outside the purview of the PCP is appropriately analyzed and measures are reported based on all available data. Reporting at the HIE level permits greater coordination of care and decreased unnecessary duplication if the DPC provider does not share a common electronic health record with providers of specialty and ancillary care.
2) Shared decision-making
PCPs will use established communication techniques to assure patients are educated, enlisted and activated. Patient preference, patient ethics and economic concerns should be respected.
PCPs along with employers and health plans should make well-written and validated health information available to their members. Examples include Choosing Wisely and Comsumer Health Choices, both available through Consumer Reports Health.
3) Care Coordination: PCPs should actively coordinate care with specialists and ancillary providers. Post hospital and post-surgical follow-up should be appropriately thorough.
Care coordination should not be predicated upon or dependent upon all providers sharing a common electronic health record (see above). Employers and plans should exert leverage on all providers to share information via an HIE if they do not share a common EHR.
4) Population Health Management
Chronic condition management should be proactive, aggressive and team-based through the various use of patient advocates, care guidance nurses and personal health assistants/coaches. Care can be facilitated through the use of patient registries, either embedded in the electronic health record or through collaboration with the HIE.
Preventive services should include evidence based screenings (and specifically exclude screenings known to be harmful or of questionable value). Practices should actively pursue both childhood and adult vaccinations according to current recommendations from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.
5) Value based payment models
Compensation models that recognize physician work by other than volume of visits are desirable. Those models include scaling compensation based on the overall number of patients for which a provider is responsible or straight salary. Purchasers should look for a portion of DPC provider compensation being based on value as determined by some combination of quality metrics, patient experience scores and resource stewardship. The general nature of the compensation model should be transparent to the purchaser to help inform the purchaser’s selection of providers.
6) Patient experience
Standard methods should be used for patient experience and patient engagement measurement. CG-CAHPS surveys are one example of industry-standard measures. Patient advisory panels should be incorporated in the primary practice to guide service functions and assure a patient-centered orientation. Purchasers should expect transparency into aggregated experience scores as one measure of quality.
7) Evidence Based Medical Care
Purchasers should assure that both primary care and specialty care practice is grounded in evidence based medicine. This can be accomplished through examination of clinical process and outcomes measures and well as provider education and collaboration. Evidence based medicine should always be applied while respecting insurance or other financial coverage as well as individual nuances, personal preferences and ethics.
8) Participation in a Health Information Exchange (HIE)
The practice should be sharing data with specialists, other providers including hospitals and other involved parties through participation in a health information exchange. The practices should make HIE access a regular part of care and demonstrate this through the adoption of appropriate workflows
9) Ease of access to care and care information
The practices should make available a patient portal that provides asynchronous communication. A patient should not be expected to make an office visit unless physical presence is necessary for quality of care. The practice should collect data on standard access metrics (time to urgent appointment, time to third next routine appointment, etc) and share those results with the patient advisory panel and the healthcare purchaser. The practice should provide complaint resolution and follow-up.The practice should provide 24/7 telephone access to a healthcare professional, such as a registered nurse, who has immediate access to the patient’s electronic health record and who has physician or advanced practitioner backup. Such access will reduce emergency room utilization when unnecessary and encourage prompt emergency treatment when needed.
10) Clinical pharmacy and mental health embedded within practice
The practice should provide clinical pharmacy expertise for patients with complicated drug regimens and those patients requiring additional support for drug-related concerns.
Clinical pharmacy support should include provision of resources to help patients unable to afford prescribed pharmaceutical treatments. Mental health services for common issues (typically depression and anxiety) that can be managed on an ambulatory basis should be readily and conveniently available through the primary care office.
11) Physician allegiance
At all times and in all matters, including testing, referrals, hospitalizations and all care outside the office, the physician and other providers in the PCP office should align with the interests and personal economics of the patient. Physicians should strive to deliver the highest quality at the most reasonable cost and put patient interests above others when directing care.
Challenges To Expect
- Administrative Challenges: Your broker, consultant, carrier or TPA may be unable or unwilling to facilitate an evaluation of the appropriateness of DPC for your business.
- Employee Education: Individuals in established primary care practices may at least initially be unwilling to switch. Inertia, comfort with current providers and lack of awareness of their current care quality are all impediments. Demonstrating both financial and non-financial benefits are key, as is assuring potential converts that DPC is not being forced to see a “company doctor.” The need for frequent, clear communication with the workforce and dependents can’t be overemphasized.
- Care Dislocation: Having large numbers of people switch primary care physicians can be problematic, especially when physicians in the receiving practice may be overwhelmed by large numbers of patients wanting to get in within a short period. Have effective dialog with the new physicians to understand capacity and access issues; don’t wait to hear from your employees and families.
- Criteria for choosing a practice: Practices may market themselves as low-cost providers. Primary care should never be purchased based on cost. Employers should expect to spend more on high-quality primary care in return for downstream savings and other benefits (increased productivity and employee satisfaction) that more than pay for the increased primary care costs. Choose primary care based on service to patients, demonstrated clinical quality metrics and demonstrated attention to stewardship of the purchaser’s dollar.
- Care Coordination: Incumbent providers and health systems may warn against DPC as encouraging care fragmentation and loss of coordination. In a 21st century environment of communication, this is no longer a tenable argument. Purchasers should insist on the adoption of health information exchange technology to overcome this barrier.
- Slow Migration to the New Primary Care Model: Arrange for your new PCPs to visit with your employees at the workplace. People are much more willing to change PCPs when they get to meet the doctor beforehand. Also, arrange tours of the new facility to dispel the unwillingness of some to move out of their comfort zones. Employers willing to provide strong incentives to try out the new primary care model will achieve much higher adoption.
- Incumbent Obfuscation to Preserve Status Quo: Incumbents who aren’t forward-looking are likely to use common “Fear, Uncertainty & Doubt” tactics meant to freeze progress. As stewards of your organizations’ and employees’ hard-earned money, one must choose whether they care to protect their own bottom-line or that of their supplier.
- ASK your broker, consultant, insure or TPA if they are currently working with or have experience with Direct Primary Care (DPC) Practices.
- ENCOURAGE your broker, consultant, carrier or TPA to facilitate getting and interpreting reliable cost and quality data from primary care groups competing for your business.
- CONSIDER comparing primary care groups through a structured and disciplined RFP process. Also consider modifying your benefits plan to provide incentives for employees and their families to access care from DPC practices.
- VISIT a local DPC practice and see for yourself. Click here for a PDF version of the Key Elements.
Patient-Centered Primary Care Collaborative is a “not-for-profit membership organization dedicated to advancing an effective and efficient health system built on a strong foundation of primary care and the patient-centered medical home.”
Comprehensive Primary Care Initiative is a four year “multi-payer initiative created by the Centers for Medicare & medicaid Innovation to reform and reinvigorate primary care by enhancing population health management and other key elements. It’s a cooperative between governmental and private payers. In its third year, CPC is already reducing costs and improving quality. Purchasers should examine what’s working well in this model.
American Academy of Family Physicians offers guidance and a toolkit for physicians interested in transforming practices to DPC and explains the distinction between DPC and concierge practice.
Case Studies & Background reading
Request to DPC orgs: Please add links to results/ROI from primary care organizations
Comprehensive Overview of Direct Primary Care (Slideshare)
Atul Gawande, MD published The Hot Spotters in The New Yorker in 2011. He showcased the ability of a redesigned direct primary care practice to radically improve the care of chronically ill persons in a casino worker’s union in Atlantic City. They focused on the very small percentage of employees and dependents that drive a large portion of the cost by developing a special facility to handle the unique needs of these individuals.
Value-based Primary Care Practices available in multiple markets to employers and unions
Iora Health is a DPC practice with a successful model for better managing the human and financial costs of chronic disease through a team care approach that utilizes health coaches. This approach has proven successful especially in caring for populations where dismal results were previously (and often erroneously) attributed to poor patient compliance and economics.
MedLion is a network of independent DPC practices. MedLion’s market has expanded from the uninsured, to include businesses of all sizes who wish to provide affordable quality health benefits for their employees.
Paladina Health is an innovative employer-sponsored healthcare provider based on a medical home model that helps self-insured employers comprehensively manage the health and healthcare cost of their employees and families.
Qliance Is a monthly-fee primary care practice that provides comprehensive, high-quality, personalized primary care to individuals, employers, unions and payers. Patients enjoy unlimited access to in-person, phone, email, and video visits, and receive coordination of any care needed throughout the healthcare system.
Vera Whole Health delivers primary care, acute care, and health coaching via on- or near-site clinics.