Solving for X at Primary Care 23
XPC Virtual 48 hour Hackathon on AI + Healthcare kicks off in 2 weeks on June 9. We’ve brought together an incredible group of mentors, judges, and sponsors. $5K in prizes. Deadline to apply is June 1.
XPC Course: Many of the principles discussed in this post will be covered in our course launching at the end of June. Our target audience is non-clinicians and companies seeking to improve primary care knowledge for their workforce.
Primary Care for America came together in 2021 as a collaboration among 11 of the top primary care organizations in the country. Last week, they held their third gathering of primary care leaders at Primary Care 23 in Washington DC to discuss all aspects of primary care. Thanks to Shawn Martin, EVP & CEO of the American Academy of Family Physicians, I had the opportunity to attend the event in person.
While covering a large landscape, several themes stood out across all the talks:
Fee-for-service (FFS) care does not make sense for primary care and all primary care should shift to a value-based model (VBC).
Lots of friction exists in converting current practices from FFS to VBC.
Primary care is central to a functional healthcare system.
Team-based care will supplant the single PCP to create a more comprehensive, holistic experience for the patient.
Developing strong relationships with patients is core to primary care.
Primary care continues to be underfunded despite numerous studies showing benefits as well as comparative studies with other countries.
Degradation of primary care in payment and prestige has created a huge challenge in maintaining and growing the primary care workforce.
Out of the 4 C’s of primary care, continuity and comprehensiveness received most of the emphasis and attention.
Telehealth, spurred by COVID, has been a mixed blessing and how to use the technology properly to the full extent of its potential has yet to be determined.
Functional primary care improves health equity and reduction of primary care in a community increases health access discrepancy.
As a joint venture of organizations with a similar goal of improving and promoting primary care, hearing the recurrent themes across all the speakers came as no surprise. But even though the “foundational why” was consistent, the “how” varies widely. Individual talks were mostly panels organized by the different sectors and aspects of primary care.
Medicare: CMS innovation Center continues to produce and study various models to drive accountable care and shift resources to incentivize development in underserved areas. Some challenges they face are optimizing predictability with accuracy as well as data sharing between CMS and providers. While most CMS efforts have focused on larger systems, they recognize more collaboration needs to happen with community partners. New models take 18-36 months to develop and CMS plans to roll out 3-4 new payment models later this year.
Operators who work heavily or primarily with Medicare continue to push for predictable and increased payments to primary care while understanding the budget neutrality constraint on CMS. Current outcome measures remain burdensome, while key benefits of primary care such as trust and access do not have metrics and are harder to measure. Working with specialists also is a bit of a friction point since they do well from fee for service. Developing a model where everyone wins requires a global aligning of incentives which has yet to happen.
Medicaid: While Medicare is sometimes subject to the whims of political activity, Medicaid feels those effects at a 50x multiple due to political factors at each state. Overall, Medicaid patients continue to be the highest need and require the most care, but Medicaid continues to pay the least at a fraction of Medicare (which already is a fraction of commercial payers).
Employers: Employers exist on a spectrum of understanding health benefits. The ones engaging in value based arrangements are generally progressive employers with a decent understanding of healthcare benefits and the importance of a strong primary care foundation. Trusted PCPs can help drive employees towards certain medications or specialists better than any plan design can. Onsite and near site clinics improve engagement and positively affect outcomes.
Primary Care Across the Lifespan: Environmental and social factors have disproportionate impact at the ends of lifespan (childhood and geriatric). Primary care has an increased role in screening and addressing social determinants of health in these populations. Even within a single age group, one type of care model may not solve problems for the entire age group. Building relationships helps understand patient needs and provide individual care.
Primary Care in Different Communities: Working in specific settings requires understanding the culture of the community as well as the unique needs of the population. Using big data to map communities is easy, but more important is finding anchor communities to build partnerships and deepen local relationships. The type of community can determine strategy in building new clinics vs. supporting the existing primary care infrastructure.
Workforce: Supply of primary doctors continues to decrease as more residents choose to subspecialize. Many primary care trained physicians also choose to go to other settings like urgent care or telehealth or move to non-clinical roles like admin or research. The demand for traditional PCPs keeps increasing with a rapidly aging population and more chronic conditions overall. Money is necessary but not sufficient to solve the supply issue. Current messaging about the woes of primary care is not helpful, the narrative needs to shift more optimistically to entice more students to choose primary care.
Community Health Centers (CHC): Governance by community boards where at least 51% of members are patients make CHCs very responsive to community needs. Federal funding has been a major source to help these centers grow. Expansion has economic benefits as these centers hire many in the underserved community, decreasing poverty, which is the leading social driver of poor health outcomes. Some of these centers have also started residency programs for nurse practitioners and social workers and find a high retention rate of these providers after graduation.
Health Tech: Most tech up to now has been built for episodic, fee for service medicine and focused on optimized billing rather than medical care. Data analytics and administrative task simplification are two high yield areas where tech can make a sizable difference in primary care. Uptake of new tech is often low because startups make widgets in a vacuum and then realize clinicians don’t want or need it when going to market. Primary care stakeholders need to create more awareness of their needs in the health tech community and health tech people should make more of an effort to understand day to day primary care challenges.
XPC Commentary
Most VBC models require risk sharing by the PCPs, which in a sense simply moves the metrics from numbers to outcomes. For example, in a diabetic, instead of controlling A1c, the primary care team now focuses on decreasing hospitalizations and exacerbations of chronic disease caused by diabetes, both of which generally involve lowering A1c. PCPs regularly complain about metrics like the A1c because, even with the best medical management and counseling, they can’t control what patients do outside the office. This is where the team based discussion begins.
The current primary care team (PCT) involves providers, clinical staff, coding staff, and billing staff. While vital in FFS, the last two don’t contribute to improved patient outcomes. Capitation enables a shift of resources from billing and coding personnel towards the formation of innovative teams that can enhance patient outcomes, including staff who engage the patient outside of the office visit. Many of the panelists showcased the flexibility of capitation-based team building by describing the unique PCTs they built which suited their community. But one ongoing challenge for capitated payments stems from its flexibility. Since value-based payments are prepaying for services, payors need to decide how much to pay out and how much risk sharing is involved. Exactly how much payment is required to develop an outcome improving PCT without creating redundant roles or excess profit will remain top of mind for all payers.
Direct primary care (DPC) arrangements stand out as the only VBC model which doesn’t directly involve risk sharing. Most DPC employer arrangements involve a per-member-per month (PMPM) with the promise of savings for the employer without partaking in the savings. Retail DPC goes further and cares more about customer service than risk sharing since the individual patient pays for the service and market forces determine the capitated payment.
On the topic of consumers and markets, absent from the wide-ranging discussion on primary care were companies from the growing direct to consumer (DTC) market. Comprehensive care and continuity took center stage, but growth of the DTC and urgent care markets suggest point of first contact needs more attention from establishment and larger primary care groups. Many people now consider urgent care centers as their primary care, and as DTC solutions grow, more people will have their first or only interaction with healthcare through a DTC company, which then has tremendous opportunity to develop more primary care services or even guide referral and health system navigation. Most users of DTC services and urgent care facilities tend to skew younger which stands in stark contrast to many discussions which focused on the Medicare population.
VBC arrangements make sense for Medicare aged patients because their risk is more predictable (no unexpected new chronic diseases and less risky behavior) and a beneficiary will more likely stay with their Medicare product for the rest of their life compared to younger populations with employer-sponsored or commercial insurance. In the game of risk sharing, time horizons matter. The average person only stays with a commercial insurance plan for 2 years on average and 4 years with an employer. These short time horizons make payments for preventing chronic disease, which may not manifest for decades, hard to justify. Furthermore, chronic diseases and risk adjustment plays a big role in determining the amount of capitated payment. Finding the right capitation amount for younger, healthier populations, may prove a harder challenge and perhaps may not even be the best financial model of care for them.
As organizations make the push towards VBC, they hope to bolster the dwindling trickle coming from the primary care pipeline. Awareness and payment are the top two challenges to improving it. Most students will rotate in FFS primary care offices or with hospital-based PCPs who don’t even know if they are in a VBC arrangement. Students also generally wouldn’t even know what VBC is if they saw it. Even if they saw a functional primary care practice, the underfunding and belittling of primary care still makes primary care specialties amongst the least competitive. VBC arrangements, if they hold up to their promise and potential, may help turn the tide as PCPs take more control over global patient care and receive commensurate compensation. Clinics which have their own residencies solve the awareness problem and could help develop a new generation of clinicians trained specifically in value-based care.
Today’s students are also computer-native and are training in a world of AI and rapidly advancing technology. The healthcare system is notoriously slow at adopting modern tools (as it continues to support the pager and fax industry). Part of the lack of tech adoption, or at least the appropriate adoption, was because of small practice consolidation into hospital systems where those who decided what to adopt were not the end users. While most “tech-enabled” practices are DTC ones, advancement of certain platforms has allowed smaller practices to start and grow by simplifying and decreasing the cost of practice management. Smaller practices can adopt new innovative solutions faster and fuel development of tools which actually improve patient care rather than just optimize billing. A feedforward process can begin as tech spurs growth of smaller practices and smaller practices fuel the need for more and better solutions.
Primary care is hurtling down an unsustainable path of majority FFS where it delivers poor service and outcomes and students have low and waning interest in the field. Those gathered at PC23 all share the goal of trying to carve a new path and bring primary care to greener pastures. Primary care continues to be a topic of intense interest as everyone tries their own solutions and groups gather to push their philosophies, sometimes even trying to redefine primary care itself. In a sense everyone is solving for X, where X = Primary Care.
Recordings from Primary Care 22 and the inaugural sessions are available, which means the recordings from this year’s sessions should be posted soon as well.
The event kicked off with a wide-ranging breakfast panel which was not recorded or live streamed. Takeaways from the breakfast are available for paid subscribers.