As the U.S. health care system steams toward a model that encourages value-based payment and seeks to limit the role of fee-for-service payment, the AAFP continues to stand in strong support of alternative payment models (APMs).
As part of its work in that arena, the Academy recently reviewed a draft white paper(hcp-lan.org) released by the Primary Care Payment Model Work Group(hcp-lan.org) -- an offshoot of HHS' Health Care Payment Learning and Action Network (HCP-LAN)(innovation.cms.gov).
In a Nov. 15 letter(350 KB PDF) addressed to work group members, AAFP Board Chair Wanda Filer, M.D., M.B.A., of York, Pa., responded to recommendations in the draft paper.
- The AAFP recently responded to a draft white paper on primary care payment models released by the Primary Care Payment Model Work Group.
- AAFP Board Chair Wanda Filer, M.D., M.B.A., noted that the draft paper was consistent with AAFP principles on alternative payment models that call for them to provide longitudinal, comprehensive care and to improve quality, access and health outcomes.
- In her letter, Filer discusses various issues related to each of seven principles laid out in the draft paper.
According to the authors, primary care payment models should rely on seven principles that, when activated in unison, will
- support the effective delivery of high-value primary care for all patients,
- enable primary care to focus on work that benefits patients,
- encourage collaboration between primary care and other health care professionals,
- use performance measures that promote the achievement of patient-centered outcomes,
- facilitate integration with behavioral health and linkages to community services,
- support efforts to make caregivers and patients partners in health care delivery, and
- rely on the collaboration of payers and primary care teams for success.
Filer stated the AAFP's support for the mission of the HCP-LAN and said it would "play an integral part in consistent deployment of alternative payment models across all payers."
Furthermore, the model outlined in the draft white paper is consistent with AAFP principles that dictate APMs must provide longitudinal, comprehensive care and improve quality, access and health outcomes. They also should promote evidenced-based care and "be multi-payer in design."
There is no "one-size-fits-all" transformation scenario, said Filer, because patient panels and primary care practices vary. "We urge the HCP-LAN to recognize that further work needs to be done to improve quality and patient engagement while reducing total cost of care," she noted.
Strengthening primary care is imperative to improving health outcomes and curbing health care spending, said Filer. She suggested that increasing primary care spending from the current percentage of the total health care spend -- estimated at no more than 6 percent -- to at least 12 percent would be an important "first step."
Additionally, "Value-based incentives, to the greatest extent possible, should reach the physician across the primary care teams that directly deliver care rather than being absorbed by intermediaries, as is often the case today," said Filer.
Filer commented on recommendations related to each of the work group's seven principles. Below are some highlights of those responses.
Regarding a recommendation related to the first principle that calls for primary care payment models to adjust payment to account for underlying differences in patient populations, Filer said it was critical that resource use and quality measures be combined with "adequate and useful feedback reports for all members of the care team" to enable them to make "value-based care decisions for their practice as well as for those to whom they refer."
Filer agreed with the second principle that suggests primary care payment models should focus on work that promotes the health of patients and minimizes work that does not promote high-quality care.
"Primary are teams must be freed from administrative burdens that do not directly improve the patient-centered relationship," she said. Furthermore, every practice's primary focus should be on improving patient outcomes and population health, reducing costs, and providing a positive work setting for the primary care team.
Filer also gave a nod of agreement to the third principle. It calls for primary care payment models to enhance collaboration between specialists, hospitals, ERs, and other health care professionals so that patients receive timely, appropriate and efficient care.
"It is critical that primary care teams are able to send and receive information across all settings to promote effective transitions in care," she said. She named medicals homes as the "appropriate conduit to manage care transitions."
The AAFP agrees with the need for performance measurement, said Filer, as covered in the fourth principle. Measures must be, among other things, clinically relevant, minimally burdensome to report and cost-effective to gather.
"It is only when a provider has access to timely and actionable data that they can have an impactful influence on performance," she noted.
The fifth principle addresses the need for "robust integration" of primary care and behavioral health resources, including substance use treatment programs, as well as links to community resources.
Filer's letter noted the AAFP's strong agreement and said increased value-based payment for counseling and services was paramount to improve access to behavioral and counseling staff.
"AAFP members struggle with trying to secure these services in many areas of the country," said Filer. She also pointed out the need for appropriate risk-adjustment in primary care payment models.
Filer agreed with principle six that patients and caregivers should be included as partners in the delivery of care, and she said electronic health record functionality to create personalized care plans must be operational to achieve this.
Filer also concurred with the seventh and final principle that calls on payers and primary care teams to build partnerships to ensure the success of primary care payment models. She noted, in particular, the importance of data-sharing to manage utilization and care transitions and addressed the issue of related cost to physicians.
"We would stress that the acquisition of data should not require additional investment in technology or staff by the physician or practice," she said.
Filer suggested that primary care physicians receive "a separate risk-stratified care management fee for each of their patients" and noted that primary care practices needed external coaching support and technical assistance to help them transition to new payment and delivery models.
Lastly, Filer said the AAFP agreed with the work group's statement that improved patient outcomes and the resulting impact on the total cost of care would take time -- perhaps years -- to materialize.
On the other hand, the work group suggested -- and Filer agreed -- that some return on investment from implementing primary care payment models could be recognized within five years in areas such as
• reductions in hospitalizations, readmissions and unnecessary imaging;
• improvements in medication management; and
• increased integration of care.
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