Health Insurance Exchange Plans Must Emphasize Primary Care

WASHINGTON — Health insurance exchanges must require that participating plans provide access to team-based, coordinated primary health care if they are to successfully improve outcomes, address health care disparities and bend the cost curve.

That was the message taken to the HHS Stakeholders Conference on Exchanges by Lori Heim, MD, president of the American Academy of Family Physicians. Heim was one of five panelists discussing the role of health insurance exchanges in improving quality and affordability of health care. The daylong conference brought together patients and representatives from business, labor, consumers and the health care community to discuss implementing the health insurance exchange provisions of the Patient Protection and Affordable Care Act.

“Primary care is under siege,” Heim told conference participants. The nation doesn’t have the primary care workforce it needs. “First and foremost, we have to address the pay difference between what primary care specialists make and what subspecialists make.”

Health care reform begins to address this disparity of pay, but it’s not the only answer, according to Heim. That’s where health insurance exchanges come in. They are, Heim said, the opportunity to move toward paying for care coordination and the team approach that underpin primary care physicians’ medical expertise.

Studies consistently show that access to a primary care physician — as well as to health insurance — dramatically reduces health care disparities among ethnic, racial and socioeconomic groups, Heim said. Passage of the Patient Protection and Affordable Care Act will begin providing insurance coverage to more Americans. And by constructing insurance exchanges that support the primary care system, HHS will help ensure patients will have a primary care physician to meet their health care needs.

To that end, health insurance exchange standards should support primary care by requiring plans to reward quality, not the number of tests or procedures provided to a patient, Heim said. In addition to paying for patient visits, plans should compensate for the time and expertise involved in coordinating care — particularly for patients with multiple chronic conditions — with hospitals, long-term care facilities, allied health professionals, nurse practitioners and other members of a patient’s health care team, Heim told the conference audience.

“The key to improving quality … is to invest in primary care,” Heim said. Such an investment is inherent in the patient-centered medical home model, where patients receive comprehensive, whole-person care and physician payment depends on outcomes rather than the number of tests and procedures.

Medicare is moving federal physician payment design toward such a system as a result of health care reform legislation. With clear requirements for health plans to establish quality-of-care payment systems, health insurance exchanges can make that same progress in the private sector, according to panel members.

The trick, said Heim, will be to develop a system that accurately measures quality of care. That system should go beyond the current, static report cards because simply gathering data on a provider does little to improve care. The system also must provide a rapid feedback and support loop that enables the providers to improve their quality of care.

“We need to do a better job of care coordination, and we have to change how we pay for that,” Heim said. Health insurance exchanges “are an opportunity to pay (for health care) differently.”