Congressional Testimony Underscores Value of Primary Care in Health Reform Plans

Congress needs to fundamentally revise the Medicare physician payment system to better reward the provision of primary care services if it expects to pass health care reform legislation that achieves the simultaneous goals of higher quality, lower costs and enhanced access. That's according to witnesses who testified before the House Ways and Means Committee here on April 1.

"Our citizens deserve a system that can deliver quality care at an affordable price," said family physician Allen Dobson, M.D., of Concord, N.C., chair of North Carolina Community Care Networks Inc. and vice president of the Carolinas Healthcare System. "Reform that only focuses on providing health insurance to all will clearly be economically unsustainable without an overhaul of our current fragmented and volume-driven health care system."

Dobson told the committee that any system reform effort must be built on a solid primary care foundation.

"For decades, we have failed to invest in our primary care and public health infrastructure, and our citizens are now paying the price," said Dobson, a former assistant secretary for health policy and medical assistance at the North Carolina Department of Health and Human Services. "The values and principles outlined in the patient-centered medical home model must be the first and foundational step in health care system reform."

Dobson cited Community Care of North Carolina, or CCNC, as an example of an investment in primary care and a public health infrastructure that has improved quality and enhanced patient access while saving billions of dollars for North Carolina. CCNC is a public-private partnership between North Carolina and 14 nonprofit networks that include primary care physicians, hospitals, health departments, social service agencies and safety net organizations.

The CCNC model can serve as an important national model for health care reform, Dobson said. Lessons learned from the project include

In his testimony to the committee, Robert Berenson, M.D., a senior fellow at the Urban Institute, focused on the need for payment reform as a way to strengthen the primary care workforce.

"Whatever the blueprint for delivery system reform, it is likely to fail unless immediate steps are taken to address the likely collapse of the primary care physician workforce infrastructure in many parts of the country," Berenson said.

The nation has a clear need for a health professions workforce that includes a larger supply of primary care physicians, he said. Medicare's current physician payment policies "ignore these workforce needs and, instead, disproportionately reward the provision of niche specialty services, such as imaging and performance of minor procedures."

Meanwhile, policymakers are just beginning to realize the implications created by Medicare beneficiaries with chronic diseases who are living longer, especially beneficiaries with multiple chronic diseases, said Berenson. Twenty percent of beneficiaries with five or more chronic diseases account for two-thirds of Medicare spending each year, he noted, with each of these patients typically seeing about 14 different physicians and making 40 office visits in that period.

Berenson called for an improved payment model that would support integrated delivery systems, which, in turn, would serve the diverse and complex needs of patients with an array of chronic and acute care needs. He urged Congress to move away from the Medicare Resource-Based Relative Value Scale, or RBRVS, saying it is an example of a "one-size-fits-all payment system."

Glenn Hackbarth, J.D., chair of the Medicare Payment Advisory Commission, or MedPAC, also assailed the current Medicare fee-for-service payment system in his testimony, calling it fragmented, duplicative and filled with gaps.

About 18 percent of Medicare hospital admissions result in readmission within 30 days of discharge, which accounts for $15 billion in spending, said Hackbarth. A significant portion of those readmissions could be avoided, he added.

Hackbarth called on Congress to adopt a payment system that rewards quality and outcomes rather than the sheer volume of services. According to him, there is enough money in the Medicare system to pay physicians adequately, but the money is not "aggregated" properly, resulting in a system that undervalues primary care.

Hackbarth called for a primary care bonus of 5 percent to 10 percent, a revaluation of the RBRVS to better reward primary care services, and an expansion and expedited implementation of the current Medicare medical home demonstration project.