Health Insurance Exchanges Create Opportunities for Primary Care, Says AAFP President

The creation of state-based health insurance exchanges under the recently enacted health care reform act will give federal and state governments the opportunity to move from a volume-based to a value-based health care system by putting in place measures to better reward the provision of primary care services. That was one of the main messages delivered by AAFP President Lori Heim, M.D., of Vass, N.C., and other speakers who participated in an HHS panel on Aug. 30.

"Here is an opportunity to support primary care, to change how we fund things and to move to that patient-centered medical home … to move toward value-based purchasing and the things that patients care about," said Heim. She was joined on the panel, which focused on the role of insurance exchanges in promoting quality and affordability, by representatives from the AFL-CIO, the National Business Group on Health, and the Leapfrog Group, a national organization that represents employer purchasers of health care.

The Patient Protection and Affordable Care Act requires health insurance exchanges to operate in each state by 2014. The exchanges, which are expected to cover as many as 24 million people by 2019, will function as insurance markets and allow individuals and small businesses to purchase insurance from qualified health plans within the exchanges.

HHS is mandated by law to establish minimum requirements for the exchanges, but each state can determine the governing rules, powers and scope of the entities. States have the option of operating separate exchanges for individuals and businesses or combining the exchanges into a single entity that encompasses both groups. They also have several options regarding administration: A state may establish exchanges for geographic subregions of the state, or it may join with other states to form a multistate exchange. States also can allow the federal government to operate their exchanges.

Heim said the exchanges represent an "opportunity to make an investment in primary care" and to "pay more and pay differently for primary care services." This would mean moving away from fee-for-service to a system that rewards care coordination and value, she added.

"We are stuck with fee-for-service for a while," said Heim. "But, hopefully, these exchanges can help lead us in readjusting (the) proportion of payments so that we get the outcomes we want."

Heim said much would depend on how the health care plans within the exchanges construct their networks. For example, she noted, the networks will have to assure adequate access to primary care physicians and subspecialists. The exchanges also can address health care disparities by providing adequate access to primary care, said Heim, citing a Commonwealth Fund report that said one way to eliminate health care disparities was to ensure access to insurance and primary care.

Helen Darling, president of the National Business Group on Health, also said during the panel discussion that the exchanges could serve as a "force for transformation in the health care system," one that could lead to a primary care-based system.

"If we take overuse, waste and inappropriate nonevidence-based medicine out of the health care system, we will have a lot more money to pay for all of the things we have already committed to pay for," said Darling. "We shouldn't waste this moment."

Gerry Shea, assistant to the president for governmental affairs at the AFL-CIO, said a patient's experience with the health care system often is determined by access to a "good primary care setting."

"First of all, we have to give people primary care coverage," he noted. "But secondly, we have to think of ways to make the primary care situation as good as it possibly can be."

However, according to Heim, "primary care is under siege."

"We don't have the primary care workforce that we need," she said, noting that income disparities between primary care physicians and subspecialists represent a major reason why medical students don't go into primary care.

"There are things within the legislation that begin to address that, but you can't rely on that alone," said Heim.

Shea, meanwhile, said it is important to apply past lessons to the creation of the state exchanges.

"We know that we can measure quality and that reporting on quality drives significant improvement," he said. "We know that having uniform national standards on quality is very important."

He called for measuring and reporting quality measures at the individual physician level and for episodes of care. Heim pointed out, however, that "physician report cards have not been as helpful as they were predicted to be."

"If you give me information on how I am doing with my diabetics, and then if I also have the support of resources, I can start to retool my individual practice to do a better job with that," said Heim.