Pay-for-Performance May Boost Role of Primary Care

Pay-for-performance may be the best possible health care reform to hit primary care physicians. That's because, if the concept truly focuses on quality improvement, it must rely on medical homes with primary care physicians who prevent the onset of or complications from illness and who coordinate comprehensive care when illness strikes, according to speakers at the Feb. 6-8 National Pay-for-Performance Summit here.

As more P4P architects acknowledge the link between successful P4P programs and primary care, they also have begun discussing the need for boosting the primary care workforce through adequate payment. Speaker after speaker at the summit voiced concerns about the future of primary care, as government, insurance industry and health care leaders discussed engineering a P4P system that improves quality of care and reins in health care costs.

Jack Lewin, EVP and CEO of the California Medical Association, was among the first to broach the subject.

"I've had the chance to spend time at medical schools, and I was shocked at how few medical students want to go into primary care," he said during a standing-room-only P4P panel discussion Feb. 7. "We're behind the curve in physician recruitment in primary care, and that poses a real crisis if we want pay-for-performance to turn out well. We have a crisis in payment for the most critical professionals" in a P4P environment.

Businesses that buy health insurance and the private insurance industry have long recognized the link between primary care and success in P4P programs, according to two speakers, who lamented the current system of paying for interventions and procedures but not for the medical expertise that can prevent the need for such interventions.

"We have a system that doesn't reward care coordination, that doesn't reward the time spent counseling a patient with multiple chronic conditions," said Peter Lee, president and CEO of Pacific Business Group on Health, during the debate.

Samuel Nussbaum, M.D., EVP and chief medical officer for WellPoint Health Networks, agreed, noting he had sent that message to the Medicare Advisory Commission in testimony he presented Sept. 8. (PDF file: 311 pages / 388 KB. More about PDFs.) In his testimony, Nussbaum called on Medicare to establish positive P4P incentives of at least 5 percent and preferably 10 percent for primary care physicians who meet P4P quality standards.

"We can encourage prevention through better financial incentives" for primary care, Nussbaum said during the P4P summit debate. "More students would go into primary care if pay-for-performance rewards it. If we can get (P4P incentives) up to 20 percent, we can grow the specialty of primary care medicine."

Moreover, poorly designed P4P programs -- with their inherent demand for paperwork and electronic health records -- could undermine their own foundation by driving physicians out of business, said speakers. They acknowledged that, although 65 percent of all physicians' practices have five or fewer physicians, most current P4P plans favor large multispecialty groups.

"One pitfall is that so many doctors feel left out and feel it (P4P) is a cost shift to them," said CMA's Lewin. "We have the potential for creating haves and have-nots."

That scenario, said Margaret O'Kane, president of the National Committee for Quality Assurance, would spell disaster.

"We don't want to put doctors out of business," she said during a Feb. 8 panel discussion on setting national P4P standards. "The last time I looked, we don't have enough primary care physicians, and that's where we're putting a heavy burden of pay-for-performance paperwork. What we need to do is give primary care physicians the tools to be the coordinators of care, and we need a payment system that rewards them. That's a major strategy to move this forward."