National Coalition on Health Care Forum

Panelists: Payment Reform Must Emphasize Primary Care

March 06, 2017 02:47 pm Michael Laff

New payment models and dedicated efforts to coordinate care are changing the delivery of health care, but more progress needs to be made, primary care physicians said at a recent forum on health policy.  

AAFP President-elect Michael Munger, M.D., of Overland Park, Kan., discusses how new payment models are changing the way care is delivered during a recent policy forum held by the National Coalition on Health Care.

"Primary care has been overlooked for too long in discussions about health care reform," said National Coalition on Health Care President and CEO John Rother, J.D., during the March 1 event in the Dirksen Senate Office Building titled "Primary Care: Its Essential Role in Value-based Health Care."

AAFP President-elect Michael Munger, M.D., of Overland Park, Kan., spelled out key areas that need improvement. For instance, the United States has much lower average life expectancy than other developed countries despite outspending all other industrialized nations on health care. Wasteful spending in the nation's health care system( -- $765 billion a year -- is equal to the gross domestic product of the Netherlands. The figure includes $210 billion in unnecessary services, $130 billion in inefficient care delivery and $190 billion in excess administrative costs.

Munger emphasized that new payment models are needed to support coordinated care at the primary care level. The fee-for-service model does not pay for coordination or services outside of office consults with patients, he pointed out. He described his typical day, during which he meets with 25 patients but manages care for another 200 to 300 patients. That means reviewing medications, writing prescriptions and reviewing lab tests, all of which requires clinical decision-making -- much of it uncompensated.  

Story Highlights
  • Physicians who spoke at a recent forum on value-based health care said that new payment models must support coordinated care at the primary care level.
  • AAFP President-elect Michael Munger, M.D., said new payment models can save money as they help improve patient care.
  • Such payment models can ensure physicians are paid properly for care delivered outside traditional office visits.

"At the end of the day, there is no credit for that" in the fee-for-service model, Munger said. "But the newer payment models are recognizing how we provide care."

Besides being a patient-centered medical home, Munger's practice is also participating in the Comprehensive Primary Care Plus program, a five-year pilot led by CMS in which payment encourages flexibility in caring for patients beyond traditional office visits.

Munger said new payment models have enabled his practice to hire a case manager and a care coordinator. And after three years in the medical home model, his practice made significant strides that included reducing the 30-day hospital readmission rate by 6 percent.

"That's a real savings and more importantly, it's much better for patients," he said.

If physicians are paid differently, they can adjust how they manage their time, as well.

Family physician Silvio Alan Del Castillo, D.O., of Burbank, Calif., discussed how the Regal Medical Group created "protected time" periods that allow patients who call before 3 p.m. to be seen that same day. The group also created "desktop time" when physicians can handle email, telephone or electronic visits with patients. Healthy patients can make appointments without having to schedule too far in advance, and referral coordinators ensure that patients make appointments with subspecialists and that primary care physicians receive notes about these visits.

Benjamin Miller, Psy.D., director of the Eugene S. Farley Jr. Health Policy Center at the University of Colorado in Aurora, spoke about the need for greater integration between primary care and mental health, noting that treatment of physical and mental needs is too often artificially segregated.

"The separation of mental health and primary care leads to inferior care that costs more," Miller said.

Many chronic care patients arrive in primary care with mental health needs. They should be able to obtain physical and mental health care at the same time in the same facility, but traditional payment models do not support that aim.

Miller pointed out that mental health needs don't just affect a small segment of the population. At some point in their lifetime, 46 percent of adults will require mental health or addiction treatment, he said.

Patients may receive referrals to mental health specialists from their primary care physicians, but Miller said that often proves ineffective. A patient who has to worry about transportation, more time off work and an additional copay might not show up for the mental health consult. Miller said a patient's condition can worsen if addressing mental health concerns is delayed.

Patients with chronic conditions and mental health needs should be able to receive treatment during a single visit without having to go to a separate facility for mental health care, and payment for mental health care should be integrated with that for primary care.

"There is little incentive to collaborate if they are paid out of a separate pot of money," Miller said.

The forum was the first in a three-part series co-hosted by the AAFP, National Coalition on Health Care, National Association of Community Health Centers, American College of Physicians and American Osteopathic Association. The next event is a March 28 forum on primary care's role in underserved communities. A third event, on building the primary care workforce, will be scheduled later.

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