The call for the movement “from volume to value” in health care has resounded for many years, but progress toward a payment system that recognizes and rewards value — especially for primary care — has been slow.

The Health Care Payment Learning and Action Network (HCPLAN) created a framework for assessing payment progress across commercial payers, Medicaid, and Medicare (traditional and Medicare Advantage). In its 2022 report based on 2021 data, 41% of payments were still in fee for service (FFS) with no link to quality, 20% of payments were in FFS with some link to quality, 33% of payments were in alternative payment models (APMs) built on FFS architecture, and just 7% of payments were made in the most advanced APMs that rely on shared savings or risk, bundled payments, and other population-based payments.¹ For context, in 2015, 62% of payments were in FFS with no link to quality and 23% were in some type of APM. (See the graph below.)

We are making progress, but not nearly fast enough or at a scale large enough to meaningfully advance toward achieving the quadruple aim for health care — improving the work life of clinicians and staff — in addition to the original aims of improving the patient experience and health of populations while decreasing the cost of care.² Further real progress from a primary care perspective will occur when APMs implement value-based payments consistent with certain principles.

WHY VALUE-BASED PAYMENT IS NEEDED

While FFS may continue to work as payment for very discrete services common in highly specialized care, it does not recognize the importance of teams or the broad range of services necessary to deliver comprehensive, continuous, whole-person primary care — much of which is not visit-based and not easily captured or paid under FFS. To adequately support primary care's unique role in caring for the whole person, payments need to shift away from the predominant reliance on FFS toward prospective payment sufficient to support a comprehensive array of primary care services delivered by physicians and care teams. One study estimated that more than 60% of a primary care practice's revenue needs to be prospective to sustainably support comprehensive, team-based primary care.³

A critical review of how evolving payment models influence primary care and its impact on the quadruple aim also identified prospective payment as the approach best suited for primary care because, when sufficiently funded, it supports a more comprehensive, team-based approach, including care the team provides outside of a “visit,” which is generally not readily captured and paid under FFS.⁴ The teams might also include a broad range of non-physician members such as social workers, community health workers, patient navigators, medical assistants, behavioral health specialists, pharmacists, nutritionists, and others. Capturing their work often requires significant coding knowledge and documentation to qualify for FFS payment, if it is eligible at all.