Hybrid Primary Care Payment Structure Crucial to Quality Care

High quality, patient-centered care requires a hybrid primary care payment system that encourages value-based care and physician quality assurance, according to an opinion article published recently in JAMA.  

Researchers responded to a recent report from the National Academies of Sciences, Engineering, and Medicine (NASEM), titled “Implementing High-Quality Primary Care.” The NASEM report depicted a fragile primary care structure in the US and recommended using a hybrid reimbursement model to pay primary care practices.

The NASEM authors concluded that a part fee-for-service, part capitated model would be most effective. But the report left some researchers wanting more specific and tangible action items to implement this hybrid payment model.

“The report stops short of defining the specifics of the proposed hybrid payment model. If each payer designs its own approach, primary care practices would be subject to a confusing array of different rules and incentives,” the article suggested.

“The optimal approach may be an all-payer hybrid model that aligns payments with the types and intensity of services the patient needs.”

The opinion article highlighted potential approaches to shifting the primary care practice and payment structures to promote high quality value-based care.

“In a team-based practice, a high proportion of preventive and chronic care tasks can be delegated to nurses, medical assistants, and other practice staff, while most of a clinician’s time will be spent on acute care,” the article pointed out.

“Current risk adjustment systems, which are based on the amount of chronic disease in each clinician’s attributed patient population, do not align capitation payments with clinician time and effort in acute care. A hybrid payment model must address this problem.”

To implement this hybrid model, the researchers recommended monthly payments for chronic disease management and wellness services to provide primary care practices with predictable payments. This model would allow the practices to maintain a care team with the proper skill mix to tailor care to each patient.

Primary care practices would receive higher monthly payments for patients with chronic disease or social risk factors that reflect the amount of care they may need, and patients could enroll with the practice for these services in particular.

“Enrollment could avoid the need for the complex systems currently used to ‘attribute’ a patient to a practice based on the frequency of office visits,” the article reasoned.

Researchers also suggested implementing fees for treatment and diagnosis of each new acute condition. Clinicians would receive a payment for each newly diagnosed acute problem that would cover the costs of working with the patient to develop a treatment plan.

Essentially, the acute care fees paired with the monthly payments would provide a risk adjustment for practices and allow primary care practices to treat patients at a population health level.

Researchers found that “this model would better align revenues with the costs of providing team-based care than either fee-for-service or risk-adjusted capitation payments alone, and that it could be implemented by primary care practices and health insurance plans using existing billing and claims payment systems.”

Pay-for-performance or value-based care systems present clinicians with financial incentives for improving primary care. But they have largely failed to achieve this, the researchers claimed, because these models do not provide practices with the resources to actually deliver better care.

The first step to remedy this problem is to create standardized patient-reported outcome measures to enable quality assurance, the article suggested. Web-based survey tools are easy to implement and give practices tangible data to measure performance and identify care gaps.

In addition, personalized, evidence-based care, along with networking with other primary care practices, can help clinicians deliver quality care and account for deviations.

“This is feasible even for small, independent primary care practices, and results in improvements in patient self-management and targeting of services to patients at higher risk for costly care,” the article stated.

But revamping payment models won’t solve everything. Quality patient care also necessitates professionalism and trust between patients, clinicians, and payers.

“Whole-person care requires a patient-centered approach to payment,” the researchers concluded.

“These hybrid payment and quality assurance mechanisms, supported by modern information technologies, professionalism, and trust, could achieve the goals of the NASEM report—enabling primary care practices to identify each individual patient’s needs, deliver care that addresses those needs, and be paid adequately for doing so.”