Health Care Reform Center

Dave A. Chokshi, M.D.

In the current political environment, forging consensus on health care reform has proven challenging. Yet the value of a strengthened primary care infrastructure is one apparent zone of agreement among policymakers. Leading professional societies have converged upon principles for restructuring primary health care in their support of the patient-centered medical home (see Table 1).¹ In addition to this reorganization of primary care delivery, experts have recommended three other areas of improvement: payment reform, augmentation of the primary care workforce, and better tracking of care coordination between primary care physicians and specialists.^2,3

Despite the apparent agreement on reforming primary care, there is no assurance that the health care reform bills currently under debate will make these consensus-based recommendations a reality. Primary care has thus far taken a back seat to the more contentious elements of the health care reform bills, such as methods of expanding insurance coverage, the institution of individual and employer mandates, financing strategies, and medical malpractice reform. When primary care is discussed, it is often lumped together with “preventive care” — for instance, in the context of increasing incentives for screening — but other important functions of the primary care provider, such as managing chronic disease, are given short shrift.

The major legislative proposals under consideration would implement varying degrees of reform along the four axes listed above (see Table 2). With respect to reorganizing primary care delivery, both the Senate and the House bills would create “accountable care organizations” that could share in any cost savings achieved for Medicare and be eligible for incentive bonuses based on performance. The House bill is more explicit in its support for the medical home concept, allocating almost $3 billion for 5-year demonstration projects within Medicare and Medicaid; on the Senate side, medical homes are mentioned as one model of practice reform to be promoted by a new Innovation Center. The Innovation Center would be housed within the Centers for Medicaid and Medicare Services and would receive $10 billion in funding over a 10-year period. Finally, the bill passed by the Senate Health, Education, Labor, and Pensions (HELP) Committee would initiate a Primary Care Extension Program that would educate providers about evidence-based therapies, preventive medicine, health promotion, chronic-disease management, and mental health.

Payment reform refers both to narrowing the income gap between primary care physicians and specialists and to changing methods of reimbursement to provide incentives for improved performance on quality measures. Under the House bill, Medicare payments for primary care services would increase by 5%; under the Senate Finance Committee bill, these payments would increase by 10%. In addition, the House bill would allow Medicare payments for such services to grow at a faster rate than payments for other services; it would also link state Medicaid reimbursements for primary care to Medicare rates and provide federal funding to support this change. The Senate Finance Committee’s bill includes a provision authorizing payment for each new Medicare enrollee to visit his or her primary care provider for the specific purpose of creating an individualized prevention plan. In both houses of Congress, however, incentives for improved performance do not go beyond demonstration projects. The Senate bill’s Innovation Center, for example, calls for promoting models that transition practices away from fee-for-service reimbursement toward comprehensive payment for episodes of care.

In terms of augmenting the primary care workforce, the House bill is more robust than the Senate bills. Both houses would redistribute currently unused medical residency slots in favor of training for primary care practitioners. Both would also fund “teaching health centers,” or ambulatory-based primary care training in, for instance, community health centers. The Senate Finance Committee’s bill authorizes $230 million over 5 years for this purpose. The House bill goes further by appropriating almost $7 billion over 10 years for various programs to buttress primary care training. The plans include expanding the National Health Service Corps, which offers debt relief to physicians working in regions that have a shortage of health care professionals; providing financing for loans to medical students pursuing primary care careers; and building academic capacity in primary care by directly supporting residency programs in family medicine, general internal medicine, general pediatrics, and geriatrics, as well as those for physician assistants.

The fourth pillar of primary care reform, better tracking of care coordination, flows from the other three: it is a necessary step in measuring the effects that reorganization of care delivery, payment reform, and workforce augmentation will have on patient outcome. The economic stimulus package passed earlier this year — the American Recovery and Reinvestment Act of 2009 — allocated $19 billion for support of health information technology. The current bills would build on that investment by establishing national quality-improvement clearinghouses that would track and report on certain measures of quality, such as health disparities and appropriateness of care. The bills cite measures of care coordination as falling under the purview of quality-improvement initiatives, though none of them explicitly describes the specific measures of quality that would be used to track care coordination.

A critical look at the major primary care components of health care reform legislation reveals both potential for progress and substantial shortcomings. Pilot programs for accountable care organizations and models of care based on the medical home will provide evidence to guide large-scale reorganization of care delivery. However, skeptics point to the substantial startup costs associated with transforming physician practices into novel delivery structures — and conjecture about the practical difficulties of balancing objectives related to the coordination and accessibility of care with cost-containment goals. Payment reform could help to relieve that tension, and current legislation would increase Medicare (and in the House bill, Medicaid) reimbursements for primary care services. Yet a tangible shift in health care spending from specialty services (including imaging and procedures) to primary care would probably require spending increases beyond those included in the current bills. Tilting the spending scale more toward primary care, in turn, may be necessary to pave the way for more fundamental payment reform, such as “comprehensive payment for comprehensive care.”⁴

On workforce issues, Congressional proposals would augment the absolute number of residency positions dedicated to primary care and shift the locus of training from hospital-based programs to ambulatory settings. Only the House bill, however, would appropriate enough funding to ensure that these changes were substantial and long-lasting. The House bill would also pilot another provision with long-term implications: altering graduate medical education (GME) to allow funding to flow directly to residency programs instead of to hospital systems. The antiquated and byzantine structure of GME payments is partially responsible for the inertia that has kept medical training hospital-centered. Finally, as we have seen in Massachusetts, a key plank of workforce reform is anticipating the immediate surge in demand for primary care providers that will accompany any significant coverage expansion.⁵ Providing funds for the National Health Service Corps and other loan-forgiveness programs is probably the only type of policy change that would work rapidly enough to address the surge in demand.

Progress in the delivery of primary care cannot be measured in a vacuum. Success must be defined by the extent to which the system can coordinate the primary and specialty care services needed to improve outcomes. It is here that the legislation currently under debate leaves the most room for improvement. Delivering high-quality care will require the careful collection of data to track both the implementation of primary care reforms and the effects of those reforms on patients’ health. Genuine progress in health care reform can be evaluated only in this way — both now and for many years to come.

No potential conflict of interest relevant to this article was reported.

Source Information

From Brigham and Women’s Hospital and the Southern Jamaica Plain Health Center — both in Boston.

This article (10.1056/NEJMp0909345) was published on October 28, 2009, at NEJM.org.

References

1. Joint principles of the patient centered medical home. Washington, DC: Patient-Centered Primary Care Collaborative, 2007. (Accessed October 26, 2009, at http://www.pcpcc.net/node/14.)
2. Bodenheimer T, Grumbach K, Berenson RA. A lifeline for primary care. N Engl J Med 2009;360:2693-2696. [Free Full Text]
3. Sandy LG, Bodenheimer T, Pawlson LG, Starfield B. The political economy of U.S. primary care. Health Aff (Millwood) 2009;28:1136-1145. [Free Full Text]
4. Goroll AH, Berenson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med 2007;22:410-415. [CrossRef][Web of Science][Medline]
5. MMS Physician Workforce Study — 2009. Waltham: Massachusetts Medical Society; 2009.