4 Payer Responses to Primary Care Challenges

Primary care providers are the foundation of the healthcare system. With the pandemic putting its future at risk, health plans can take 4 steps to address this challenge.

It’s been said that the coronavirus pandemic hasn’t created any new problems; it’s just escalated existing ones. This maxim seems especially true for primary care providers. Primary care practices have really struggled during the pandemic – at a time when their role has never been more important. Patient volumes are down by more than half, which makes it difficult for them to stay afloat in largely fee-for-service arrangements. But even under ordinary circumstances, independent practices tend to operate at an unsustainable net loss of 20 to 30 percent a year.

Primary care providers are the keyholders for our healthcare goals: improving the health of populations, enhancing the experience of care for individuals, increasing health equity and reducing the cost of healthcare. How can payers support primary care in a way that helps improve the clinician experience so they can better fulfill their role’s potential? Let’s explore the landscape around primary care, including how it has been impacted by COVID-19, how consolidation and other factors are affecting its future, and steps health plans are taking.

Role of Primary Care

Even before the novel coronavirus, Americans in an increasing number of “provider deserts” suffered from lack of reliable access to care. As a result, they experience some of the worst issues in our healthcare system: poor healthcare outcomes and increased healthcare costs due to complex conditions exacerbated by lack of management and overuse of emergency rooms. These vulnerable populations are more likely to experience adverse effects of COVID-19, and the difference comes down to primary care.

A 2019 report found that Americans with dedicated primary care received significantly more “high-value” services, such as recommended cancer screenings, diagnostic and preventive testing, diabetes care and counseling. Those with primary care also reported better healthcare access and experience, compared to those without. These results are intuitive, but their significance can’t be overstated.

A primary care provider is often termed the “quarterback” of the healthcare system. It’s usually the longest-term relationship a patient has and, especially in the current environment where interoperability is lacking, primary care often has the most comprehensive health information available. They know the patient health history and social determinants of health, and they understand how the healthcare system operates.

Conversely, a person without a primary care provider – due to poor proximity, healthcare coverage, schedule availability, or a combination of these factors – may have access to a specialist or two, but they are likely largely relying on a cobbled together arrangement of emergency care and walk-in urgent care. None of which is designed for whole-person care and can lead to complicating events like dangerous medication interactions.

Pandemic Impact

With the patient volumes at primary care practices down significantly, revenues have also been cut in half. Even with CARES funding, small business loans and telehealth payment parity made available, it has been a struggle for this group of providers. Recently, the HHS provided nearly $6 million in funding for COVID-19 training and technical assistance activities to 52 state and regional Primary Care Associations (PCAs), which support non-profit and safety net primary care providers. While this is certainly a welcome lifeline, it covers only a small segment of providers and services and doesn’t address the administrative burden that is particularly onerous for primary care.

A recent survey indicated in May that many practices are at risk of closing in a matter of weeks. Specifically, 45% report layoffs and furloughs, 28% skipped or deferred salaries and 14% have temporarily closed – numbers that have remained constant. In fact, one tool projects a catastrophic loss of family medicine physicians by the end of June – almost 60,000 fewer, leaving over 1,800 shortage area counties.

Threats to the Future of Primary Care

Demand for primary care providers is increasing more rapidly than supply, and provider availability is seen as one of the top barriers to meeting the healthcare needs of patients in this country. In 2013, 53% of states were already experiencing primary care physician (PCP) shortages. By 2025, experts expect that shortage will include 72% of states.

The number of doctors going into primary care continues to decrease in favor of better-paying specialties. And consolidation – in the form of doctors employed by health systems or payers, or joining larger practices – continues to increase, which further decreases provider access and drives up healthcare costs.

Another factor contributing to the primary care shortage is our rapidly aging population. For one, physicians themselves are growing older. Fully one-third of currently practicing physicians will be over retirement age in the next decade. In addition, seniors are a rapidly growing segment of the population, increasing by 50% over the next decade, and tend to require two to three times more healthcare than their younger counterparts. At the same time, there continue to be reports of primary care physicians exiting Medicare, due to lower reimbursement combined with higher administrative burden to participate.

In fact, there is some evidence of primary care providers dropping out of onerous reimbursement arrangements entirely in favor of more predictable compensation models. So-called “membership medicine” like concierge or direct primary care (where patients pay upfront fees for access to doctors) is a small segment of how these physicians practice but is growing in popularity, especially in affluent areas.

What providers encompass “primary care”?

When you think of “primary care” you may be only thinking of your family doctor. But primary care includes a broad spectrum of credentials – doctors, nurse practitioners, nurses, pharmacists – and a range of specialties that fulfill the general medical needs of patient populations:

• Family medicine
• Internal medicine
• Pediatrics
• General OB/gyn
• Gerontology
• Behavioral health
• Community health
• Optometrists

How Health Plans Can Respond to Primary Care Challenges

The future of primary care stands to impact all areas of quality and satisfaction in healthcare but, perhaps most relevant and impactful for health plans, are the ways it affects short-term and long-term healthcare costs. According to an expert on the intersections between public health, primary care, and health care policy, “If you think that investing more significantly in primary care and preventive public healthcare is expensive, try not investing. That’s way more expensive. And not just economically, you’re also ignoring the suffering that goes on as well.”

In addition to the potential increased costs, consolidation is also not preventing a loss of primary care providers. As the new president of the AMA relates, “The recent issues during the pandemic with physicians who are employed by large health systems not being able to get the PPE that they need, being disciplined for wearing PPE in certain situations, being furloughed, being laid off, being disciplined just for doing what they thought was best for their patient, I think, highlights the importance of physician autonomy.”

In the face of these challenges – impacting payer bottom lines, member satisfaction and health, and provider networks – health plans have a few avenues to pursue in shoring up this cornerstone of the healthcare system. Here are 4 ways that payers can respond to primary care challenges:

1. Extend telehealth

Health plans providing leeway on virtual care has been a real boon for providers and their patients. But, along with extending telehealth payment parity, effectively communicating those changes and appropriate education really makes this benefit useful. The leader at a technology provider for clinician practices noted, “Most physicians don’t even know how to code correctly for the phone call or virtual visit to take advantage of the changes Medicare (and other payers) have made during the pandemic to increase phone call reimbursement and pay for telehealth visits at the same rate as in-person visits.”

2. Promote value-based care contracts

We wrote before how those providers who were already engaged in alternative payment models were better prepared to weather the patient volume dips associated with the pandemic. Primary care providers seem especially suited to this model because of their role in preventive care and unique ability to screen for social determinants of health and impact overall patient care outcomes. For health plans positioned with advanced technology to offer real-time communication, two-way data exchange, and telehealth flexibility, their primary care provider networks should be better prepared to withstand perceived risks and more open to these modern arrangements.

CMS is already piloting the Primary Care First project with similar structure and goals. The program covers a variety of providers – MD, DO, CNS, NP and PA – and will be active in 26 regions across the U.S. With a simple flat fee payment structure plus upside revenue sharing, it aims to reduce primary care practitioners’ administrative burden to allow them to focus on effective care and the doctor-patient relationship.

3. Continue prepay payment integrity efforts

When it became clear how seriously the pandemic was affecting providers, health plans fast-tracked their plans to transition more payment integrity efforts prospective. Because post-pay audits increase the provider administrative burden and increase costs for payers as well, this move to prepay is a trend that’s here to stay. Especially when combined with provider education and two-way communication, supported by an engagement platform like Pareo Provider, this activity should increase engagement with valuable network providers.

4. Support and engage providers

With the understanding that without providers, there is no effective healthcare system, health plans have been directly supporting providers financially. While this effort is admirable and well-intentioned, it is a short-term solution. But extending technology and policy to reduce providers’ administrative burden promise to offer long-term relief.

The work providers have to perform in EHRs is particularly burdensome, with primary care providers particularly hard hit among specialties. With around 20 minutes per patient visit, on average, dedicated to this administrative task, it’s an outsized contributor to burnout and minimizes primary care availability. And this time doesn’t even include pulling medical records for health plans’ payment integrity needs. With real-time communication and seamless data exchange – supported by advanced technology platforms like Pareo – health plans can promote interoperability and reduce cumbersome administrative tasks.

One health plan has launched a new partnership with this intent. This arrangement consolidates all necessary medical records and administrative processes like prior authorizations into one place. By allowing for a quicker and more structured view of patient information, it should reduce documentation time in favor of patient care.

Pareo Transforms Engagement in Healthcare

Even before the global pandemic hit our shores, the healthcare industry had been focusing on innovating in the face of coming disruption. Pareo was created with this initiative in mind, supporting health plans at the top of this chain to transform engagement in healthcare. The integrative technology platform may start with payment integrity, but it extends to real-time communication with providers – including primary care – to reduce their administrative burden and add to the time they spend caring for members. It’s an effort with real implications in reducing healthcare costs and improving outcomes.