The Path to Multipayer Primary Care Transformation: How Far Have We Come?

The Milbank Memorial Fund Multipayer Primary Care Network facilitates and supports health system transformation. We therefore find ourselves navigating the often-conflicting priorities of the people who deliver health care at the front line, and the policymakers who are responsible for the allocation of resources. Our guest blogger, Evan Saulino, MD, PhD, straddles those worlds. As a practicing family physician in Portland, Oregon, he has personally implemented the quality improvement efforts and observed their effects. He also has served as a physician leader, working with clinics and community stakeholders as clinical advisor for the Oregon’s Patient-Centered Primary Care Home Program, and as a national voice for change through Medicare’s Comprehensive Primary Care Plus and similar programs.

As a primary care physician and an advisor to the state of Oregon on primary care reform, I’ve had the opportunity to see both the “rough” and “shiny” aspects of efforts to transform the way we pay for and deliver primary care over the last decade. With so much attention paid to metrics and money, it can be easy to lose sight of the individuals for whom we are trying to improve the system. But I was recently reminded of one of these people while addressing an audience of insurers, clinicians, consumers, and self-insured employers in Oregon’s Primary Care Payment Reform Collaborative.

“Clyde,” who became my patient in the mid-2000s, was an inspiration. Despite his health problems, including paraplegia from a gunshot wound, Clyde was focused on becoming an alcohol/drug counselor. But in this era before medical homes and primary care teams, I was overwhelmed by his complex medical and psychosocial needs. Soon after we lost a coverage fight with his insurance company to pay for just $57 in medical supplies, Clyde developed an infection that led to more than $2 million in health care spending. During his recovery, Clyde looked me in the eye and said, “Y’know doc, primary care and prevention works! So much pain and expense could be prevented if our health care system was just smarter.”

By maintaining my primary care practice while also becoming involved in policy development and implementation, I have had the opportunity to honor Clyde’s vision. In our state, clinicians and payers benefit from an emphasis on primary care established through state law and our Coordinated Care Organizations, which deliver care to Oregon’s Medicaid recipients and are designed to focus on prevention and chronic disease management. Another catalyst for change has been our participation in federal Center for Medicare and Medicaid Services’ primary care initiatives, Comprehensive Primary Care (CPC) Classic and CPC Plus, in which multiple payers in a state or region join forces to pay primary care practices for enhanced care.

While we have made progress on improving care and lowering costs, there are key communication and functional gaps between payers and providers we have yet to address.

Communications Gaps

There is broad agreement that our health care system needs to move away from paying for volume of services using last century’s “fee-for-service” payment strategy, toward paying for “value.” Actually doing this is difficult. Payers and clinics struggle to transition to a value-based payment approach that includes dollars to support aspects of care besides in-person office visits, such as clinic-based complex care managers and pharmacists.

Payers often do not know if or how money primary care clinics receive through these new value-based payments is spent differently. And clinics often do not understand how or whether payers plan to support their efforts to deliver care differently over the long term, or how the new payments will reliably flow to them. Clinics and payers don’t even necessarily agree on who “their” patients are because payers and clinics use different language and strategies to determine which patients are assigned to a given practice.

Payers and clinics across the health care market are therefore often working in silos that result in duplication, such as pharmacists and care managers in both the insurance companies and the clinic doing overlapping work. Even in the structured CPC project, because of historically adversarial relationships between payers and providers, communication gaps inhibit innovation, good patient care, and cost savings.

Functional Challenges

Along with improving communication, we must work to address some operational issues, including:

• avoiding “whack-a-metric-mole,” where clinicians learn to track one measure only to have it inexplicably replaced by another one (or three!);
• investing in and creating an adequate primary care workforce and infrastructure;
• reducing administrative burden to minimize clinician/team burnout;
• engaging patients and families more effectively.

There are potential solutions to these problems, but they require participation from all the players to work effectively. In Oregon, the Primary Care Payment Reform Collaborative is trying to address some of these issues by, for example, agreeing to a limited set of metrics for all payers and clinics to use in value-based payments, and calling for all participants to invest in a coordinated infrastructure for peer-to-peer technical support for clinics.

Moving Forward

Despite significant challenges, I am heartened to see specific payers display leadership that sets the bar for other insurers. Pioneering payers move beyond financial transactions to engage clinics in conversation about how care could be better supported and delivered, invest in key staffing such as behavioral health providers, and offer clinics technical assistance to promote effective use of value-based payments.

Likewise, with direction, leadership, and financial support, clinics often follow the pattern of maturation I saw in my own clinic and others across my state: a three-to-four-year process of adaptation to reach a place where clinic staff feel empowered to address more root causes of poor health.

If Clyde were my patient today, thanks to primary care transformation efforts, I would have many more resources available to help him, including behavioral health clinicians, pharmacists, social workers, and others who are supported in part by new federal, state, and commercial payer investments.

Our continued success with primary care in Oregon rests on our ability to build on our pioneering strategy of engagement and collaboration and to keep our focus on not some, but all payers, patients, and providers of care. We will also need to sustain the non-linear process of innovation that requires adequate investment, assistance, and time to mature.