Better health care starts with primary care

Want to make health care better? The usual prescriptions are to expand coverage to everyone, reduce out-of-pocket costs, increase price transparency and competition, invest in health information technology, put spending on a budget, move to value-based payments, end disparities and discrimination, and address social determinants of health. All are needed, as ACP argued in “Better Is Possible: ACP's Vision for the U.S. Health Care System,” released in January 2020 yet even more relevant today to the challenges created by COVID-19.

There is another idea that gets short shrift, although it has been talked about for a long time and could do more than any other single thing to make health care better: Put primary and comprehensive care at the front and center of the U.S. health care system. We know from the evidence that having more primary care physicians in a community is associated with fewer preventable hospitalizations and increased longevity. When a patient has an established relationship with a primary care physician, care will be better coordinated and be less fragmented, unnecessary testing will be minimized, communication will be better, trust will be established, prevention will be emphasized, and illness will be diagnosed and treated at an earlier and more treatable stage.

Yet instead of being at the front and center of U.S. health care, primary care is too often relegated to the back of the line in getting access to the support it needs to survive and thrive. We see this in the fact that payments for primary and comprehensive care have been systematically undervalued compared to other services. We see this in the fact that the U.S. spends far less on primary care, about 5% to 7% of total health spending, than the average of 15% spent by other industrialized countries. We see this in the enormous amount of paperwork and administrative tasks that are dumped on primary care physicians. We see this in the relative value unit-based assembly-line medicine that encourages and often requires primary care physicians to rush through as many patients per day as can possibly be seen. We see this when supposed medical school mentors encourage students to go into the so-called “prestige” (and better paid) specialties rather than primary care.

This situation has been developing for a long time, the result of policies that intentionally redirect resources away from primary care to other services and disciplines and those that have unintentionally harmed primary care, like performance measurement programs that fail to measure and value the care provided by primary care physicians while adding more burdens on them.

What would a health care system that instead put primary and comprehensive care front and center look like?

First, it would pay physicians more for their primary and comprehensive care services, as ACP called for in its vision for U.S. health care. There finally is good news on this front. Effective Jan. 1 of this year, Medicare substantially increased payments for office visits and other related evaluation and management (E/M) codes. This is the direct result of ACP advocacy, over several years, to persuade Medicare to increase relative payments under the Medicare Physician Fee Schedule for E/M services. While these increases initially had broad support among physician specialties, there was a concerted effort by some specialty societies to persuade Congress to undermine them.

Under Medicare law, changes in relative values for individual services that cause aggregate spending on physicians to increase must be offset by an across-the-board budget neutrality cut to all physician payments. To offset the cost of the higher relative value units for E/M and other services, CMS therefore applied a 10% budget neutrality cut to the 2021 fee schedule. To prevent this, Congress was being urged by some specialties to hold their services “harmless” from the budget neutrality cut over the next two years while allowing it to go into effect for primary care. ACP led an advocacy effort to counter this push, urging Congress instead to add more money to physician payments equally for all physicians and their services, while allowing the E/M increases to go into effect as scheduled and finalized by CMS.

ACP's position prevailed: Legislation enacted in the closing days of the 116th Congress added $3 billion that is being distributed equally to all physicians and all services, not only to services being cut. As a result of ACP's advocacy, internal medicine physicians are estimated to gain, on average, about 6% in total Medicare payments in 2021. Many will gain even more if they bill mostly for the E/M services getting increased. They will also benefit from the fact that many other payers will incorporate the higher E/M payments into their rates.

Second, primary care physicians would be relieved of unnecessary administrative tasks. There is good news here as well. Along with the higher payments for E/M services, CMS greatly simplified what is required to document the level of each visit in order to be paid by Medicare, as recommended by ACP. Physicians now have the option of billing based on either time or medical decision-making. ACP has created practical resources for members on how to document, code, and be paid for such services under the new rules.

Third, all payers would be required to increase their total investment in primary care, as some states are doing. ACP urged the new Biden administration to make this a requirement of all health care programs run by the federal government, as well as insurers that contract with the federal government.

But much more needs to be done than the incremental improvements to date. In December 2020, ACP joined with six other leading primary care physician organizations in an unprecedented call to fundamentally change the way primary care is financed, improve health equity, and boost clinicians' ability to offer seamlessly integrated care. In an open letter to policymakers, the groups called for a “paradigm shift,” including new models to support primary care physicians and their practices in payment, investment, and other aspects of care.

Putting primary care at the front and center of U.S. health care will help achieve all of the other changes needed to make health care better, including providing universal coverage, reducing disparities, and lowering costs. Better is possible, and that needs to start by society valuing primary care as much as patients value their own primary care doctors.