ACP, agencies work to prioritize primary care

The Office of the Assistant Secretary for Health (OASH) has appointed an internist, Judith L. Steinberg, MD, to be the senior advisor leading primary care efforts at the Department of Health and Human Services (HHS). The intent of these efforts is to work with federal agency partners and external stakeholders to develop a plan for HHS to strengthen primary health care in our nation, aiming to improve outcomes and advance equity.

Will this approach lead to the sea change ACP has been seeking to support primary care? It certainly indicates progress toward realizing the recommendations in a recent report from the National Academies of Science, Engineering, and Medicine (NASEM), “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” This report called for the creation of a Secretary's Council on Primary Care to coordinate primary care policy across HHS agencies, addressing a broad swath of areas including payment, workforce, research and investment, technology, quality of care, and metrics. However, is this enough, and will it be effective?

Momentum has been building in this direction for quite some time, starting over a decade ago with the early patient-centered medical home (PCMH) models, largely led by entities within states who were able to engage private payers and physician practices in demonstration and pilot programs. Then the Center for Medicare & Medicaid Innovation (CMMI) began to engage in multipayer models with the creation of the Comprehensive Primary Care initiative in 2012, followed by the Comprehensive Primary Care Plus (CPC+) program in 2017, and now the Primary Care First and Global and Professional Direct Contracting models. In a recent blog post at Health Affairs, the current CMS administrator, Chiquita Brooks-LaSure, and others stated, “CMS should increase the number of people in relationships with care providers, such as advanced primary care providers and ACOs, that are responsible for managing patients' care and are accountable for their patients' costs.” The post also discussed the need of CMMI to reevaluate how it designs models' financial incentives to ensure meaningful participation, including having options that would allow more manageable levels of risk.

There is also movement to better support primary care outside of CMMI, with CMS implementing increased payment rates and reduced documentation requirements for evaluation and management (E/M) codes starting in 2021. These changes build on other recent CMS efforts to improve payment within fee-for-service Medicare, such as providing coverage for chronic care management, transitional care management, and advance care planning, among others. The COVID-19 pandemic has further led to payment and policy changes related to telehealth and remote monitoring services, which have helped ensure patient access to the internal medicine physicians responsible for managing their care.

The Merit-Based Incentive Payment System (MIPS) component of CMS’ Quality Payment Program, which is a blend of fee-for-service Medicare with value-based elements, is also starting to demonstrate some forward progress for primary care physicians. CMS has been looking to evolve the MIPS program toward one based on MIPS Value Pathways (MVPs). MVPs are intended to streamline MIPS participation by allowing physician practices to report on more focused sets of measures and activities that are (hopefully) more meaningful to their practice, specialty, or public health priority. In the Proposed Rule for the 2022 Physician Fee Schedule, CMS has outlined a new MVP focused on chronic care management, likely expecting it to offer greater opportunity for success to many primary care practices.

ACP has advocated for and in some cases been directly involved in advising on or developing all of these efforts. Yet, as the College noted in our New Vision for the U.S. Health Care System, much more is needed. Varying levels of risk for value-based innovations, as proposed by the current CMS administrator, is an important step, but as was stated in one of those papers, without “significantly increasing the relative and absolute payments for primary care commensurate with its value in achieving better outcomes and lower costs,” these models will not succeed over the long term. The NASEM report reflects the need for this investment as well, calling for payers to “ensure that sufficient resources and incentives flow to primary care.”

Beyond our own policy and advocacy work, ACP has been engaged in a number of efforts with external stakeholders to keep this momentum going. As a founding member of the Primary Care Collaborative (PCC), the College engages with other physician and clinician groups, patient organizations, health plans, employers, and others to work toward consensus around policy solutions to further primary care. In 2020, we worked with other medical societies and boards to build on our New Vision and develop a “New Primary Care Paradigm for Financing”—one that is also aligned with the NASEM report recommendations. Most recently, ACP has partnered with other physician and health care organizations to establish Primary Care for America, with the goal of educating policymakers and health policy influencers about the value of comprehensive, continuous, and coordinated primary care.

This latest initiative by HHS to prioritize primary care by appointing a senior advisor is another positive step—and it could certainly provide some coordination across agencies, including CMS, as well as with the Health Resources and Services Administration's Bureau of Primary Care, the Agency for Healthcare Research and Quality's National Center for Excellence in Primary Care Research, and other relevant areas. However, to truly be successful, such an initiative must have adequate funding and authority and must not simply add another layer of bureaucracy to an already complex set of efforts. The NASEM recommendations regarding the work that would fall under the purview of a Secretary's Council are ambitious and wide ranging and would likely need to be approached stepwise. In the meantime, momentum must continue to obtain increased investment in primary care through practical policy changes—with payment that sufficiently recognizes the value of primary care as a top priority.