“A Paradox Persists When the Paradigm Is Wrong”: Pisacano Scholars' Reflections from the Inaugural Starfield Summit

What is the Paradox?

Primary care is better at improving the health of the forest than of the trees. Dr. Kurt Stange explored this paradox and summarized numerous studies illustrating that when primary care teams are measured by care for individual diseases, primary care performance is inferior to specialty care with regard to disease-specific outcomes and adherence to disease-specific guidelines and recommendations.⁴ However, in ecological studies, improved population health outcomes are associated with a larger, stronger, and more integrated primary care system.^4,5

The Starfield Summit explored several additional paradoxes relevant to primary care. Although the United States spends more on health care than other high-income countries, we have poorer health outcomes.⁵ These outcomes are thought to have been driven by a historic lack of commitment to social services and primary care.⁶ In the United States, clinical care is responsible for only 14% of health status^7,8, but accounts for 95% of US health care costs.⁹ Furthermore, the United States is the only high-income country without a publicly funded universal health system⁶ and 9% of Americans remain without insurance.¹⁰

What is the Paradigm?

In our current system, fee-for-service reimbursement and productivity models reward the administration of tests, procedures, and medications aimed at treating individual diseases,¹¹ with minimal reimbursement for coordinated services that consider the whole patient in the context of their community. This disease-centered paradigm creates vertical medical silos focusing on specific organ systems and illnesses. Without an incentive for holistic treatment and without measures for comprehensive care, integration across care domains is often not prioritized. Further, a critical aspect of health care delivery—the relationship between provider and patient—has been devalued, as evidenced by shorter primary care visits and inconsistent reimbursement for care coordination and asynchronous care services (eg, phone calls, emails),^12⇓–14 which are capable of strengthening connections and increasing “touches” between patients and primary care teams. Current systems of care are fragmented, force patients to choose specific in-network providers, and provide few resources for delivering preventive health care services or addressing the social determinants of health.¹⁵ Without a radical shift in care delivery and payment to adequately address the upstream causes of illness, sustainability of preventive services and coordinated chronic disease management is threatened. Continuation of the current paradigm will lead to escalation of health care costs without the assurance of improved actual health of individuals and of populations.

Is a Paradigm Shift on the Horizon?

In a ground-breaking decision to move the United States away from fee-for-service reimbursement and toward value-based payment, Congress passed the Medicare Access & CHIP Reauthorization Act (MACRA) in April 2015. MACRA attempts to alter the way in which Medicare will pay for services, including ending the sustainable growth rate formula for how Medicare payments were previously determined, creating a new framework for paying health care providers for comprehensive care, and establishing new quality metrics.¹⁶ Although this new system shows promise, specific details about these payment mechanisms and quality reporting have yet to be released. Without established standards, MACRA leaves primary care leaders wondering how value-based payments will change health care delivery. Will the current measurement and delivery infrastructures remain or will value-based payments encourage and incentivize innovative delivery models? Will primary care's emphasis on whole-person wellness and population health be adequately valued or is the paradigm shifting only incrementally from fee-for-(individual) service to fee-for-(individual) measurement? Will the financial viability and, thus, the long-term survival of primary care become more certain or will it continue to be threatened? Can our health care system reach a place where a healthier forest equates to healthier trees?

What Would Be a True Paradigm Shift?

The 2016 Starfield Summit created an opportunity to examine primary care bright spots, disruptive innovations, policy-relevant issues, and research priorities. New primary care ideas arose and old ideas re-emerged. Participants envisioned a new US health care system in which the strengths of both primary and specialty care could be combined with public and behavioral health to emphasize better quality of care, greater whole-person wellbeing, improved population health outcomes, and improved physician satisfaction. Together we envisioned a paradigm shift in which a redesigned system of delivery, payment, and measurement could energize the primary care workforce and create a structure for improved health outcomes for the individuals and populations of our nation. The 3 tables included list “brainstorming themes” that emerged from the discussion of each of the 3 featured topic domains (payment, measurement, and team-based care) and include representative statements from these discussions.

1) Payment: Breaking Down Vertical Silos of Care, Creating Global Budgets

Although the Summit could not define a scalable payment model for the entire US health care system and the primary care function, several themes regarding important elements of an effective payment system arose in Summit discussions and are summarized in Table 1. Several presenters highlighted the limitations of our current payment structures and the need for broader support of primary care services. Systems of payment based on fee-for-service reimbursement favor procedures and specialists, driving health care into vertical medical silos and promoting volume of services over value. This trajectory inhibits the improvement of primary care and the financial sustainability of the health care system.^11,17 Despite inherent problems in the fee-for-service model, it can be valuable if restructured to place higher fees on services that support improvement in overall health outcomes rather than individual disease states and when used for low-cost and underutilized services such as vaccines.¹¹ Alternative models that incorporate different payment schemes are being implemented across the country. Summit participants discussed advantages and disadvantages of these models and how some experiments show promise for the future. For example, the state of Maryland created global budgets in which hospitals partnered with the Centers for Medicare and Medicaid Services to abolish fee-for-service payments and replace them with a global funding structure, creating the first hospital risk-adjusted rate regulation system.¹⁸ This transformed payment model allows hospitals to focus on outcomes and value while maintaining financial stability. In the first year alone, Maryland saved Medicare $116 million while reducing the rate of potentially preventable conditions by 26.3%.¹⁹ In Rhode Island, a policy change created a mandated increase in primary care expenditures to 10% of total health care expenditures, leading to a savings of over $100 million in its first 4 years.²⁰ Rather than simply increasing fee-for-service rates for primary care services, payers were required to instead invest in other primary care resources such as care management, behavioral health services, and increased health information exchange. Summit participants also learned about a disruptive payment innovation, Direct Primary Care (DPC), and about how DPC organizations such as Qliance, Iora Health, and One Medical Group are changing the traditional paradigm through per-member payment models that allow flexibility in service delivery.^{21⇓⇓–24} These new payment paradigms require clinical leaders, employers, and patients to come together in unique ways. MACRA may also help to shift these payment paradigms, but it is too soon to predict whether it will inspire the radical change needed for transformation.

Innovations in financing and delivery of health care provide hope and direction for the future, but many questions remain. Which of these payment and delivery models will work to provide the best health outcomes and will be scalable on a national level? Perhaps the best answers will emerge, as in Maryland and Rhode Island, by turning to individual states for solutions that will create a healthier America. To determine which of these payment systems has the most potential, we must begin to create metrics that capture outputs relevant to primary care.

2) Measurement: Are We Measuring What Matters Most?

Summit discussions around pay-for-performance included some positive comments regarding its value in individual disease-based evaluation and reimbursement, while drawing attention to important limitations. It remains unclear how to measure components of care delivery that influence broader health outcomes, especially in complex patients. Table 2 summarizes themes that emerged from the Summit discussions regarding the quality metrics that can be used, or need to be developed, to assess the ability of primary care to change health outcomes and improve population health.

A variety of Summit talks explored what we know about measuring the primary care function.

Currently $15.4 billion is spent annually on monitoring quality.²⁵ Professor Amanda Howe, an academic general practitioner from the United Kingdom (UK) and the incoming president of the World Organization of Family Doctors (Wonca), shared a cautionary tale of how an initiative to measure and reward primary care quality across the UK (the Quality Outcomes Framework [QOF]) did not have the consequences it intended.²⁶ The QOF attempted to provide value-based payments to physicians, but its multiple disease-based metrics supported process driven rather than outcomes-based care. Over time it tended to fragment the way primary health care was delivered, rather than improving whole-person or population care. This contributed to a decline in physician satisfaction with the QOF, and there was no overall measurable improvement in health inequities.²⁶

Measuring clinics on their ability to maintain optimal access and a comprehensive array of services are 2 examples of ways in which metrics can support some of the features of primary care that are thought to underlie the value it brings to patients and health systems.^27,28 Another aspect of primary care that is difficult to measure, but arguably the most personally meaningful, is the effect of a therapeutic relationship with a consistent clinician.^13,14 Although not all aspects of clinical practice can be measured, metric reform has the potential to truly transform primary care delivery.

Quality metrics and subsequent payments that incentivize and support the primary care function have the potential to affect individual and population health. However, radically shifting the current measurement paradigm presents challenges including the difficult tasks of development, implementation, and evaluation of metrics that lead to improved outcomes and are relevant to patients. In addition to capturing important primary care functions, measurement needs to account for social vulnerabilities so that quality can be evaluated in the context of the social determinants of health and health disparities.

3) Team-Based Care: Revisiting and Revitalizing Old Models

Summit discussions yielded consensus that teams are critical for the success of the primary care function. Table 3 reflects themes that came out of the varied discussions on the topics of teams. Summit participants examined roadmaps for transforming primary care practices with team-based approaches. Examples highlighted included the 10 Building Blocks of High-Performing Primary Care,²⁹ team strategies for integrating behavioral health and primary care,³⁰ incorporating patients and communities into primary care teams (eg, community health workers),³¹ and approaches for increasing joy in practice.³² Participants concluded that effective teams must be adaptable with regard to the needs of the population, size of the community, and specific roles of team members.^33⇓–35 The patient as a vital team member must remain at the center of all team activities. Team-based care must also exist across specialties and locations of the health system (eg, clinic, emergency department, hospital), and community engagement as a form of team care is crucial.

Team-based care can improve access to a broad scope of primary care for individuals and communities. For example, team members can share routine well-care and preventive care tasks (eg, referrals for cancer screenings, immunization forecasting) as well as care coordination and education, enabling clinicians to see fewer, but more complex, patients per day for longer visits and freeing time for additional leadership and administrative tasks.^{36⇓⇓⇓–40} Although team-based approaches have improved efficiency and quality in many studies⁴¹, they have shown limited effect on addressing social determinants of health and connecting patients with specialty care.⁴²

Sidney and Emily Kark, the founders of community-oriented primary care, incorporated community needs assessments, population health data, community health workers, and multi-disciplinary teams using community-oriented, team-based approaches in the rural South African Pholela Health Centre during the 1940s.⁴³ As the paradigm continues to shift away from volume-based care and toward teams, we should revisit these and other pioneering models of integrated primary care, public health, and behavioral health. Patient-Centered Medical Homes with patient navigators, health coaches, integrated behavioral health, and daily huddles are also reemerging as a path to improved care.⁴⁴