Table 4.

Impact of Primary Care Payment Models on the Quadruple Aim and Tenets of Primary Care

Payment Model	Quadruple Aim				Allows Proactive Investment in Primary Care	The 4 Cs of Primary Care				Elements Associated with Successful Programs
Payment Model	Health Outcomes	Experience of Care	Cost Control	Provider Satisfaction	Allows Proactive Investment in Primary Care	Contact (Access)	Continuity	Coordination	Comprehensiveness	Elements Associated with Successful Programs
Fee-for-service (FFS)	↓	↓	↓	↓	˟	↓	←→	↓	↑↓^*	Billing mechanisms available that recognize primary care tenets and non-face-to-face services
Traditional (full-risk) capitation	←→	Mostly ↓	Mostly ↑	↓	✔	↓	Insuff. evidence	Insuff. evidence	↑↓	Risk limited to primary care services
Traditional (full-risk) capitation	←→	Mostly ↓	Mostly ↑	↓	✔	↓	Insuff. evidence	Insuff. evidence	↑↓	PMPM determination based on anticipated need rather than FFS^*
Pay-for-performance (P4P)	↓↑	↓↑	↓↑	↓	˟	↓↑	↓	←→	↓	Appropriate, aligned measures for use in primary care^*
Bundled payment (episode-of-care)	←→ (weak)	Insuff. evidence	Insuff. evidence	Insuff. evidence	✔/˟ (retroactively triggered)	Insuff. evidence	Insuff. evidence	↑ (weak)	Insuff. evidence	N/A, may not apply to primary care given difficulty defining and assigning bundles
Shared savings	↑	↑	↓↑	Insuff. evidence	✔/˟ (providers often paid FFS)	Insuff. evidence	Insuff. evidence	↑^*	Insuff. evidence	Target high-needs patients
										Address psychosocial needs
										Appropriate risk-adjustment
										Non-FFS incentives at provider level^*
										Physician-led or integrated ACO
Blended FFS and capitation	↓↑	↓↑	↓↑	Insuff. evidence	✔/˟	↑	↑	↑	Insuff. evidence	Target high-needs patients
										Appropriate risk-adjustment
										Multipayer alignment
										Real-time data sharing
										Optimal FFS/capitation blend (more research needed)
Comprehen-sive primary care payment	↑ (weak)	↑ (weak)	↑ (weak)	↑ (weak)	✔	↑ (weak)	Insuff. Evidence	Insuff. evidence	↑ (weak)	Appropriate risk adjustment
Comprehen-sive primary care payment	↑ (weak)	↑ (weak)	↑ (weak)	↑ (weak)	✔	↑ (weak)	Insuff. Evidence	Insuff. evidence	↑ (weak)	Payments based on 10% total cost of care rather than prior FFS
Direct primary care	Insuff. evidence	↑ (weak)	↑ (weak)	↑ (weak)	✔	↓↑^* (better indiv. access, but affordability and workforce concerns)	Insuff. evidence	Insuff. evidence	Insuff. evidence	Coupling with appropriate wraparound insurance to avoid high patient costs for non-primary care services^*

↑, evidence of positive outcomes.
↓, evidence of negative outcomes.
↓↑, evidence of mixed effects.
←→, no significant effect or change.
✔, allows proactive investment in primary care.
˟, does not allow proactive investment in primary care.
✔/˟, some components allow proactive investment in primary care, while others do not.
Insuff. evidence, no available evidence; (weak), limited or poor quality evidence (ie, <1 study examined and/or not a comparison study).
↵* No or limited evidence, but a strong theoretical likelihood of effect.
Proactive investment in primary care can support all of the 4 Cs.
ACO, accountable care organization; PMPM, per member per month.