Table 4.

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

Payment ModelQuadruple AimAllows Proactive Investment in Primary CareThe 4 Cs of Primary CareElements Associated with Successful Programs
Health OutcomesExperience of CareCost ControlProvider SatisfactionContact (Access)ContinuityCoordinationComprehensiveness
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. evidenceInsuff. evidence↑↓Risk limited to primary care services
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. evidenceInsuff. evidenceInsuff. evidence✔/˟ (retroactively triggered)Insuff. evidenceInsuff. evidence↑ (weak)Insuff. evidenceN/A, may not apply to primary care given difficulty defining and assigning bundles
Shared savings↓↑Insuff. evidence✔/˟ (providers often paid FFS)Insuff. evidenceInsuff. evidence*Insuff. evidenceTarget 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. evidenceTarget 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. EvidenceInsuff. evidence↑ (weak)Appropriate risk adjustment
Payments based on 10% total cost of care rather than prior FFS
Direct primary careInsuff. evidence↑ (weak)↑ (weak)↑ (weak)↓↑* (better indiv. access, but affordability and workforce concerns)Insuff. evidenceInsuff. evidenceInsuff. evidenceCoupling 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.