I agree with the tenets expressed by Dr. Clive Fields in his op-ed “COVID-19 exposes flaws in our primary-care system” especially with the need to enhance primary care. Developed countries with an effective primary-care infrastructure commit 10% to 15% of their healthcare spending on primary care, not the 5% the U.S. spends.
The current fee-for-service model has seen significant increases in procedural service reimbursement compared with primary-care reimbursement, with some specialties earning more than twice what a primary-care physician earns. This pay differential is not ignored when medical students choose their ultimate specialty, and it contributes to the scarcity of medical graduates in the U.S. entering primary-care residencies.
The burden of value-based care will fall on primary care. Though the move to value-based payment is important, it is critical that we do not repeat the mistakes of the HMO era. In that model, capitated payment for primary care was based on previous actuarial fee-for-service expenditures. Moving the same amount of reimbursement from fee-for-service to value-based care will only increase primary-care physician burnout, regulatory overhead and complexity unless there are significant positive adjustments to the base reimbursement rate.
To be successful with value-based care, practices will need to hire care managers, quality practice managers and social workers. These adjustments must be made prospectively, and not years after the fact. Primary-care practices do not have the capital to front-load the investment needed to transform to a value-based practice.
Dr. Thomas J. Weida