As the COVID-19 vaccination effort struggles to get off the ground, people are instinctively turning to their primary-care clinicians to learn about risks and benefits and where to get vaccinated.
Too many will be disappointed. Many cannot find a primary-care provider. Those who have one will too often find their clinicians to be overwhelmed by work, financially stressed, and even on the brink of closure. Surveys show that 1 in 5 primary-care physicians is considering retiring. Nearly half report that their mental exhaustion is at an all-time high.
Decades of research show that a robust primary-care system is linked with better outcomes, more equitable care for everyone, and lower costs. During a pandemic, primary care is a critical gateway to vaccination and to early, life-saving diagnosis and treatment. Yet, the U.S. stands apart from other western countries in its neglect of primary care. This neglect has disproportionately burdened people of color, those with low incomes, rural residents and women.
A recent Commonwealth Fund survey found that 45% of lower-income adults reported turning to hospital emergency departments in the past two years for much more costly care that could have been delivered by a primary-care provider, had one been available. This is significantly more than other high-income countries, including Australia and the United Kingdom.
Shoring up the supply and availability of primary-care clinicians has been a continual struggle in this country. But the federal government can help. Some of the required steps are laid out in a recent report from the Commonwealth Fund Task Force on Payment and Delivery System Reform. Critical among these is changing the way primary-care clinicians are paid.
The great majority of primary-care practices live or die financially on the volume of compensated patients they see in face-to-face visits. This is the fee-for-service payment system. But because of dramatic reductions in face-to-face visits, the pandemic has placed unbearable financial pressure on many vulnerable primary-care practices. This is especially problematic in rural communities where small practices were financially vulnerable to begin with and are often the only source of primary care for miles around. These practices are trying to stay afloat while advising and treating patients with COVID-19 symptoms and addressing chronic health conditions that people have neglected during the pandemic.
There is a solution. We need a compensation model that offers primary-care practices financial stability and predictability, freedom to innovate and seize new opportunities (like telehealth) and incentives to keep people healthy and out of hospitals. A capitated system in which doctors and medical practices are rewarded handsomely for better outcomes and paid per patient rather than per visit or procedure, is a more reliable way to pay for medical care.
The evidence supports the merits of models that go under the general description of value-based payment—since they pay for the value of outcomes achieved, not the volume of services delivered. In traditional Medicare, over 10 million beneficiaries are in the Medicare Shared Savings Program, which has reduced Medicare costs each year for the last six years. Many Medicare Advantage plans, now caring for more than one third of Medicare patients, are using it to produce significant improvements in quality of care and constrain costs.
The Biden administration has the authority to spread value-based care without waiting for Congress. CMS can use its current powers to increase the benefits for practices—and patients—to embrace these delivery models in Medicare, Medicaid and Affordable Care Act exchange populations. Since private-sector payers frequently follow in the federal government's footsteps, CMS could stimulate widespread change in the payment of primary-care clinicians.
As Winston Churchill allegedly said, we should never let a crisis go to waste. COVID-19 has brought a long-simmering crisis in our primary-care system to a boil. We know what to do to solve it. It would be a tragedy to once again turn our backs on building the foundational element in every successful modern healthcare system.