PRIMARY CARE PAYMENT REFORM: THE MISSING LINK

Over the past several years as the patient-centered medical home (PCMH) has become a prominent feature in the design of family medicine in the future, we are seeing supportive data suggesting that this model has great potential to improve our health care system and lower cost of care. However, we’ve also had reports of the impact of implementing the PCMH model in various clinical settings with differing payment models. The basic summary of this information is that clinics operating with a fee-for-service model attempting to implement PCMH have very high rates of staff and physician burnout and are losing revenue for non-office visit encounters with patients, making the model unsustainable within the fee-for-service environment. Furthermore, systems where there is either primary care capitation or full capitation that support PCMH implementation are showing just the opposite—high provider satisfaction, patient satisfaction, and improved revenues to support the clinic operations.

The other obvious danger of jumping onto the PCMH bandwagon without reformed payment models is that the intense amount of work that is done in care management or non–office-based care (ie, e-visits, phone visits) will go unrewarded. It is clearly in the interest of the insurance industry to encourage family physicians to fully embrace the PCMH model without having to pay for it. If we allow this to happen, we will doom ourselves to a practice model that is high demand but we will not be able to shrink our panel sizes or visit volumes to manageable levels and still keep our office open unless we are paid in a different way.

If we step back and look at what kind of payment model would best motivate physicians and their health care teams to perform at the highest level in the care of their patients, it would not be a fee-for-service model. The closer we tie the responsibility for the outcomes of care to both physician and patient, the greater the accountability. Developing primary care capitation payments to family medicine clinics based on population management with specific incentives for patient experience markers (a strong correlate to quality) and for key disease management and prevention measures would be our best blend of incentives for payment reform. Our European counterparts have experimented with multiple models and have found that having the bulk of a payment to physicians being a primary care capitation with careful incentives creates an optimal balance. The only way to resource clinics to carry out the work of an effective medical home is to shift more resources into the clinic via payment enhancements but how those payments are structured is critical to getting what we all want—accessible, rational, quality primary care delivered by care teams led by family physicians.

How does this impact residency training? The simple answer is that if the PCMH is the model of care for now and the future, then we need to train residents in an environment that fulfills that model. However, given the high stress and high burnout risk, we need to couple our PCMH implementation with education on change management, burnout prevention, and leadership skills. In doing this we will position the next generation of family medicine graduates to be the PCMH leaders of the future.

• © 2012 Annals of Family Medicine, Inc.