RE: State experience with moving toward "Primary Care as a Common Good"

I was excited to read Kevin Grumbach’s article in Annals entitled “Forging a Social Movement to Dismantle Entrenched Power and Liberate Primary Care as a Common Good”. I completely agree that primary care is a common good and that “Market-driven medicine has been inimical to primary care as a common good.” I love the concept of the “Primary Care for All” model. I agree with Kevin that starting at state level could stimulate incremental change to move toward this model. So I’d like to share some of the experiences in our state of Delaware, and would be interested in hearing the experience of others.
I have been the physician lead in our state’s primary care reform efforts over the past seven or eight years. We had been one of the worst states in region with regard to access to primary care, largely due to the fact that we were one of the worst in the country with payment for primary care. We also had one of the highest overall costs of care in the country, partly because of poor access to primary care but also because of enormous overpayments to our hospital systems.
We followed in the footsteps of Rhode Island and Oregon with primary care reform, first getting legislation passed five years ago to require payments for primary care services be at least at Medicare rates (yes, it is sad that this represented a tremendous improvement) and then two years ago getting legislation passed to require a minimum spend on primary care (increasing from the baseline of four percent gradually to 11.5 percent of overall spend, with the goal of moving toward a capitated model). This was despite the strong opposition from the payers and the hospital associations (partly because the 2nd bill also required a slowing of the dramatic increase in payment for hospital services). Our experience with this opposition certainly illustrates Kevin Grumbach’s statements that “Reason, as Starr notes, often collides with power”, and that “Power doesn’t willingly relinquish itself.” I have appreciated help from national family medicine leaders such as Bob Phillips, Andrew Bazemore and Jack Westfall in providing us with some of the data needed to push this legislation over the finish line.
But despite the seeming victory for “primary care as a common good” in our state, we discovered that the impact has been very small and the challenges much greater than we thought. The first challenge is that state law does not apply to Medicare, Medicare Advantage, or any self-insured employers. It can be applied to Medicaid, but our state Medicaid resisted participation and so were not included in the legislation. This left us with the law applying only to 10 percent of the population at best. I would be interested to hear how others have dealt with the “ERISA-exempt” problem that leaves 70-80 percent of commercially insured out of the purview of state laws. Without much broader participation, state laws will do little to move us toward primary care for all.
A second challenge has been the façade of “value-based care”. While no one can argue that any health care should have “value”, in reality value is almost never measured in a way that has anything to do with value. Payers measure value in ways that require enormous administrative burden to already overburdened primary care clinicians, such as checking boxes and submitting CPT2 codes for data on BMI and blood pressure that already exist in the EHR. There have been important initiatives to measure value appropriately, such as The Center for Professionalism & Value in Health Care’s “Measures that Matter”. These focus on true measures of value in primary care, such as access, comprehensiveness and coordination. But these measures are not used by payers (certainly not in our state). Instead, payers use the “value-based” mantra as a mechanism to avoid payments when clinicians fail to meet their administrative burdens.
While the experience in our state has been disappointing and frustrating, I am heartened by Kevin’s call to engage patients and the community in our efforts. I agree that “Family physicians and their organizations must forge authentic partnerships with allies. Principal among these should be patients and community members.” I think we are past the time of thinking that our partners are payers and hospital systems that benefit from the status quo and have little interest in the common good. I will be engaging with our state medical organizations and policy makers to move in this direction. And I would be interested in hearing others’ experiences and plan along that vein.