While value-based payment models seem great in theory, research shows that many primary care providers aren’t partaking in these models.
Over the last 14 years, the Centers for Medicare and Medicaid Services (CMS), as well as several states, have introduced value-based care models directed at primary care. The goal is to move away from the fee-for-service model — in which care is paid for by the volume of services — and instead tie payment to the quality of care provided and the ability to bring down costs.
Yet, only 46% of primary care physicians receive value-based payments, according to a 2022 survey. And smaller practices with less resources are even less likely to participate in value-based care.
So what’s holding primary care back? A recent study published by the Commonwealth Fund and conducted by researchers at Mathematica provides some insight. It found that primary care providers are actually very interested in value-based care models, but financial barriers, workforce shortages and documentation burdens are preventing them from engaging in these models.
“The primary care practitioners were actually very enthusiastic about the goals of primary care value-based payment models,” said Ann O’Malley, MD, a senior fellow at Mathematica Policy Research and co-author of the study, in an interview. “They think … the desire to strengthen primary care and improve quality is really laudable. The problem is in the actual execution. Their enthusiasm was tempered by a lot of challenges that they faced.”
However, there are ways to make it easier for primary care physicians to adopt VBC, according to the report and other experts. These solutions include creating incentives to encourage more physicians to go into primary care and offering more upfront payments to physicians.
‘Great on paper’
Study researchers interviewed 12 primary care physicians in leadership positions and other primary care experts. They also held focus groups with 17 frontline primary care providers who haven’t previously participated in value-based care models. Participants came from 18 states, and the focus group participants practiced in rural, suburban and urban communities at independent practices, group practices, health systems and federally qualified health centers.
According to one focus group participant, “When I hear the term [value-based payment]I think ‘great on paper, impossible to implement in reality.’”
The participants said they face numerous financial barriers. For example, there is a lack of participation from commercial payers, leading to practices receiving inadequate funding to make changes to their care delivery. According to Health Care Payment Learning & Action Network, the commercial sector has the lowest percentage of healthcare dollars in two-sided risk alternative payment models at 16.5%, compared to 38.9% for Medicare Advantage.
In addition, health systems aren’t giving frontline primary care providers enough resources to be successful in value-based care, the report found. Two physicians said that when they requested more nurses at practice sites, the health system hired a nurse but put her at the corporate office.
Small, independent practices in rural communities face even more financial barriers.
“Primary care practitioners serving rural populations face a lot of challenges related to having a population that has, frankly, less access to all types of healthcare,” O’Malley said. “And they have fewer resources so the size of their patient population is often not as large as one in an urban practice. … Their ability to participate in these models is somewhat limited from both a resource perspective and just the sheer volume of patients. You have to have a certain number of patients to really be in these models.”
The report added that more primary care physicians would likely be interested in value-based care if the workforce shortage was tackled. Participants noted that “enrolling in a [value-based payment] model that some see as increasing their work without reducing their challenges feels overwhelming.”
Primary care providers also face challenges with documentation, including for quality measures.
“With value-based payment, there’s a big emphasis on quality metrics,” O’Malley said. “One of the challenges around quality metrics is it’s really hard to measure quality well, particularly in a primary care setting where you have a lot of patients who may be at an advanced age and have a lot of chronic conditions. Some of the quality measures that are currently widely used aren’t always clinically appropriate for more complex patients that primary care practitioners see, particularly in the Medicare population.”
The president of the American Medical Association echoed a lot of the challenges laid out in the report.
“AMA research has found that there are numerous barriers, including the complexity of models and the significant variation between value-based care arrangements among payers,” said Bruce A. Scott, MD, president of the AMA. “This complexity and lack of alignment create a heavy administrative burden for many primary care physicians participating in such arrangements — and is a considerable barrier to those contemplating adoption. This is disproportionately true for small, rural, safety net, and independent practices that are already under-resourced and overburdened.”
What needs to change
Frontline primary care practitioners also gave several potential solutions. For example, to address financial barriers for smaller practices, physicians need more upfront payments. Frontline primary care providers also need more say in how health system resources are distributed, such as staffing at clinics.
O’Malley added that funding for primary care has to go up.
“The fee-for-service payment rates are quite distorted,” she said. “Primary care is relatively under compensated compared to their specialist counterparts, and the fee-for-service payment rates are outdated, and that’s gone on for decades. So that’s one thing that has to change because these models are still based on a fee-for-service system and until that underlying fee-for-service system is corrected, it’s going to affect the ability of these models to attract doctors to perform.”
To address the workforce shortage, there need to be better incentives to encourage people to go into primary care. This includes programs like loan forgiveness for primary care providers in underserved areas and training support to help physicians succeed in value-based care.
The participants also recommended making “performance measures less onerous and more relevant,” such as decreasing the number of quality measures and the use of condition-specific measures.
“They’d like to see less emphasis on documentation for quality measures and risk scores, more emphasis on the things that really matter to patients and to providers,” O’Malley said. “[This includes] improving access to primary care, ensuring a continuous, trusted relationship with the primary care practitioner who knows the patient well, and meeting the needs that the patient has.”
Scott of the AMA added that “central to increasing sustainable adoption of VBC payment arrangements is the need to provide a broader, more predictable pathway for primary care physicians (alongside other types of physicians) to engage in such efforts. This can only be accomplished with more substantial input from primary care physicians on the design and operations of these arrangements.”
Another expert said he agrees with many of the recommendations laid out in the report, but noted that it will still be difficult for small, independent practices. However, there are companies that are working to support independent primary care practices, said Tyler Giesting, director of healthcare and life sciences at Chicago-based West Monroe. Value-based enablement companies like Privia and Aledade work with independent practices and provide them with resources to succeed in value-based care.
“I think that’s probably where you’ve seen the most progress, with those groups that are helping enable the independent physicians,” Giesting said in an interview. “I would expect that to continue. A lot of that’s oriented around Medicare Advantage, but not exclusively. It’s still going to be slow going.”
Ultimately, O’Malley would like to see primary care practitioners’ input “strongly” considered in value-based models.
“We’ve got to get more primary care practitioners into [these models] and we have to be cognizant of the challenges they face in everyday practice,” she said.
Photo: atibodyphoto, Getty Images
