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February 2, 2015
View from Here
Christopher F. Koller
Jul 18, 2022
Jul 11, 2022
Jun 30, 2022
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Improving population health by building more and better primary care in the United States might be considered an exercise in what a nun I once met called, “the theology of the long haul.” I am not sure we have God on our side here, but we do have evidence—much of it published in The Milbank Quarterly by research titans like Barbara Starfield. The evidence is clear—the foundation of any high performing health care system is high quality, easily accessible primary care.
It is worth recalling what Starfield wrote in 2005:
This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.
The act of faith comes in believing that health policy in the U.S. will ever move forward on this evidence. We relentlessly pursue increased specialization and more complex therapies in the costly service of preserving and extending individual lives, while failing to support a more cost-effective collective investment in primary care. As a result, total primary care expenses in the U.S. comprise a mere 5 to 7% of total medical spending, compared to figures reportedly approaching 20% in OECD countries.
Consistent with its mission of improving population health by connecting leaders and decision makers with the best evidence and experience, the Fund continues to lead in the field of primary care transformation. And sometimes there are signs that its faith may be well placed; the last month has been a good one for advocates of primary care.
New CMS Report Released
On January 23, the Centers for Medicare & Medicaid Services finally released closely held results of the first year of both its Medicare Advanced Primary Care Practice (MAPCP) demonstration and Comprehensive Primary Care (CPC) initiative. Participants in these multi-payer primary care transformation projects comprise the bulk of the Multi-State Collaborative, which the Fund has been supporting.
In a blog post, Patrick Conway, Deputy Administrator for Innovation and Quality and CMS Chief Medical Officer, summarized the projects’ performance: “The CPC initiative, in its first year, decreased hospital admissions by 2% and emergency department visits by 3%, contributing to the reduction of expenditures nearly enough to offset care management fees paid by CMS. The MAPCP demonstration generated an estimated $4.2 million in savings through the use of advanced primary care initiatives.” Read about the reports here.
These results, conducted with meticulous evaluation processes, are encouraging if not astounding, and augur well for the future as the projects mature. In addition, subsequent evaluations by the projects themselves of later year performances indicate that the January report results will be exceeded. Between the MAPCP demonstration and the CPC initiative, however, there are also important organizational and procedural differences that will merit further examination in the coming years.
New Evidence on PCMH
Then, on January 30, the Patient-Centered Primary Care Collaborative (PCPCC) released its third annual report (sponsored by the Fund), summarizing recent evaluations of the patient-centered medical home (PCMH). The PCMH is the industry standard for describing the elements of high-quality primary care. In reviewing recent peer-reviewed and gray literature, the report found, as Professor Starfield would have predicted, the PCMH to be associated with improvements in cost and quality.
In the peer-reviewed literature alone identified in the PCPCC report, six of the 10 studies found the use of PCMHs reduced health care costs, and 12 out of 13 reported “improvements in utilization,” such as reduced ED visits and inpatient hospitalizations. Fewer studies measured clinical quality and patient satisfaction, but those that did were positive. Similar results were noted in state government conducted reviews and health plan assessments.
Engaging Self-Insured Employers
The findings of the most-recently released Fund report demonstrate where more work needs to be done. In spite of the growing evidence base for primary care and the fact that Multi-State Collaborative members treat over 6.5 million patients in 17 states, a report by the Pacific Business Group on Health for the Fund released earlier this week notes limited participation by self-insured employers in multi-payer initiatives in four states—Arkansas, Vermont, Oregon and Minnesota. Reasons cited include limited awareness of the importance of primary care for multi-payer projects; a wait- and-see attitude about the merits of multi-payer projects, results not withstanding; and a resistance to participate in collective activities.
These are important and disconcerting findings. The number of employees covered by self-insured plans is growing, and these plans are not subject to state-based regulation. Nor are they, apparently, subject to mounting evidence and local appeals to the wisdom of collective action. Self-insured employers need to be brought into these efforts.
The collective message, however, is one that would make Professor Starfield proud. Primary care transformation is proving its value in the U.S. It is not a question of whether more or better primary care is needed, but how to get it into our country’s mixed health care financing model and political culture. Evidence indicates that we are learning how to do these things; but the haul is indeed long, and the work continues.
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