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The Milbank Memorial Fund is an endowed operating foundation that publishes The Milbank Quarterly, commissions projects, and convenes state health policy decision makers on issues they identify as important to population health.
April 24, 2020
Multipayer Primary Care Network Primary Care Transformation Delivery System Reform Primary Care Investment COVID-19
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Primary care practices—many of which are independent small businesses—are in grave danger at a time when the country needs them most. The Primary Care Collaborative/ Larry A. Green Center survey of primary care practices found that fewer than half of respondents feel they had enough patient volume to stay open for the next four weeks (46%) or enough cash on hand to stay open for the next four weeks (47%). Yet strong primary care, working in concert with public heath, will be needed to help the country open again, as well to meet what will surely be pent-up demand for chronic disease care, behavioral health, and more. In this Q&A, Julie Schilz, the senior director of Mathematica’s Health Unit and a former leader at Anthem and at Colorado’s Multi-Payer Patient Centered Medical Home pilot, discusses how commercial insurers can take essential steps to support vulnerable primary care practices.
There are individual insurers around the country following the lead of the Centers for Medicare and Medicaid Services (CMS) by paying for telehealth services at the same rate as for in-person visits. There is variation, however, with some organizations covering all types of electronic or phone visits, and others not. For practices in value-based or capitated payment arrangements, some insurers have committed to accelerated payments based upon previous billing history, enabling suddenly under-utilized primary care practitioners to retain their staff and frankly to keep the doors open. Medicare and private insurers such as United, CareFirst, and Blue Shield of California are providing accelerated payment options to fee-for-service practices. HealthNow and Independent Health Association in Buffalo, New York are making accelerated payments to regional primary care practices. And member payer organizations of the Alliance of Community Health Plans are developing triage tents, providing drive-by testing, and supporting further research.
To shore up primary care into the future, all insurers could proactively invest in resources for primary care by:
It takes technology, personnel, and financial resources to respond to the CMS interim final ruling on telehealth and accelerated payment policies. This is true for primary care within accountable care organizations or hospital systems, but even more so for independent community-based primary care practices, especially those in rural America. The weekly COVID-19 Primary Care Survey led by Rebecca Etz at the Larry Green Center and supported by Primary Care Collaborative surfaces the disconnect between the intent of the policy and the realities of implementation. The Week 6 survey results found that just under half (44%) of respondents reported that COVID-19 is having a “severe” impact (level 5 on a 5-point scale) on their practice.
I have personally had the opportunity to engage with several primary care teams in the past few weeks. The new demands of securing personal protective equipment and COVID-19 tests, keeping up with new policies and billing rules, developing curbside testing, and shifting visits to telehealth and phone visits, are unprecedented. Implementing telehealth, understanding new waivers, and varied payer coding and billing expectations are very difficult while delivering care during a pandemic.
“I have a patient coming into the office today. We tried to get him to do a televisit and he refused. He wants the personal interaction. The patient has advanced pancreatic cancer and wants to discuss his next steps of treatment that oncology recommends. I am fighting for what patients want and need.” —Glenn Kotz, MD, Basalt, Colorado
One lesson from the early primary care–focused innovations is that policy and payment consistency matter. Specifically, there is evidence that payment made to primary care practices, by all insurers, needs to be aligned in order to capitalize on primary care delivering value. When each insurer has unique payment rules and codes, the burden to sift through their requirements to get compensated becomes untenable.
There is precedent for this kind of alignment. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 and the Patient Protection and Affordable Care Act (ACA) of 2010 included “Administrative Simplification” provisions requiring that payers use only one type of claim form. This standardization was initially met with resistance, but everyone survived the transition. CMS, which has made “patients over paperwork” a priority, has been actively testing new strategies through the Comprehensive Primary Care programs, with emerging encouraging results.
This is not the time for individual payers to implement policies and payment models that will strengthen primary care as a “competitive advantage.” This is a time to standardize both payment and billing in order to reap the benefits new COVID-19 policies intend to provide. It is also time to take the next step, to permanently increase primary care investment so it becomes “business as usual” rather than an experiment.
It is not an exaggeration to say that the pandemic’s economic impact could lead to primary care’s demise. In a recent post on the Health Affairs blog, Robert L. Phillips, Andrew Bazemore, and Aaron Baum underscore that many primary care practices, especially independent ones, are at risk of closing their doors as a result of the current crisis. The authors estimate primary care will lose between $10 billion to $15 billion. We cannot let this be legacy of COVID-19. We are in the eye of the storm and have to consider large-scale solutions that will serve as primary care’s lifeline. The community of payers also needs to consider finally implementing longer-term solutions. The current pandemic highlights the need for all payers, public and private, to invest in primary care consistently to sustain transformation and viability.
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