Podcast episode transcript: A key solution to health care costs and quality is staring us in the face

With L. Gordon Moore, MD

Gordon Moore: Welcome to 3M’s Inside Angle podcast. This is your host, Gordon Moore. And with me today is Ann Greiner, she serves as President and Chief Executive Officer of the Primary Care Collaborative, PCC, where she is focused on defining and implementing an advocacy research and education agenda that furthers comprehensive, team-based, and patient-centered primary care. Welcome, Ann.

Ann Greiner: Gordon, thank you so much for having me.

Gordon: I have seen your work overtime with primary care and have been fascinated by the PCC as an organization working to help, what I think of as, create that solid foundation of primary care upon which high-performing health system stands. PCC has been around for a while and doing this work. It seems like it’s still an issue, there are still problems, but when I look at colleagues in primary care, it feels like they’re in despair. And so I’m wondering, what do we do with all this, but why don’t we start with telling me a little bit about PCC, where it’s been, where it’s going, and how your vision has evolved overtime?

Ann: Sure. So we’re about a dozen years old, and we were formed, I think, at a period where there was a sense that primary care clinicians could not deliver the kind of care they wanted to. And those purchasing primary care, big corporations, couldn’t buy the kind of primary care that they could in Europe, and they were really frustrated by that. And so employers, and at the time, physician specialty organizations came together and said, “Let’s redefine primary care, care delivery and payment.” And they rallied around a model that had been developed by the pediatricians called the Patient Center Medical Home Model. And through team-based advocacy, so advocacy across various stakeholders in health care, they were remarkably successful in getting PCMH adopted by private health plans, states, and the federal government.

Fast forward 10 years, and we in 2017, took a look at the principles that really undergird the Patient Centered Medical Home and felt that we had learned a lot in the last 10 years, and so we went about updating those principles and issued something called the Shared Principles for Primary Care that have over 350 organizations that have signed on to them. And how they differ is that we now know that primary care has a really important role to play in addressing health inequities, and those have become so apparent in this last year. So there’s a whole principle, there are seven principles focused on equity.

We also understand that primary care is a team-based sport. To really meet patient needs, we need a team that has lots of different skills and competencies. And so while the physician-patient relationship is really important, so is the whole team. And then finally, we’ve also begun to understand that our health system really does not serve patients very well. And so we have really focused on how do we design or redesign a health system to better meet patient and family needs. And so our understanding of patient-centeredness has really deepened.

Gordon: And I hear that when you talk about adding the understanding of equity and how that relates to primary care and the team-based sport, and I think about if I’m going to work on equity in a practice, then I need somebody who understands which community-based organizations they are, what they do, what are their eligibility criteria, what are their hours of operation, and that is time and effort. And so that goes back to your team-based sport, that’s not going to be the PCP necessarily, it could be somebody else working collaboratively on behalf of the people who are coming to that practice. Is that where you’re going, has that been the evolution you’re describing?

Ann: Absolutely. And we also need the data to understand what are our outcomes related to different parts of the patient population that we’re serving. And without the data, we don’t know how we’re doing in terms of outcomes, so the data and analytics is critical. And that was true 10 years ago, but now we have much better data and analytics, thank goodness. We also have an appreciation for how much interaction there is with patient’s mental health and their physical health, and so when we treat patients holistically and think about their mental health and more broadly their behavioral health and even their oral health, we’re going to better be able to meet a whole range of patient needs. So you don’t do that with a doc and an MA, you really need this team working together collaboratively, and you need a really different payment system.

Gordon: When I think about the PCMH work, there was a lot of signaling to clinicians and practices to say, “You need to think about doing these things. And there are certain policies and procedures that, when in place, are likely to enhance the experience and outcomes for the people you serve in practice.” And there was a lot of infrastructure that had to be built to do that. Is that also the future, and is there an infrastructure need and supporting practices to do this? Because I’m wondering about an average clinician in practice who’s running so fast, they didn’t even have time to look outside the window and see what’s coming down the pike.

Ann: Absolutely. So I think PCMH did such a service by helping practices to develop data and analytic infrastructure and to begin to manage proactively their patients that have diabetes or asthma or congestive heart failure, and also really began to think about, how do we expand our access so we can better meet patient need. And that was an incredibly important innovation and really helped to propel primary care forward. However, the model is not as powered as it could be because it’s still largely on a fee-for-service chassis, and so we’ve learned a lot through research how if you have this volume imperative, you have short visits, you’re cycling through, you’re not sure what your revenue will be and so it makes you more hesitant to build out a team.

You may be managing across all different payment models, fee-for-service and value based, and that has its own level of complexity. So there’s a lot of issues with the fact that 60 to 70 percent of primary care practices are still on fee-for-service, and that’s coupled with another trend that we see that is really troubling. And the PCC put out reports about this in both 2020 and 2019 as have many other organizations across the country. We are seeing a decline in what is being spent on primary care as a percentage of total cost of care. And we’re approximately five to seven percent of the dollar is being spent in primary care, and we see declines going back to 2013.

So at a time when we look to primary care to take on a more comprehensive set of services that patients really want and need their physical health, but yes, their mental health, their behavioral health, social needs, we’re not investing more, we’re in fact investing less in primary care and that really is a huge disconnect.

Gordon: It’s interesting, there’s such a complexity in what you’re describing, but it’s like, I can sense it, I’m looking for the right words so people can understand this. It’s like, if we reduce the interaction at the point of care to a set of a couple of codes and things that are going to trigger a payment through a fee-for-service payment volume model, you get this transaction that doesn’t necessarily address what that person is bringing. And I’ve sensed that in practice and I see that where, like, “Tell me your top three things on your agenda, I need to get through this visit, I’m going to write you some orders, give you a prescription because I have to get out the door because I have the next patients already half hour late, and I don’t have time for this.”

So I see evidence around doctors who are cutting patients short when they’re trying to tell them what’s going on, who don’t necessarily have the time to dive into complex issues in the family, in the home and other things. But that’s where the problems can be, that’s where the real issues may lie. And so this model of fee-for-service in low primary care payment means we’re robbing the upfront health promotion disease prevention, which is what leads to the downstream, missed opportunity, high cost, very, very high cost hospitalization for things that also add human suffering. And I’m thinking that is the foundation of what’s wrong with the US health care system is that we don’t have this solid foundation of primary care. And so how do we fix this?

Ann: Yeah. Well, I could not agree with you more. And you think about an initial visit when you go in, when you’ve got some issue and maybe it’s 12 minutes, maybe if you’re lucky, it’s 15, and you’ve got a whole raft of challenges. And maybe the doctor’s able to address one that day and then sends you off for lots of different tests, and you’re going back and forth, ping ponging back and forth as you get these test results instead of, “Let’s sit down and have a more thorough assessment of what is going on with you,” a 360 if you will, and a plan to really address the whole person, if you will. I think we’d be so much more successful, I think it would ultimately be less costly, and we’d probably find fixes to things that were low tech and not very expensive.

You have an asthma exacerbation because of mold in your home or whatever it is, so we really are failing our patients. I do feel that COVID-19 helped people to understand the value of primary care because we all were having to try to understand a quickly-evolving virus. And what is science teaching us? What is the medical advice we’re getting? What should I do given my particular health conditions? And so patients were really looking for primary care to help them navigate. At the same time, we had stay-at-home orders, and so primary care quickly pivoted to getting on the phone, setting up telehealth visits over Facebook and other platforms to try to meet patient need.

And I think we will eventually understand how important primary care was in triaging people and keeping them out of those really packed emergency rooms where they could have put themselves at further risk, and help to manage mild COVID disease in people’s homes. And so I think we’ve understood how valuable primary care is, but also in that process, primary care became more vulnerable because its whole platform initially collapsed because it couldn’t bring patients in for face-to-face visits.

Gordon: So that maybe lights up this conversation about health care financing policy and how we do this, just in the context of paying for telemedicine. I remember back in the day that of course, it was valuable to get on the phone and talk to people when that was clinically appropriate. And of course, there were many circumstances where the clinical appropriateness was easy, but that didn’t add to the revenue stream. So I could do this, but it ended up driving down revenue in the practice, and so it became one of these stupid financial disincentives under the fee-for-service system.

In COVID times, that flipped, then payment was allocated to telemedicine and in visits and that helped. Is that going to sustain and is that the model for how we need to address this so we need to light up more codes around STOH management and things like that?

Ann: Well, what I really think we need is a payment system that is agnostic as to how you get your care, because it may be appropriate to come into the office or it’s a quick touch over e-mail or it’s a telehealth visit because it’s ongoing management of a chronic condition. And we shouldn’t be asking our clinicians to tie themselves up in knots and figure out, “How could I get paid for the service that would be most appropriate at this time?” So we really need a system that doesn’t care how the care is delivered, but really wants to support the care that’s most appropriate. And that I think is a perspective or a capitated payment arrangement.

It was terrific that first, Medicare and then private payers had pay parity for video visits and then finally telephonic visits as well. But I think when the public health emergency is over, I don’t believe that will stay as it was because I think that when that gets scored, we’re going to see that it is more costly. So I think we want the ability to provide care in lots of different ways, many modalities, but we’re going to need a payment system that can let primary care and specialists, if they want to, to do that without having to think about the CPT code for a particular kind of intervention and for a particular kind of modality.

Gordon: I’m trying to think about a parallel that people could hear and maybe understand how crazy it gets at a PCP level when they’re responding to these requirements around measure these processes of care, is I’m thinking about a pilot who has to, at every moment that they touch the yoke or twist a knob or do something, they after then get on to their computer and log in and say, “Well, I turned three degrees left because of this reason,” or “I had to deal with some buffeting turbulence,” something like that. And it’s, like, “You know what, dude, please stop that and fly the plane.” It’s just crazy. It’s, like, we’re telling nurses and doctors, like, “Go look at the computer and enter all this detailed transactional information.” It’s, like, “Yeah. You know, I really would rather you had more time to care for me.” It’s just gotten too crazy, and then I think it’s born of our financing.

All right. So I think about health plan executives I talked to and they think, as you signaled, “Boy, this telemedicine thing makes me nervous, it’s just a new revenue source for clinicians and somebody could grab on the handle of that thing and just crank it and drive a lot of money. And we don’t know if it’s just adding cost to the system, which is already overwhelming, or is it resulting in better outcomes?” Why is it that moving to global payment gets us out of that game?

Ann: Because it is incenting your outcomes and not your volume. And so how do you do in managing that patient’s diabetes or that patient’s asthma? That’s really what you want to get rewarded for. And if you are getting a prospective payment with performance bonuses of some sort, that’s what you’re going to be managing against, not driving volume to take care of something very focused that has a CPT code attached to it, so it’s a really different way of thinking. And we have examples of innovative primary care practices across the country. Some of them on the commercial side, many of them in relation to Medicare advantage plans, taking a global payment and managing against it and the outcomes are just terrific.

Gordon: I have also read that practices who had that revenue source did well under the COVID emergency.

Ann: Absolutely. And that gives me hope that we’ve got an object lesson here in 2020 that face-to-face, fee-for-service payments in an environment where you can’t see your patients, well, that’s an epic fail. And so I hope that gives primary care clinicians more of a desire to move to these new payment models. I think also the fast pivot that primary care undertook to get on telehealth platforms, they can transform quickly, they’ve proven that. And so let’s keep that muscle that has been stretched, our transformation muscle, let’s keep working that and move quickly via Medicare, Medicaid, commercial payers, but I think we start with Medicare, to moving quickly to prospective payment and away from something that really has become quite toxic, this fee-for-service payment infrastructure.

Gordon: Let me go back to something we were talking about earlier, which is the idea that high-performing primary care may not be what we see a lot in the United States, not because of lack of desire and just to be there, because maybe the practices don’t have an understanding what that model looks like, they don’t have the infrastructure to support it, they don’t have a payment system that enables that work may in fact punish them for doing that work. But as I think about those elements, we talked about hiring staff, bringing in new technology, having the data and analytics, that all comes with costs. And when I think about the typical models of pay primary care, the way I hear it from health plans is, “Okay, primary care is five percent of spend, we’ll just take that five percent and turn it into a global cap.”

Ann: Right. And we’ve seen that playbook before and it didn’t work. We need to both tap a tape, but invest much more than what we have historically if we want to get the outcomes that we’re looking for. And so I think it has to be a both pay differently and invest more. And there will be dividends. There will be dividends down the road, first off on the quality front. I mean, I think that happens almost immediately when you start providing more access for people. We see that that really makes a difference in terms of population health outcomes. And also, many studies show it begins to reduce emergency department use and hospitalizations that also happens, and then eventually, costs do come down.

Gordon: Well, I would think every time we have a missed unnecessary emergency department visit, urgent care visit, or hospitalization, that’s a huge benefit. But it makes me nervous, I’m glad you addressed that because I was thinking, “Boy, invest more? We’re already a three-plus trillion dollar annual industry.“ And we’re spending more per capita than any nation in the world on health care. And in one survey I saw from Families USA, they were saying that 44 percent of people in America are still saying, “I can’t afford needed care.” That’s breathtaking to me, it’s absolutely shocking. We spend so much and we have that many people saying that, and still 60 percent of personal bankruptcies are driven by health care costs to the person. It’s mind blowing. So more money for health care, where is it going to come from? How does that work?

Ann: Point well taken, Gordon. Absolutely. And when we work with states or have conversations with the federal government, I mean, we are very clear that what we cannot do is grow the health care pie. We need to be spending on the things that we actually know can achieve better outcomes. And right now, we’re not doing that. And in fact, we have benefit structures like high-deductible health plans, where there really is a financial barrier to getting the preventive care that you need beyond routine screening. And so many low and moderate-income folks don’t go to the doctor until they have to go to the emergency room. I mean, the incentives are all wrong.

So we’ve got to shift our emphasis and make sure that everybody has a primary care home or a primary care clinician and has access to help them take care of their chronic care conditions and prevent things. And that doesn’t happen very well outside of a relationship, by the way. If you’re going to change your behavior to better control your diabetes or reduce your weight, it’s probably going to be because you are working with a partner that helps you along your journey. And it really is that kind of relationship that can get us the outcomes that eventually will help us turn the corner, because not only are we the costliest health care system in the world, but we also are not doing well with life expectancy. And as we know, COVID made things much worse.

So we’re paying more and we’re getting a lot less in terms of years of life. On average, US citizens live two years less than their European counterparts, that’s just nuts. I also think our lack of investment in both public health and primary care, I believe we’re going to eventually see data that suggests this was a contributor to why—one of many factors why the US health care system did so poorly in terms of COVID infections, COVID hospitalizations, and COVID deaths.

Gordon: I think about the intersection of primary care and public health, that makes so much sense, but there’s another book of work of how do we do that collaboration? I think now, in the midst of COVID, we had hospital workers got the first COVID vaccines and the first allocations of personal protective equipment. And then I talked to colleagues in primary care practices where people returning immediately, as you said earlier, for, “Hey, I think I’m sick. Help me, I’m scared.” And those doctors didn’t have masks, they didn’t have vaccines. We’ve gotten our system so backwards, so we need to shift funding.

The sense I have when I look at some of the health spending data from health plans, from governments, that we spend so much on missed opportunity. We spend so much money on very expensive cleaning up of the mess when with health promotion, disease prevention, we might’ve done something. So I want to ask you to think big, and if you had a few levers to pull to say, “We need to change these things,” like the incentives around telemedicine and the fast pivot you think that high-performing primary care and that foundation would solidify across the nation, what would those levers look like?

Ann: I think we have to have a focus, number one, on independent primary care practices who are more likely to serve the safety net, in order to really shore them up because they’ve experienced worse financial outcomes as a result of COVID-19 than others that were attached to health systems. I think to shore them up, we need not only investment, but we need organizations that can help aggregate their data and help them with their care management activities. So that’s what ACOs do, certainly primary care practices might want to join ACOs. But I think there are other models out there where you have aggregators that are supporting independent practice.

That’s important not only for the safety net, which obviously is critical, but also we know that when primary care practices are absorbed by health systems, that prices go up, and we can ill afford to have higher prices and more costs. So I think there’s a whole body of work that needs to focus on these independent practices. I think Medicare has a big role here, specifically CMMI, to try to figure out maybe a focused model on those independent practices coming out of CMMI.

I also think that we just need to get on with this movement towards capitation, and many are talking about not a slow glide into prospective payment models, but really mandating that we get there. I’m still examining whether or not I’m on that ship, but I think it’s a really interesting idea. We’ve been moving very slowly over the last 10 years. In fact, some analysts like Bob Berenson have written that we are further behind today in terms of our primary care payment models than we were in the 1980s and 1990s. So we really have got to recognize that we’ve got to make some pretty bold steps here to move us in the right direction.

And then finally, just in terms of investment, we’ve got to make those investments, and where will that money come from? That is the million dollar question. But I think we want to, as decision makers, is our current system and where we’re investing, giving us the outcomes that we are comfortable with, and I think unequivocally, it is not. And so it is really time to shift dollars toward primary care so that we can enhance population health, enhance the longevity of our country, and over time, get a handle on costs.

Gordon: Ann Greiner from the PCC, thank you so much for your time today.

Ann: Thank you. I really enjoyed the conversation, Gordon.

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