If Covid-19 has a silver lining for healthcare, it is the light it shines on the value of primary care. On the front lines of pandemic testing and management, primary care serves the majority of patients, enabling emergency departments and hospitals to treat the acutely ill. But primary care – and the relationships that form its foundation – is equally important in treating the everyday epidemic of chronic conditions we face in the U.S. today, especially in diverse communities.
There, primary care builds trust, reaches people in the languages they speak and how they speak them, and serves their physical and behavioral health. Since the 1970s, Federally Qualified Health Centers (FQHCs) have emerged as trusted coordinators of primary care in low-income communities, addressing health disparities common among people of color and the pressing social issues that cause them.
Addressing the full range of physical, behavioral, and social needs in complex, low-income populations requires an enhanced primary-care model featuring an expanded, multidisciplinary team that includes community health workers addressing social determinants of health, and peer supports and recovery coaches working with people with mental health and substance use disorders. It demands flexibility for community health workers, nurses, and even providers to spend time with patients outside of the health center, virtually and in-person. These innovations don’t work under the fee-for-service (FFS) payment model, which incentivizes providers to generate volume, rather than prioritize the comprehensive teamwork that is needed to provide patients with optimal care.
The health and wellness of Americans, especially our lowest-income, hinges on investing in primary care; we can best do that by adopting primary care capitation. Although there is much to like in the American Academy of Family Practice’s proposed monthly global-payment plan, it needs to be less physician-centric. To best serve the needs of complex, low-income populations, our payment model must cover multidisciplinary care teams and build on FQHCs model of care to achieve better outcomes without increasing total cost of care. We need capitation that pays for the full model of care, addressing the bio/psycho/social needs of patients, including screening and referring for social determinants of health — engendering flexibility of action, critical during the current public health emergency and beyond.
A model that we are developing – the Integrated Primary Care Home (IPCH) – holds the central principle that effective primary care capitation isn’t based on providing what’s been paid for in traditional care; it must be built on teams and services that people need. That will be unique based on community, environment, and demographics; the social and health needs of the population determine the offering. Financed by per-member, per-month capitation, ICPH provides the platform to address the full range of physical, behavioral, and social issues required for true population health for complex populations.
IPCH builds-out seven primary care domains that meet specific communities’ needs. These include engaged leadership and quality improvement methodology and strategy, essential for the success of any health care organization, but also domains that are particularly critical for complex Medicaid populations, such as integration of behavioral health and primary care teams, technology, and processes, as well as full integration of medication-assisted treatment and peer-support models, including recovery coaching. The model also addresses the need for flexible, patient-centered access and a patient-focused culture grounded in trauma-informed care. Not every domain will be correct for all states and all types of primary care settings, but the important point is the need to look beyond what is currently reimbursed as we define and finance primary care.
Our model recognizes that not all primary care organizations will be able to implement these domains fully, nor quickly, and practices won’t achieve full capitation on day-one of the process. Therefore, we’ve defined three adoption stages that allow FQHCs to increase the scope of the capitation they receive as they build additional required capabilities.
From a payer perspective, this model provides a framework to hold primary care accountable for total cost of care and other contract requirements. The approach builds on the one used in New York, Ohio, and Oregon, which starts with the Patient-Centered Medical Home, as defined by NCQA, and adds capabilities needed for success in value-based care.
While sticking with FFS is doubling-down on a losing bet, primary care capitation is a far more rational payment model that can help bring equity to healthcare. We must seize this opportunity to break the systemic trap of poverty and ill-health to which communities of color have been consigned for far too long.
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