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Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care (2021)

Chapter: 12 A Plan for Implementing High-Quality Primary Care

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Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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12

A Plan for Implementing High-Quality Primary Care

Primary care is the heart of a high-functioning health care system. Properly done, it serves the majority of most people’s health care needs the majority of times, with continuous, coordinated, comprehensive, and convenient care. It also serves as a vital navigator to assist people and their families in obtaining external services care.

Primary care is the only component of health care where an increased supply is associated with better population health and more equitable outcomes. Neither hospitals nor specialty care can make this claim. For this reason, the committee considers primary care to be a common good, making the strength and quality of U.S. primary care services a public concern.

Yet there are many characteristics of today’s U.S. health care system that are weakening primary care. Provider payment policy for publicly financed care, such as Medicare and Medicaid, and market-based negotiations for privately financed care reward those parts of the system with political and economic power, while the primary care sector has neither. One result is that primary care teams deliver 55 percent of ambulatory care services but only receive about 5 percent of total health care spending—a figure that continues to decline (Martin et al., 2020; PCPCC, 2018; Reiff et al., 2019). Visits to primary care clinicians are declining, and the workforce pipeline is shrinking, with physicians and other clinicians opting to specialize in more lucrative health care fields.

This weakening of primary care comes at a time when the country needs it more than ever.

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×
  • The number of individuals in the United States with chronic health conditions is increasing, and U.S. life expectancy is steadily declining. Primary care is associated with improved management of chronic health issues and longer life expectancy.
  • COVID-19 has revealed the vulnerabilities of the U.S. health care system and stressed many parts to the breaking point. High-quality primary care can reduce demands on other parts of the health system, allowing for more efficient deployment of scarce resources. Yet, primary care practices, paid predominantly by the visit and denied COVID-19 federal relief funds, have struggled to keep their doors open.
  • The United States is experiencing a period of racial unrest and growing economic inequity. High-quality primary care, widely distributed, can reduce health care disparities.

This report aims to address the shortcomings of the current health care systems that have devalued primary care by offering a vision for high-quality primary care and a set of evidence-based recommendations that will strengthen the heart of the health care system at a time of great need. The committee declared its vision for high-quality primary care in the United States with the definition it stated in Chapter 2:

High-quality primary care is the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams who are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.

To make this vision a reality for everyone in the United States, the committee recommends specific actions, detailed below, that fall under five critical implementation objectives:

  1. Pay for primary care teams to care for people, not doctors to deliver services.
    • The nation gets what it pays for, and payment reform that supports and encourages high-quality primary care, rather than actively discouraging it, is fundamental to the committee’s vision of high-quality primary care.
  2. Ensure that high-quality primary care is available to every individual and family in every community.
    • Everyone in the country should have easy access to high-quality primary care that is person centered, relationship oriented, and responsive to the needs of its community.
Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×
  1. Train primary care teams where people live and work.
    • When primary care training is interprofessional and located in community settings, it is more effective at developing the skills that will keep people connected and healthy.
  2. Design information technology that serves the patient, family, and interprofessional care team.
    • New health information technology standards should prioritize and facilitate integrated care that is person centered, supports relationships, and is responsive to the needs of its community.
  3. Ensure that high-quality primary care is implemented in the United States.
    • Implementing high-quality primary care requires clear and meaningful measures of whole-person care, ongoing research, and leadership in the federal government to ensure federal policies support its development.

If clear recommendations supported by strong evidence were enough, the landmark 1996 Institute of Medicine (IOM) report Primary Care: America’s Health in a New Era would have had a greater impact, and primary care in the United States would not be in its current weakened state. For this reason, the committee’s scope of work calls for an implementation plan, not merely a set of recommendations.

The committee’s implementation plan—comprising a set of actions for each implementation objective—is built on an implementation strategy consisting of three elements:

  1. An implementation framework, one that accounts for the complexity of the U.S. health care system and its public- and private-sector actors.
  2. An accountability framework, one that establishes a process for assessing the adequacy and completeness of implementation activities.
  3. A public policy framework, one that prioritizes the development of government policy to implement high-quality primary care, consistent with its status as a common good.

These elements are fundamental to a strategy for overcoming the current barriers to implementing high-quality primary care in the United States. Of them, the third is most important. Health care is not a functioning market in the United States, and resource allocation is subject to the concentration of political and economic power. High-quality primary care—and the benefits it brings—will not thrive without supportive public policy.

Taken together, the actions recommended below comprise the committee’s implementation plan. They attempt to build the necessary public

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

support and political will; call for appropriately scaled actions by public- and private-sector actors at the macro, meso, and micro system levels; and create accountability structures to ensure the work gets done. Evidence supporting the value of primary care is ample, with extensive research identifying policies and practices that facilitate high-quality primary care. These activities focus on what is needed to promote and effectively scale them. See Appendix D for a table that sorts the committee’s recommended action by system level and actor.

OBJECTIVE ONE: PAY FOR PRIMARY CARE TEAMS TO CARE FOR PEOPLE, NOT DOCTORS TO DELIVER SERVICES

Action 1.1: Payers—Medicaid, Medicare, commercial insurers, and self-insured employers—should evaluate and disseminate payment models based on the ability of those models to promote the delivery of high-quality primary care, as defined by the committee, and not on their ability to achieve short-term cost savings.

Action 1.2: Payers—Medicaid, Medicare, commercial insurers, and self-insured employers—using a fee-for-service (FFS) payment model for primary care should shift primary care payment toward hybrid (part FFS, part capitated) models, making them the default method for paying for primary care teams over time. For risk-bearing contracts with population-based health and cost accountabilities, such as those with accountable care organizations, payers should ensure that sufficient resources and incentives flow to primary care. Hybrid reimbursement models should:

  1. pay prospectively for interprofessional, integrated, team-based care, including incentives for incorporating non-clinician team members and for partnerships with community-based organizations;
  2. be risk adjusted for medical and social complexity;
  3. allow for investment in team development, practice transformation, and the infrastructure to design, use, and maintain necessary digital health technology; and
  4. align with incentives for measuring and improving outcomes for attributed populations.

Action 1.3: The Centers for Medicare & Medicaid Services should increase the overall portion of spending going to primary care by:

  1. accelerating efforts to improve the accuracy of the Medicare physician fee schedule by developing better data collection and valuation tools to identify overpriced services, with the goal of increasing payment rates for primary care evaluation and management services
Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×
  1. by 50 percent and reducing other service rates to maintain budget neutrality; and
  2. restoring the Relative Value Scale Update Committee to the advisory nature as originally intended by developing and relying on additional independent expert panels and evidence derived directly from practices.

Action 1.4: States should implement primary care payment reform by:

  1. using their authority to facilitate multi-payer collaboration on primary care payment and fee schedules and
  2. measuring and increasing the overall portion of health care spending in their state going to primary care.

Any effort to implement high-quality primary care must begin with a commitment to pay primary care more and differently because of its demonstrated and superior capacity among health care services to improve population health and health equity for all society, not because of any ability to achieve short-term return on investment for a specific payer. High-quality primary care is not a commodity service whose value needs to be demonstrated in a competitive marketplace but rather a common good to be promoted by responsible public policy and supported by private-sector action. Implementation of primary care spending policies should attend to the characteristics and practice of what constitutes primary care in accordance with the committee’s definition. As the largest payer in the country, Medicare creates payment policies that set the standard for other public and commercial payers, and it merits priority. In exchange, primary care must be accountable for developing additional capacities consistent with the committee’s definition and garner additional merit for superior performance.

The actions recommended here are tested. Hybrid capitation and FFS arrangements, paired with practice transformation resources and aligned across payers as set forth in Action 1.2, have been shown to build primary care capacity consistent with the committee’s definition. Medicare fee schedule changes have been discussed widely and recommended previously and are actions well within the current purview of the U.S. Department of Health and Human Services (HHS).

Many health systems providing primary care services through employed or contracted models have accepted global capitated payments but continue to operate and compensate primary care on an FFS model, blunting the effects of payment models intended to strengthen primary care. Health systems in these arrangements should honor the intentions of payers and evidence of superior performance, seeing that new payment models allocate sufficient management authority and resources to the practice of primary care.

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

Because primary care makes up a small proportion of overall health care spending, the reduction in other service prices noted in Action 1.3 will be minimal and will help to equilibrate compensation between primary care and other specialties, making primary care a more attractive choice for medical graduates. Changes to the fee schedule are necessary because capitation, budget rates, and compensation within health care systems typically rely on calculations powered by the fee schedule. In addition, the Medicare fee schedule is the basis for relative prices set by other payers. States and local markets that have implemented Action 1.4 have seen benefits in terms of reduced cost trends and improved quality. More states should follow their lead.

Self-insured employers with in-state employment bases should follow the lead of their home states and participate in these efforts. Employers with a geographically dispersed workforce should follow Medicare’s lead and recognize the need to prioritize and pay for high-quality primary care.

These recommended actions, while supported by evidence, have not been scaled and widely implemented for two reasons. First, high-quality primary care requires additional resources. These payment reform innovations have been evaluated against the wrong standard: short-term savings, rather than promoting high-quality primary care, which is a value in and of itself. The focus on repeatedly testing new primary care payment models with a few clinicians, in search of “a better mousetrap” to achieve these short-term savings, has left most primary care clinicians to languish in underpaying FFS arrangements with the wrong incentives. Attention should be focused on moving more clinicians to existing models rather than testing new ones.

Second, budget neutrality or premium stability requirements mean increasing the investments in primary care, redistributing funds, and prioritizing it over other health care services, which is what the committee is calling for in designating it as a common good. Achieving this rebalancing requires leadership, particularly in the public sector. The COVID-19 pandemic’s further weakening of primary care has opened the policy window and leadership opportunity for the Centers for Medicare & Medicaid Services (CMS), employers, and more state officials to act without delay.

OBJECTIVE TWO: ENSURE THAT HIGH-QUALITY PRIMARY CARE IS AVAILABLE TO EVERY INDIVIDUAL AND FAMILY IN EVERY COMMUNITY

Action 2.1: To facilitate an ongoing primary care relationship, all individuals should have the opportunity to have a usual source of primary care.

  1. Payers—Medicaid, Medicare, commercial insurers, and self-insured employers—should ask all covered individuals to declare a usual
Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×
  1. source of primary care annually and should assign non-responding enrollees using established methods, track this information, and use it for payment and accountability measures.
  2. Health centers, hospitals, and primary care practices should assume and document an ongoing clinical relationship with the uninsured people they are treating.

Action 2.2: To improve access to high-quality primary care for underserved populations, and to facilitate empanelment of uninsured people, the U.S. Department of Health and Human Services, enabled by congressional appropriations, should target sustained investment in the creation of new health centers (including federally qualified health centers, look-alikes, and school-based health centers), rural health clinics, and Indian Health Service facilities in federally designated shortage areas.

Action 2.3: To improve access to high-quality primary care services for Medicaid beneficiaries, the Centers for Medicare & Medicaid Services should:

  1. Revise and enforce its fee-for-service (section 1902) and managed care (section 1937) access standards for primary care for Medicaid beneficiaries, ensuring them adequate access to primary care as defined by the committee, and
  2. Provide technical assistance resources to state Medicaid agencies for implementing and attaining these standards, and measure and publish state performance on these standards.

Action 2.4: The Centers for Medicare & Medicaid Services should permanently support the COVID-era rule revisions and Medicaid and Medicare benefits interpretations that have facilitated integrated team-based care, enabled more equitable access to telephone and virtual visits, provided equitable payment for non-in-person visits, eased documentation requirements, expanded the role of interprofessional care team members, and eliminated other barriers to high-quality primary care.

Action 2.5: Primary care practices should move toward a community-oriented model of primary care by:

  1. Including community members with lived experience in their governance, practice design, and practice delivery and
  2. Partnering with community-based organizations.

Accreditation bodies should encourage practices to be more community oriented by revising their standards to facilitate these changes.

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

Successfully implementing high-quality primary care means everyone should have access to the “sustained relationships” primary care offers. The committee recognizes this access is more likely to happen when everyone has adequate health insurance with no financial barriers to primary care. Absent that, payers can improve and reinforce access by taking a page from public health and making “the right choice the easy choice”: encouraging, formalizing, and administratively supporting the existing relationships between their enrollees and primary care teams. Declaring their usual source of care is a reasonable expectation of enrollees in exchange for insurer benefits. Aligned payer action will reinforce the value of primary care as a common good and reduce beneficiaries’ misperceptions that access to specialty care is somehow being limited by any one payer. While private primary care practices are not obligated to treat the uninsured, those that do and are able should assume an ongoing clinical relationship with them.

Primary care cannot be accessible if it is not available or has financial barriers to its use. The Health Resources and Services Administration (HRSA) Health Center Program now provides care to 1 in 11 Americans and has proven to be effective at improving the ability of people without insurance or in medically underserved urban and rural communities to access high-quality primary care. As an organized system of primary care, it merits additional scaling.

As the second-largest payer in the country, with disproportionate numbers of children and high-needs beneficiaries, Medicaid needs a primary care strategy, one led by CMS and implemented and enforced by its state partners, that results in addressing the documented low rates for primary care that are paid by state Medicaid agencies and their contractors and that particularly limit children’s access to high-quality primary care. This strategy should be led by CMS and implemented and enforced by its state partners. A Medicaid program that is reformed to mirror Medicare in terms of payment standards and federal responsibility may be the most straightforward path to ensuring equitable access to high-quality primary care for its beneficiaries (Perrin et al., 2020). However, short of such a complete reform of Medicaid, federal access-to-care standards for state Medicaid programs can be readily modified to catalyze state and managed care organization payment and coverage policies to prioritize high-quality primary care. Meeting federal access standards and those from accrediting bodies will require states and their contracted managed care organizations to take the actions needed, including increasing Medicaid rates for primary care and expanding primary care provider networks.

Primary care accessibility should not be limited by the walls of the practice, however. The COVID-19 pandemic forced Medicare and other payers to quickly scale the ability to access primary care teams virtually by video and telephone. The benefits of these forms of care have been shown

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

to extend well beyond improved infection control, and payment and regulatory barriers to their use need to be minimized.

Finally, much of what improves health has little to do with medical care, and efforts by primary care teams to build health-improving relationships with community organizations and public health agencies should be fostered. This will require action from practices and systems themselves but should also be incorporated into accreditation standards. In keeping with the team-based, relational nature of high-quality primary care, these efforts should place patients, their families, and community members at the center of the design and accountability efforts for successful implementation.

OBJECTIVE THREE: TRAIN PRIMARY CARE TEAMS WHERE PEOPLE LIVE AND WORK

Action 3.1: Health care organizations and local, state, and federal government agencies should expand and diversify the primary care workforce, particularly in federally designated shortage areas, to strengthen interprofessional teams and better align the workforce with the communities they serve.

  1. Public and private health care organizations should ensure inclusion, support, and training for family caregivers, community health workers, and other informal caregivers as members of the interprofessional primary care team.
  2. The U.S. Department of Education and the U.S. Department of Health and Human Services should partner to expand educational pipeline models that would encourage and increase opportunities for students who are under-represented in health professions.
  3. The Health Resources and Services Administration, state and local government, and health care systems should redesign and implement economic incentives, including loan forgiveness and salary supplements, to ensure that interprofessional care team members, especially those who reflect the diverse needs of the local community, are encouraged to enter primary care in rural and underserved areas.
  4. Health systems and organizations should develop a data-driven approach to customizing interprofessional teams to meet the needs of the population they serve.

Action 3.2: The Centers for Medicare & Medicaid Services, the U.S. Department of Veterans Affairs, the Health Resources and Services Administration (HRSA), and states should redeploy or augment funding to support interprofessional training in community-based, primary care practice environments. The revised funding model should be sufficient in size to improve

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

access to primary care and ensure that training programs can adequately support primary care pipeline needs of the future.

  1. HRSA funding (via Title VII and Title VIII programs) for other health professions training should be increased and prioritized for interprofessional education.
  2. The U.S. Department of Health and Human Services, enabled by Congress as needed, should redesign the graduate medical education (GME) payment to support training primary care clinicians in community settings and expand the distribution of training sites to better meet the needs of communities and populations, particularly in rural and underserved areas. Effective HRSA models (e.g., Teaching Health Centers, Rural Training Tracks) should be prioritized for existing GME funding redistribution and sustained discretionary funding.
  3. GME funding should be modified to support the training of all members of the interprofessional primary care team, including but not limited to nurse practitioners, pharmacists, physician assistants, behavioral health specialists, pediatricians, and dental professionals.

Black, Hispanic, American Indian and Alaska Native, and Native Hawaiian and other Pacific Islander people are currently under-represented in nearly every clinical health care occupation. For care teams to address well-documented disparities in treatment based on race and ethnicity, its members must reflect the lived experience of the people and families they serve. Primary care is no exception, and organizations that train, hire, and finance primary care clinicians bear a responsibility to ensure that the demographic composition of its primary care workforce reflects the communities and that the care delivered is culturally appropriate.

More fundamentally, developing a workforce able to deliver the committee’s definition of primary care will require reshaping what is expected of training programs and the clinical settings in which that training occurs. Continuing to train individual primary care clinicians in inpatient settings, as is commonplace today, will not accomplish this. Many examples exist of team-based training in community settings, but they can only be scaled if financial incentives, mostly in the form of GME payments, are recalibrated to support all members of the primary care team. This reshaping will not be accomplished quickly and, recognizing the significance of this task (IOM, 2014), the committee also recommends broader adoption of alternative financing sources for HRSA-developed, community-based primary care training.

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

OBJECTIVE FOUR: DESIGN INFORMATION TECHNOLOGY THAT SERVES THE PATIENT, FAMILY, AND INTERPROFESSIONAL CARE TEAM

Action 4.1: The Office of the National Coordinator for Health Information Technology and the Centers for Medicare & Medicaid Services should develop the next phase of digital health, including electronic health record, certification standards to:

  1. Align with the functions of primary care—supporting the relationship between clinicians, care teams, and patients; providing access and continuous contact over time; collecting and understanding the patient’s story; and focusing on the patient and family rather than the disease;
  2. Account for the user experience of clinicians and patients (e.g., clicks and time spent using system, data transferred without manual review, and improvements in care delivery and health outcomes) to ensure that health systems are truly interoperable;
  3. Ensure equitable access and use of digital health systems that support equitable care and deliver national standards, including guidelines, measures, and decision-making functions, while allowing local tailoring;
  4. Include highly usable sensemaking functionality, such as automated tools that make sense of data, identify clinically important data, and inform care;
  5. Ensure base products meet certification standards with minimal need for local modification to meet requirements; and
  6. Hold health information technology vendors and state and national support agencies financially responsible for failing to achieve benchmarks.

Action 4.2: The Office of the National Coordinator for Health Information Technology (ONC) and the Centers for Medicare & Medicaid Services (CMS) should plan for and adopt a comprehensive aggregate patient data system to enable primary care clinicians and interprofessional teams to easily access comprehensive patient data needed to provide whole-person care.

  1. This data source needs to be usable by any certified digital health tool for patients, families, clinicians, and care team members.
  2. ONC and CMS could accomplish this through a centralized data warehouse, individual health data card, or distributed sources connected by a real-time, functional health information exchange. Each approach has its own challenges, and an initial effort would need to decide on the right national approach.
Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

Digital health, and electronic health records (EHRs) in particular, represent both the opportunities for improving care coordination and person-centeredness and the risks of clinical burden. Digital health is a major source of professional dissatisfaction and clinician burnout (NASEM, 2019). The committee supports federal standards setting for this field, but it has determined that current certification requirements are a significant barrier to high-quality primary care. The recommended elements for new certification requirements suggested here will require additional planning before adoption as well as new policies and authorizations to enforce standards. Creating and implementing these changes requires innovation by vendors and state and national support agencies and accomplishing these goals will not be easy to ascertain.

Similarly, aggregated patient data systems, planned for and adopted by federal entities, can both ensure high-quality primary care and reduce the chances of patient data being used for personal or organizational profit. The experience of local and regional health information exchanges and other nations’ approach to solving this common problem can inform this effort. The committee acknowledges that digital health and the shortcomings of current EHRs is an issue that affects all of health care, but believes that high-functioning, user-friendly health information technology (HIT) can produce outsized benefits for primary care specifically by enabling primary care’s coordinating functions. Improved EHR functionality and a comprehensive data system can facilitate the aggregation of information across all settings, including the community, and make that information usable by the entire primary care team to promote access to care, care coordination, strong relationships, and integration with population health.

OBJECTIVE FIVE: ENSURE THAT HIGH-QUALITY PRIMARY CARE IS IMPLEMENTED IN THE UNITED STATES

Action 5.1: The U.S. Department of Health and Human Services (HHS) Secretary should establish a Secretary’s Council on Primary Care to enable the vision of primary care captured in the committee’s definition.

  1. Council members should include the Centers for Medicare & Medicaid Services Administrator; the Directors of the Center for Medicare & Medicaid Innovation, the Health Resources and Services Administration, and the Agency for Healthcare Research and Quality; the Assistant Secretary for Planning and Evaluation at HHS; and the National Coordinator for the Office of the National Coordinator for Health Information Technology.
  2. The council should coordinate primary care policy across HHS agencies with attention to the following responsibilities: (1) assess federal primary care payment sufficiency and policy; (2) monitor
Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×
  1. primary care workforce sufficiency including training financing, production and preparation, incentives for federally designated shortage areas, and federal clinical assets/investments (health centers, rural health clinics, the Indian Health Service, and the U.S. Department of Veterans Affairs); (3) coordinate and assess the adequacy of the federal government’s research investment in primary care; (4) address primary care’s technology, data, and evidence needs, including interagency collaboration in the use of multiple data sources; (5) promote alignment of public and private payer policies in support of high-quality primary care; and (6) establish meaningful metrics for assessing the quality of primary care that embrace person-centeredness and health equity goals. Additionally, the council should coordinate implementing the committee’s recommended actions that target federal agencies.
  2. As part of its coordination role, the council should verify adequate budgetary resources are allotted in respective agencies for fulfilling these responsibilities.
  3. The council should annually report to Congress and the public on the progress of its implementation plan and performance on each of these six responsibilities.
  4. In all its work, the Secretary’s Council on Primary Care should be informed through regular guidance and recommendations provided by a Primary Care Advisory Committee, created by the HHS Secretary under the Federal Advisory Committee Act, that includes members from national organizations that represent significant primary care stakeholder groups, such as patients, certifying boards, professional organizations, health care worker organizations, payers, and employers.

Action 5.2: The U.S. Department of Health and Human Services should form an Office of Primary Care Research at the National Institutes of Health and prioritize funding of primary care research at the Agency for Healthcare Research and Quality, via the National Center for Excellence in Primary Care Research.

Action 5.3: To improve accountability and increase chances of successful implementation, primary care professional societies, employers, consumer groups, and other stakeholders should assemble, and regularly compile and disseminate a “high-quality primary care implementation scorecard,” based on the five key implementation objectives identified in this report. One or more philanthropies should assist in convening and facilitating the scorecard development and compilation.

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

Table 12-1 summarizes the committee’s proposed scorecard, which aggregates a small number of already-compiled, state- and national-level measures for each implementation objective in this report. (See Appendix E for a discussion of measurement sources and considerations related to the scorecard.)

Successfully implementing a set of recommendations or a plan rests in part on clear accountability. Lack of accountability hampered efforts to implement many aspects of the recommendations in the 1996 IOM report. For these reasons, the committee’s task would be incomplete if it did not

TABLE 12-1 The Health of Primary Care: A Proposed U.S. Scorecard (Summary)

Objective 1: Pay for primary care teams to care for people, not doctors to deliver services
Measure 1.1: Percentage of total spend going to primary care—commercial insurance
Measure 1.2: Percentage of total spend going to primary care—Medicare
Measure 1.3: Percentage of total spend going to primary care—Medicaid
Measure 1.4: Percentage of primary care patient care revenue from capitation
Objective 2: Ensure that high-quality primary care is available to every individual and family in every community
Measure 2.1: Percentage of adults without a usual source of health care
Measure 2.2: Percentage of children without a usual source of health care
Measure 2.3: Primary care physicians per 100,000 people in medically underserved areas
Measure 2.4: Primary care physicians per 100,000 people in areas that are not medically underserved
Objective 3: Train primary care teams where people live and work
Measure 3.1: Percentage of physicians trained in community-based settings, rural areas, Critical Access Hospitals, Medically Underserved Areas
Measure 3.2: Percentage of physicians, nurses, and physician assistants working in primary care
Measure 3.3: Percentage of new physician workforce entering primary care each year
Measure 3.4: Residents per 100,000 population by state
Objective 4: Design information technology that serves the patient, family, and interprofessional care team
The committee is not aware of adequate measures or data sources that capture the use or availability of person-centered digital health in primary care (or any health care) settings, underscoring the urgency for further research in this area
Objective 5: Ensure that high-quality primary care is implemented in the United States
Measure 5.1: Investment in primary care research by the National Institutes of Health in dollars spent and percentage of total projects funded
Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
×

assign accountability for implementation. While state-level and private-sector innovations can provide valuable examples, the committee believes federal leadership and responsibility is essential to scaling its vision of high-quality primary care:

  • As the only health care service positively associated with improved population health status and equity, primary care constitutes a common good. Therefore its strength and viability make it a public policy priority.
  • As the first- and second-largest payers in the country, Medicare and Medicaid payments shape our health care delivery system. Medicare payment policy’s incompatibility with high-quality primary care has weakened primary care.
  • Federal payments and policy determine health care workforce training priorities.
  • Federal funding determines medical and health care services research priorities.

For these reasons, a Secretary’s Council on Primary Care at HHS is the appropriate accountable entity for coordinating the significant federal role and agency activity called for in these actions. The council should also be accountable for monitoring and aligning private-sector activities in support of primary care and ensuring that the committee’s vision for primary care is supported by future administration policy. Senior secretary–level coordination is necessary because of the various and widespread agency-level activities that affect primary care, including workforce training and safety net funding within HRSA, payment and benefits policy at CMS, HIT within the Office of the National Coordinator for Health Information Technology, and research at the Agency for Healthcare Research and Quality (AHRQ) and the National Institutes of Health (NIH). No one HHS agency can take on the task of coordination, which will continue to be in the public interest beyond the scope or term of a special task force, another accountability mechanism the committee considered and rejected.

This council, to be effective, should be given authority by the secretary to ensure adequate budgetary expenditures are made in appropriate agencies for implementing the actions in this report. Public reporting will also increase its accountability. A key task for the council, in addition to coordinating federal policies and receiving input and guidance from a Primary Care Advisory Committee, will be overseeing the establishment of clear accountability measures for providing primary care consistent with the committee’s definition. Done judiciously and with stakeholder input; a focus on core, evidence-based, high-value primary care functions; uniform guidelines that allow for flexible application based on contextual population need,

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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care delivery setting, and community input; and attention to what has been learned in the field of quality measurement, these measures can change expectations for what constitutes high-quality primary care and also facilitate learning and catalyze improved population health.

Just as the financing of primary care delivery has suffered relative to other health services, so has the financing of research on the field of primary care. The country has defunded this research at its peril, as it seeks how to have a rational, just, cost-effective health care system. To address this shortcoming, the committee recommends establishing an NIH Office of Primary Care Research, with functions similar to its Office of Emergency Care Research. This new entity, coupled with the funding of AHRQ’s National Center for Excellence in Primary Care Research, could foster a much-needed system of learning and improvement in primary care that would help make the committee’s vision of high-quality primary care a reality for everyone in the United States.

Finally, to increase the chances for successful implementation, designated actors must be held publicly accountable for their responsibilities. Ample evidence exists for what is necessary for high-quality primary care. Health service researchers regularly generate a variety of measures related to aspects of primary care delivery in the United States, which to date have not been organized and regularly compiled to assess performance and progress. Organized capacity for this work of accountability is profoundly absent: the professional diversity of the high-quality primary care team is its clinical strength but its political and economic weakness. While a single voice to advocate for public policy change exists for other health care services, such as hospitals, the pharmaceutical industry, and nursing homes, primary care has no similar voice and as a result suffers in the policy-making process. The committee’s recommended Federal Advisory Committee to the Secretary’s Council on Primary Care could serve this function. Organizing primary care clinicians, consumer groups, and other interested stakeholders (from the variety of settings in which primary care is delivered) to measure the implementation of the critical activities recommended by the committee using the proposed scorecard will not only hold the designated actors accountable and increase the likelihood of successful implementation but also catalyze a common agenda for a vital common good.

CONCLUSION

High-quality primary care for everyone in the United States will deliver benefits for individuals and society. It will make the nation healthier and enable outcomes to be shared more fairly. This is not a new insight, and it was core to the IOM’s 1996 report. The nation, however, has turned its collective back to this evidence, and the state of primary care—the heart of

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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our health system—has weakened at a time when the nation needs it more than ever.

We know how to have high-quality primary care; indeed, examples of it around the country have shown it is possible to:

  • Pay for primary care teams to care for people, not doctors to deliver services.
  • Ensure that high-quality primary care is available to every individual and family in every community.
  • Train primary care teams where people live and work.
  • Design HIT that serves the patient, family, and primary care team.

The nation should systematically implement and scale these possibilities for everyone in the United States. The nation deserves nothing less, but doing so requires leadership, accountability, and clear steps to accomplish this work. The committee hopes the work captured in this report helps realize this vision sooner rather than later.

REFERENCES

IOM (Institute of Medicine). 1996. Primary care: America’s health in a new era. Washington, DC: National Academy Press.

IOM. 2014. Graduate medical education that meets the nation’s health needs. Washington, DC: The National Academies Press.

Martin, S., R. L. Phillips, Jr., S. Petterson, Z. Levin, and A. W. Bazemore. 2020. Primary care spending in the United States, 2002–2016. JAMA Internal Medicine 180(7):1019–1020.

NASEM (National Academies of Sciences, Engineering, and Medicine). 2019. Taking action against clinician burnout: A systems approach to professional well-being. Washington, DC: The National Academies Press.

PCPCC (Patient-Centered Primary Care Collaborative). 2018. Fact sheet: Spending for primary care. Washington, DC: Patient-Centered Primary Care Collaborative.

Perrin, J. M., G. M. Kenney, and S. Rosenbaum. 2020. Medicaid and child health equity. New England Journal of Medicine 383(27):2595–2598.

Reiff, J., N. Brennan, and J. Fuglesten Biniek. 2019. Primary care spending in the commercially insured population. JAMA 322(22):2244–2245.

Suggested Citation:"12 A Plan for Implementing High-Quality Primary Care." National Academies of Sciences, Engineering, and Medicine. 2021. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: The National Academies Press. doi: 10.17226/25983.
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High-quality primary care is the foundation of the health care system. It provides continuous, person-centered, relationship-based care that considers the needs and preferences of individuals, families, and communities. Without access to high-quality primary care, minor health problems can spiral into chronic disease, chronic disease management becomes difficult and uncoordinated, visits to emergency departments increase, preventive care lags, and health care spending soars to unsustainable levels.

Unequal access to primary care remains a concern, and the COVID-19 pandemic amplified pervasive economic, mental health, and social health disparities that ubiquitous, high-quality primary care might have reduced. Primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes. For this reason, primary care is a common good, which makes the strength and quality of the country's primary care services a public concern.

Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care puts forth an evidence-based plan with actionable objectives and recommendations for implementing high-quality primary care in the United States. The implementation plan of this report balances national needs for scalable solutions while allowing for adaptations to meet local needs.

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