Smarter Continuity in an Era of Expanding Challenges in Primary Care

Am J Manag Care. 2024;30(6):In Press

Access to primary care is an essential component of maintaining health and well-being across the population.¹ Despite this, as of 2015, only three-fourths of Americans reported having a source of regular primary care, and just 64% of individuals in their 30s and 51% of Americans with little medical complexity reported having regular primary care.² Further, over the past decade, a declining number of Americans have reported having a regular source of primary care.³ Theoretically, regular visits allow for proactive delivery of preventive care and management of chronic conditions.

For Medicare beneficiaries, one study demonstrated that individuals with regular, frequent primary care visits had fewer acute care episodes (ie, emergency department visits, hospitalizations) and lower costs than those with lower levels of regular primary care.⁴ Further, patients with atherosclerotic cardiovascular disease who had frequent primary care visits had higher treatment adherence than those with fewer visits.⁵ In recognition of these benefits, there have been bipartisan efforts in the US Senate to expand access to primary care through increased funding for community health centers, primary care physicians, and nurses.⁶ In June 2023, CMS announced the Making Care Primary Model, a voluntary primary care model that aims to improve care coordination and care management, including leveraging community resources to address patients’ health-related social needs (eg, housing, nutrition). This innovative 10.5-year model will be tested across the country in 8 states starting July 1, 2024.⁷

Recent payment changes may also affect how primary care is practiced. For example, value-based payment models are designed to incentivize higher-quality care at lower costs. These types of models, although designed to optimize value for care, may encourage primary care practices to prioritize specific encounters aligned with metrics rather than other types of visits (eg, urgent care) to ensure incentive payments are obtained.^8,9 Revenue-maximizing strategies such as this may have unintended consequences, such as increasing wait times for patients with time-sensitive issues that are not tied to bonus payments or forcing patients to see another clinician in the practice rather than their usual primary care physician.¹⁰

Since the onset of the COVID-19 pandemic, the ability to maintain continuity in primary care has become even more challenging. On top of the existing shortage of primary care physicians, many primary care practices were forced to close their doors or reduce salaries or benefits to clinicians because of the pandemic, forcing patients to find alternative sources of routine care.^11,12 There has also been a dramatic rise in companies offering virtual care services, giving quick and easy access to one-time visits, the convenience of which may be appealing to patients. However, this fragmentation of care delivery may have a negative impact on continuity with a usual care provider.^13-15

Risk-Based Scheduling and Cadence

One way to optimize panel management, continuity of care, and the ability to address complex needs within primary care is risk-based scheduling to determine visit cadence, thereby ensuring that patients with the highest need are proactively scheduled on a routine basis. For example, in this issue of The American Journal of Managed Care, Matsil et al demonstrate that for patients with congestive heart failure and/or chronic obstructive pulmonary disease, those with more quarterly primary care visits had lower rates of hospitalization than those with fewer quarterly primary care visits.¹⁶ Several health care systems across the country have designed similar clinically driven scheduling programs with different services (eg, Department of Veterans Affairs Homeless Patient Aligned Care Teams program, Denver Health) targeting specific populations, social needs, or health risk status, demonstrating reduced acute care utilization and improved patient experience with tailored interventions.^17,18 Other health care systems are implementing machine learning models to help risk stratify patients and support visit cadence prioritization.¹⁹

Smarter Continuity in an Era of Expanding Challenges in Primary Care

Increasing the supply and availability of primary care physicians would likely improve the ability of patients to receive regular care with the same clinician.²⁰ Scholarship and loan repayment programs designed to increase the number of primary care clinicians are being employed, but these types of policy efforts take time to fully realize the benefits.²¹ Thus, given the existing supply of clinicians, there are several other ways to mitigate some of the challenges to continuity in primary care.

First, more efficient allocation of existing clinicians can help patients maintain continuity. For example, we must ensure that clinicians practice at the top of their license and are available for the highest-need patients. Second, appropriate risk adjustment in value-based payment models, particularly for high-need patients, is needed to incentivize high-quality care and support equity in access to care. This could include removing incentives for low-value visits (eg, limiting annual checkups for those unlikely to benefit) so that current resources can be allocated optimally based on clinical benefit.²² This could also include reimbursement to primary care providers for virtual continuity visits for their patients when they are hospitalized, even if primarily cared for by hospitalist clinicians.²³ Lastly, visit duration and cadence should be proactively tailored to patients’ clinical and social needs, with the goal of improving patient-centered outcomes and clinician satisfaction.

If we are to achieve the clinical and economic benefits of primary care in general, and of care continuity specifically, the implementation and evaluation of strategies—such as risk-based scheduling—that reward clinicians and patients are warranted.

Author Affiliations: McLean Hospital (NMB), Belmont, MA; Center for Value-Based Insurance Design, University of Michigan (AMF), Ann Arbor, MI.

Source of Funding: None.

Author Disclosures: Dr Fendrick reports serving as a consultant to AbbVie, CareFirst BlueCross BlueShield, Centivo, Community Oncology Association, EmblemHealth, Employee Benefits Research Institute, Exact Sciences, GRAIL, Health at Scale Technologies,* HealthCorum, Hopewell Fund, Hygieia, Johnson & Johnson, Medtronic, MedZed, Merck, Mother Goose Health,* Phathom Pharmaceuticals, Proton Intelligence, RA Capital Management, Sempre Health,* Silver Fern Healthcare,* Teladoc Health, US Department of Defense, Virginia Center for Health Innovation, Washington Health Benefit Exchange, Wellth,* Yale New Haven Health System, and Zansors* (asterisks indicate equity interest); research funding from Arnold Ventures, National Pharmaceutical Council, Patient-Centered Outcomes Research Institute, Pharmaceutical Research and Manufacturers of America, and Robert Wood Johnson Foundation; and outside positions as co–editor in chief of The American Journal of Managed Care, past member of the Medicare Evidence Development & Coverage Advisory Committee, and partner at VBID Health, LLC. Dr Benson reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (NMB, AMF); drafting of the manuscript (NMB, AMF); and critical revision of the manuscript for important intellectual content (NMB, AMF).

Address Correspondence to: A. Mark Fendrick, MD, University of Michigan, 2800 Plymouth Rd, Bldg 16, Floor 4, 016-400S-25, Ann Arbor, MI 48109-2800. Email: amfen@med.umich.edu.

REFERENCES

1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502. doi:10.1111/j.1468-0009.2005.00409.x

2. Levine DM, Linder JA, Landon BE. Characteristics of Americans with primary care and changes over time, 2002-2015. JAMA Intern Med. 2020;180(3):463-466. doi:10.1001/jamainternmed.2019.6282

3. Tavares JL, Cohen MA. Becoming less usual: understanding the decline in the number of people with a usual source of care. Milbank Memorial Fund. September 13, 2023. Accessed December 8, 2023. https://www.milbank.org/publications/becoming-less-usual-understanding-the-decline-in-the-number-of-people-with-a-usual-source-of-care/

4. Rose AJ, Timbie JW, Setodji C, Friedberg MW, Malsberger R, Kahn KL. Primary care visit regularity and patient outcomes: an observational study. J Gen Intern Med. 2019;34(1):82-89. doi:10.1007/s11606-018-4718-x

5. Ahmed ST, Mahtta D, Rehman H, et al. Association between frequency of primary care provider visits and evidence-based statin prescribing and statin adherence: findings from the Veterans Affairs system. Am Heart J. 2020;221:9-18. doi:10.1016/j.ahj.2019.11.019

6. News: Sanders and Marshall announce bipartisan legislation on primary care. News release. US Senate Committee on Health, Education, Labor, and Pensions. September 14, 2023. Accessed December 8, 2023. https://www.help.senate.gov/chair/newsroom/press/news-sanders-and-marshall-announce-bipartisan-legislation-on-primary-care

7. Making Care Primary (MCP) Model. CMS. Accessed December 11, 2023. https://www.cms.gov/priorities/innovation/innovation-models/making-care-primary

8. Dom Dera J. How to succeed in value-based care. Fam Pract Manag. 2021;28(6):25-31.

9. Leykum LK. Reconceptualizing primary care: from cost center to value center. NEJM Catalyst. October 3, 2023. Accessed December 8, 2023. https://catalyst.nejm.org/doi/full/10.1056/CAT.22.0462

10. Millstein J. Value-based payments are making it harder to see your primary care doctor on short notice. STAT. September 20, 2023. Accessed December 8, 2023. https://www.statnews.com/2023/09/20/value-based-payments-primary-care-physicians-appointment-wait-times/

11. Song Z, Giuriato M, Lillehaugen T, et al. Economic and clinical impact of Covid-19 on provider practices in Massachusetts. NEJM Catalyst. September 11, 2020. Accessed December 8, 2023. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0441

12. Projecting health workforce supply and demand. Health Resources and Services Administration. October 2023. Accessed December 8, 2023. https://bhw.hrsa.gov/data-research/projecting-health-workforce-supply-demand

13. Hadeed N, Fendrick AM. Enhance care continuity post COVID-19. Am J Manag Care. 2021;27(4):135-136. doi:10.37765/ajmc.2021.88508

14. Rendell J. Amazon’s doctor will see you: what to know about One Medical. CNET. November 12, 2023. Accessed December 8, 2023. https://www.cnet.com/health/medical/amazons-doctor-will-see-you-what-to-know-about-one-medical/

15. Appleby J, Andrews M. Will the doctor see you now? maybe not amid the changing health care landscape in the US. USA Today. June 27, 2023. Updated July 5, 2023. Accessed December 8, 2023. https://www.usatoday.com/story/news/nation/2023/06/27/primary-care-doctor-shortages-on-the-rise-in-the-us-as-wait-times-grow/70352744007/

16. Matsil A, Shenfeld D, Fields C, Yao A, Clair J. Primary care visit cadence and hospital admissions in high-risk patients. Am J Manag Care. Published online February 27, 2024. doi:10.37765/ajmc.2024.89509

17. O’Toole TP, Johnson EE, Aiello R, Kane V, Pape L. Tailoring care to vulnerable populations by incorporating social determinants of health: the Veterans Health Administration’s “Homeless Patient Aligned Care Team” program. Prev Chronic Dis. 2016;13:E44. doi:10.5888/pcd13.150567

18. Blumenthal D, Anderson G, Burke S, Fulmer T, Jha AK, Long P. Tailoring complex-care management, coordination, and integration for high-need, high-cost patients: a vital direction for health and health care. NAM Perspectives discussion paper. September 19, 2016. doi:10.31478/201609q

19. Bhatt S, Majerczyk N, Rose J, et al. Primary care visit cadence based on risk: a comparison of machine learning and provider judgment. NEJM Catal Innov Care Deliv. 2022;3(4). doi:10.1056/CAT.21.0322

20. Koller CF. New U.S. Health and Human Services brief on primary care offers commitments but leaves questions unanswered. Milbank Memorial Fund. November 15, 2023. Accessed December 11, 2023. https://www.milbank.org/2023/11/new-u-s-health-and-human-services-brief-on-primary-care-offers-commitments-but-leaves-questions-unanswered/

21. Kona M, Clark J, Walsh-Alker E. Improving access to primary care for underserved populations: a review of findings from five case studies and recommendations. Milbank Memorial Fund. November 14, 2023. Accessed December 11, 2023. https://www.milbank.org/publications/improving-access-to-primary-care-for-underserved-populations-a-review-of-findings-from-five-case-studies-and-recommendations/

22. Choosing Wisely: five things physicians and patients should question. Society of General Internal Medicine. Accessed December 8, 2023. https://www.sgim.org/publications/choosing-wisely-recommendations#

23. Kazberouk A, Wachter RM. Remote primary care inpatient consults can improve continuity of care. Health Affairs Forefront. December 5, 2023. Accessed December 11, 2023. https://www.healthaffairs.org/content/forefront/remote-primary-care-inpatient-consults-can-improve-continuity-care