High-quality primary care is the foundation of a high-performing health system that promotes affordable, accessible, and equitable health care for all. The U.S. system, riddled with longstanding problems of access and quality, is falling short on all these fronts.
To address these challenges, the Office of the Assistant Secretary for Health requested input on how the U.S. Department of Health and Human Services (HHS) can strengthen the country’s primary care system. The Commonwealth Fund responded to this request, highlighting three key strategies that build upon reports and recommendations from leading experts, including the National Academies of Sciences, Engineering, and Medicine, the Commonwealth Fund’s Task Force on Payment and Delivery System Reform and Commission on a National Public Health System, and Senate testimony by the Fund’s Reginald D. Williams III.
Strategy 1: Increase Financial Investment in Primary Care
Primary care is at a financial disadvantage relative to the rest of the health care system. Primary care providers (PCPs) are paid less than specialists, and spending on primary care overall is trending downward. Compared with other high-income countries, which spend an average of 14 percent of their total health care expenditures on primary care, the U.S. spent 4.7 percent in 2019, down from an estimated 6.5 percent in 2002.
To boost investment, the Centers for Medicare and Medicaid Services (CMS) could reform its process for setting physician fee schedules, which currently relies on the specialty-dominated Relative Value Update Committee. To correct distortions in the fee schedule — which has been shown to undervalue primary care services such as evaluation and management — CMS could develop independent data-collection procedures for its relative value updates and form a technical expert panel to identify incremental improvements.
Strategy 2: Shift to Hybrid or Capitated Payment Approaches
The U.S. pays for primary care primarily through fee-for-service (FFS) payments, which limit PCPs’ ability to offer optimal care. FFS incentivizes providers to order more tests and procedures, many of which are unnecessary or of low value, and to see as many patients as they can. It also limits PCPs’ ability to offer patient services that may not be included in the fee schedule but are nonetheless valuable, such as coordination with specialists or screening for social risks. Moving to hybrid models - which combine upfront, population-based payments with FFS reimbursement for high-value, underutilized services - would give physicians greater flexibility.
HHS could engage multiple agencies to advance hybrid payments. First, CMS has the authority to offer accountable care organizations participating in the Medicare Shared Savings Program the option of providing partial capitation for primary care. Next, the Center for Medicare and Medicaid Innovation (CMMI) could continue to scale and spread multipayer primary care models. HHS agencies could also collaborate to develop and pilot test alternative, equity-focused payment models for federally qualified health centers, since these providers disproportionately serve people of color and low-income patients. Finally, CMS could issue guidance to states interested in leveraging Medicaid managed care contracts to promote population-based payments.
Strategy 3: Support Integration of Primary Care with Behavioral Health, Social Services, and Public Health
Divisions between primary care and behavioral health providers and their separation from the public health and social service sectors impedes efforts to deliver whole-person care and achieve equitable access and outcomes for patients.
Behavioral health integration. Today, PCPs often encounter patients with behavioral health needs but are hampered by lack of funding, staffing shortages, and unclear billing practices. Fostering behavioral health integration will require innovative payment approaches that offer upfront investments for implementing new care models and hiring additional staff. To support sustainable integration, CMS could provide financing and guidance, while HHS could incentivize and finance initiatives that diversify the behavioral health workforce and increase funding for existing workforce development programs.
Social service integration. The COVID-19 pandemic has led to a renewed commitment to advance health equity and address the drivers of health (DOH), which account for 80 percent of health outcomes and disproportionately impact communities of color. Identifying and addressing DOH-related needs will require changing how and what the health system measures. CMMI could embed DOH measures into primary care delivery models through standardized screening, process and outcomes measurement, and reporting. Such steps would lay the foundation for more systematic patient-level data collection. Using population-level DOH data, HHS would be able to direct investments to providers serving communities at risk.
Public health integration. The COVID-19 pandemic affirmed that PCPs are a trusted source of information for patients. We can build on this trust by incentivizing these providers to contribute to routine public health activities. HHS could promote cross-sector training, data-sharing, and collaboration among public health departments and PCPs by delivering upfront funding for data systems, staffing, and other infrastructure and by establishing core competencies for health departments and PCPs.
Taken together, these evidence-based changes would close critical gaps in our health care system, better prepare primary care to respond to future public health crises, and enable comprehensive, high-quality primary care.