Several state agencies and their committees are planning to expand primary care in Connecticut – that’s a good thing. But it’s being driven by primary care doctors and their needs rather than by patients.
Primary care is the majority of healthcare. It includes checkups and screenings, managing chronic illnesses, and minor illnesses and injuries. Primary care focuses on the whole person. Ideally, your primary care provider knows you personally, has all your records, and knows your healthcare preferences. They should also understand the life circumstances and challenges that influence your health – your job, family, school, nutrition, housing, and culture.
Patients are unique, and so are their health needs. The best primary care is delivered by a team of professionals with the patient as the center of decision-making. We may have a shortage of primary care physicians in the future, but as we move to team-based care, we likely have plenty of other professionals to fill the gap. Teams may include doctors, but also nurse practitioners, physician assistants, nurses, and aides. Other team members could include social workers, community health workers, nutritionists, pharmacists, mental health, and substance abuse specialists, as needed for each patient.
It is true that healthier communities and countries usually spend more on primary care and less on specialty and facility care. But correlation is not causation. Those systems focused first on building a strong primary care foundation, and the money followed naturally. Unfortunately, the Office of Health Strategy (OHS) started with doubling the amount of money Connecticut spends on primary care with the hope that it will be directed at building the system and not just raising physician salaries.
OHS wants to double primary care spending while simultaneously ratcheting down overall healthcare spending. If they are successful, it is inevitable that spending on hospital, nursing home, home care, specialty, and other care will suffer. Seniors, people with disabilities, patients with pre-existing conditions, genetic risks, and chronic illnesses will be especially impacted. We already have shortages in many specialties.
Following their usual procedure, OHS created a committee, which was dominated by primary care physicians and large health systems, to build support for resurrecting a previous failed scheme. OHS and their consultants are leading the committee into recommending primary care capitation, an extreme payment model that has failed Medicare repeatedly for over a decade despite multiple attempts and serious investment. While primary care physician associations support primary care capitation, many practicing primary care doctors have raised concerns, including members of the OHS committee.
Under capitation, instead of being paid when we get care, primary care doctors and their health systems would be paid a set fee, adjusted based on patients’ health risks, to provide all our primary care. Capitation was a miserable failure in HUSKY. Since HUSKY ditched capitation, we have saved billions of tax dollars, more providers take HUSKY patients, and the quality of care is much better. There are much better, proven alternatives to primary care capitation that OHS is ignoring. OHS and their consultants argue that capitation gives doctors more flexibility in how they care for us, using technology instead of office visits or hiring care managers to keep us well. But large health systems and practices already use these tools, without capitation. Not surprisingly, the insurers on the committee like this idea – more financial risk is lifted from them.
Capitation encourages primary care doctors to shift patients directly to specialists for problems that could be addressed in the primary care office, which just raises healthcare costs and undermines the benefits of primary care. Despite repeated warnings from a committee member, at their last meeting the consultants stated they had not considered the impact of the shift to other parts of the health system and haven’t spoken to any specialists.
Primary care doctors are also eroding the standards that hold them accountable in two, interrelated ways. The same OHS committee, at their July 27 meeting, decided to jettison the gold-standard certification for Patient-Centered Medical Homes in favor of a weaker set of yet-to-be designed standards for just Connecticut. The decision was based on primary care providers complaints about NCQA’s independent PCMH recognition standards, which have been used across the US since 2008. NCQA recognition is comprehensive, as it should be to justify higher payments. Dozens of studies have confirmed the value of NCQA recognition improving access and quality of care, while lowering overall healthcare costs.
However, some practices have resisted improvement and lobbied for lower standards. A previous effort by Connecticut physicians to build an alternative PCMH standard for just Connecticut failed in 2014. OHS is now resurrecting that bad idea as well. My students don’t get to re-write the tests to accommodate their needs.
In another doctor-driven erosion of standards, at the Sept. 8 Care Management Committee meeting, DSS announced that they had abandoned the gold-standard CAHPS patient survey used by 46 other state Medicaid programs for a new one for primary care physicians. The CAHPS survey was developed in 1995 by independent researchers to evaluate healthcare programs and care delivery. Over 400 studies have verified its value in assessing whether healthcare programs and providers are helping patients heal and stay well.
CAHPS focuses on whether patients received quality care, not their feelings about specific providers. DSS’s new survey was funded by the Academy Board of Family Medicine Foundation. Ten of the eleven questions in DSS’s new survey ask patients for feedback on their “doctor” or “practice”. CAHPS asks the right question – if they got the care they needed. I recently got a survey after a hotel stay. They asked if the room was clean, not how I felt about the housekeeping staff.
There is ample evidence that moving health systems from a focus on providers to patients and teams of providers improves the quality of care and results in better health outcomes. The evidence is overwhelming that moving from doctor-centered care delivery to teams improves quality and access to care while controlling costs. Patient-centered care is a pervasive buzzword across healthcare policymaking. However, the reality of health policy is moving in the opposite direction. Connecticut policymakers’ actions need to follow their words.
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