On Our Minds Archives

Larry Green, MD
Lauren Hughes, MD, MPH, MSc, FAAFP, DABFM
Alison Reidmohr, MA

We recently submitted our comments for the Dept. of Health and Human Service’s (HHS) request for information (RFI) on how to improve primary care in the U.S. The HHS Initiative to Strengthen Primary Health Care aims to establish a federal foundation for the provision of primary health care for all. The purpose of the RFI was to collect diverse perspectives, experiences, and knowledge that may inform the development of the initial plan for HHS, as well as future steps for the Initiative.

Our comments primarily highlighted the following key strategies to improve primary care:

Integration of Primary Care and Behavioral Health

A substantial and growing body of evidence supports the integration of primary care and MEB health services. We recommend robust financial, data, and technical assistance support for person-centered integration independent of a particular model. There is no “one-size-fits-all” approach. The appropriate model depends on the type, size, and location of a primary care practice, its local partners, and the population(s) it serves. The availability of practice transformation coaching and collaborative, peer-to-peer learning environments is critical to the success of integration efforts. Our June 2022 report, The Building Blocks of Behavioral Health (BH) Integration, introduces a framework for BH integration designed to align care delivery expectations across payers, providers, and patients and to enable payment reform in support of this integration. The framework includes a minimum standard of care delivery expectations, as well as flexible options to reflect the variety of ways practices approach integrated care.

Medical-Legal Partnerships

Medical-legal partnerships (MLPs) are an established model of integrated services that intervene against the social determinants of health and magnify the impact primary care physicians can have on patients and communities. With proven value in more than 450 health systems across 49 states, MLPs introduce poverty lawyers into the health care team alongside social workers, care managers, patient navigators, and clinical pharmacists to tangibly reduce health inequities. Evidence shows that MLPs improve patient health, reduce stress, improve medication adherence, and reduce hospitalizations.

Despite the ample evidence of the ability of MLPs to improve health and well-being, this intervention is challenged by current business models that do not support these services. MLPs are often left with unsustainable funding models including grants, philanthropy, or short-term global payments by health systems. Policies to enable reimbursement for MLPs through public payers could provide an essential stabilizing force to this highly effective health intervention.

Payment reform

The primary barriers to implementing and sustaining primary care models and innovations are insufficient financial investment and payments that are predominantly structured in a fee-for-service mechanism. Payment on a prospective basis would reward improving well-being and allow primary care practices the flexibility to tailor the care they provide based on local population health needs. Specific actions include:

• Increase investment in primary care to a minimum of 10% of total health care expenditures, and preferably to at least 12%.
• Accelerate implementation of revised payment policies for primary care emphasizing risk-adjusted, prospective, population-based (i.e., PMPMs) payments with augmentation for desired policy objectives for all practices, not just those involved in demonstration projects.
• Provide enhanced support through non-fee-for-service means for integrating primary care with MEB health, public health, and human services, including paying for necessary collaboration costs and infrastructure.
• Fund the Primary Care Extension Program, as authorized by the Affordable Care Act: close the gap between what we know and what we do at the frontlines of primary care through practice transformation support.
• Enhance alignment of both payment and measures among Medicare and Medicaid and commercial payers. Multi-payer alignment across public and private payers is sorely needed.
• Any successful primary care model or innovation must be informed by lifespan science, i.e., children and youth must be called out explicitly and appropriately recognized in all the spaces and places in which they receive primary care: pediatrics, family medicine, child care centers, school-based health centers, etc. Any alternative payment model (APM) involving children needs to be uniquely designed to meet their needs. Ensuring children have a healthy start in life, especially children from low-income or disadvantaged populations, is a necessity to address equity.

Read our complete comment here.