Payment Reform for Achieving Reduction in Unnecessary Care
The Primary Care Perspective – Key Issues

 Allan H. Goroll, MD, MACP
Massachusetts General Hospital, Harvard Medical School

The predominant system for physician payment in the U.S., Medicare’s fee-for-service (FFS) RBRVS model as interpreted for CMS by the AMA’s RBRVS Update Committee [RUC], has had several adverse, counterproductive effects on primary care:

• Incented high volumes of short visits by paying only for face-to-face care and assigning a very low rate for evaluation and management services

• Compromised time for proper diagnosis, patient education, counseling, and care management/shared decision making (Ludmerer: “No Time to Heal”)

• Reduced the diagnostic confidence of primary physicians, who feel too rushed to make a firm diagnosis and who compensate by resorting to excessive test ordering and low thresholds for specialty referral both for patient safety and for reducing liability risk

• Discouraged prospective new medical graduates from going into primary care due to financial penalty ($3.5M lifetime pay disparity) and poor work environment (the “hamster wheel”), leading to a national work force crisis in primary care

• Depleted primary care practices of the capital needed to implement the teams and technology necessary to achieve current high-performance standards

Needed: Fundamental reform of payment for primary care, including

• Elimination of the “volume imperative,” (i.e., eliminating the predominance of FFS)

• Realignment of payment to support desired outcomes (e.g., achievement of desired Triple Aim goals); if comprehensive care is desired, pay should be comprehensive rather than piecemeal.

• Assuring sufficient financial resources for the necessary teams and technology essential to high-performance practice

• Paying for work that creates value beyond the face-to-face encounter, including payment for care management and population management

• Powerful, validated risk adjustment that protects against cherry-picking patients.

• Incentives for collaborative care with other providers

• Ability to negotiate payment within integrated systems of care to assure payment is proportional to risk and responsibility undertaken and consistent with overall goals