How investing in primary care can help us reach the triple aim

Only 6–8% of healthcare dollars are spent on primary care services even though primary care has been shown to help achieve the “triple aim” of improving care and health while reducing costs.

The “Triple Aim” includes improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations.

The Center for Medicare and Medicaid Innovation’s (CMMI) Comprehensive Primary Care (CPC) initiative and Rhode Island’s statewide payment innovation model provides evidence that additional investment in primary care is expected to assist transformation, improve patient outcomes, and will be cost neutral, or cost saving, overall.

Since the start of the CPC initiative in 2011, $371 million was spent in per-member-per-month fees and the amount spent on primary care for the most complex patients doubled. The primary care investment in Rhode Island expanded almost by 40% between the years of 2008 and 2012, where they were mostly investing in medical home transformation.

To create new and innovative models for primary care, in order to help the clinical first primary care providers and the healthcare system as a whole; there needs to be fundamental and structural alterations. The CPC initiative states five advances that will improve primary care delivery but that will require investment: 1) improved access and continuity; 2) planned care for chronic conditions, preventive care for high-risk patients, and team-based integration of behavioral health; 3) risk-stratified care management; 4) patient and caregiver engagement, and; 5) coordination of care across the medical neighborhood. All of these advances require all types of health systems to invest vital resources into their primary care framework.

Blue Cross and Blue Shield of Rhode Island administered a study with over 100,000 members, these members being practices that had sustained patient-centered medical home transformation. The transformation was done through the CTC and over a 5 year time span this study showed a 5% cut in costs and a savings of $30 million, with comparing this to other primary care practices. Using this model can bring improved patient access and improved care coordination and management as well as avoiding unnecessary hospital admissions. The savings on cost that was presented in this model shows a 250% return on investment in transforming practices into patient-centered medical homes, this being done by having 16% less hospital admissions and 30% less readmissions, compared to other primary care practices. The research from Rhode Island provides evidence that investing in the primary care delivery system can pay off by improving outcomes such as hospital use over time.

Federal investments in medical home transformations are following Rhode Island’s footsteps and are mostly being made through increased fee-for-service payments, per-member-per-month fees and a shared savings in ACO models or pay-for-performance quality incentives. Only a few have invested at the same levels as the CPC initiative or in the same CTC practices that were used in Rhode Island. Most of the time payment systems don’t come close to matching the increase in resources that is needed to make an essential investment into primary care. The average 0.5% decrease in spending due to using shared-savings models isn’t enough to to support the base that is needed to transform practices and continue care management.

A new payment system needs to be created that will enable primary care to serve as the capable and valued base of a high-functioning health system. The CPC initiative is too constrained by the limits of its investment and its dependance on the fee-for-service payment. The Rhode Island model can give the correct amount of resources needed but can be strained by the use of fee-for-service as the foundational payment structure. As of now, track two of the Comprehensive Primary Care Plus (CPC+) action is offering the decreased fee-for-service payments in exchange for larger payments paid quarterly that will make up for the loss of the fee-for-service revenue, which can have the effect of pushing practices closer to cost.

With a dedicated and thorough investment in primary care and the assessment of it, only then will we be able to save our healthcare system and realize how much promise is in the primary care system.

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