Why is it such slow going for value-based models in primary care?

Industry pundits, this one included, have been claiming that we are “at the tipping point of value-based care” for almost half a decade now. Each year, payers release new models that are destined to be the silver bullet for fee-for-service (FFS), and each year, the VBC adoption stats only creep marginally closer to the benchmarks that would indicate value-based models are achieving dominance in key segments of the care continuum. 

Progress is happening. Change is being made. But it’s slow and often frustrating, especially because the providers who are supposed to be benefiting the most from value-based care – primary care providers – aren’t necessarily seeing the biggest rewards. 

A new report from the Commonwealth Fund used provider focus groups to explore why PCPs are generally reluctant to make the leap, even though CMS has repeatedly touted the outsized successes of low-revenue accountable care organizations (ACOs) made up of independent PCPs.  

It boils down to this: they feel that the juice isn’t worth the squeeze. 

The report found three major issues inhibiting the growth of VBC in the primary care environment, starting with the lack of up-front financial support that would allow providers to make the right investments in technology and practice transformation to take advantage of new models. 

“Most commercial payers have not sufficiently engaged in [VBC models], and those that have, have chosen to make relatively small enhanced primary care payments,” the authors wrote. “Furthermore, commercial payers have shifted little of their payments in these models away from FFS. As a result, practices receive insufficient increases in primary care revenue, which limits their ability to change care delivery.” 

Hospital-based health systems, too, have little incentive to shift away from the FFS mindset, nor are they equipping their PCPs with enough resources to produce results when they do participate, PCPs complained. Primary care providers said they do not often get a seat at the table during relevant discussions, which makes it difficult for them to explain what resources they need and how to best deploy them. 

The second main barrier is inadequate staffing for practice transformation. The ongoing workforce shortage is a classic Catch-22 for PCPs. VBC is supposed to make it easier to do more with less.  But without enough staffing resources on hand to make the transition, PCPs aren’t able to take advantage of the potential benefits. 

To break the cycle, PCPs suggested additional federal, state, or local incentive programs to make primary care a more attractive career path for aspiring clinicians. They also requested more hands-on training geared toward operating in a VBC environment instead of the classic FFS industry to keep staff energized and engaged in the transition. 

Lastly, providers pointed their fingers at overly onerous and restrictive measurement and reporting requirements that don’t adequately recognize the nuances of primary care relationships. 

“PCPs in the focus groups felt that current measures that focus on binary or stark cut-offs for individual conditions or screening tests are overly simplistic and often fail to capture high-quality primary care,” said the report. “For example, one PCP described receiving a message from her health system asking her to talk to a patient about body mass index. But during a visit, the PCP observed that the patient was severely depressed; clearly, discussing the topic in that moment would have been insensitive.”  

Participants also disliked the time and effort required for comprehensive risk scoring and other documentation requirements, saying it took time away from patient relationships. They also echoed ongoing concerns about being penalized for quality issues beyond their control, and hoped to see future measures that more accurately reflected their internal capabilities, such as those related to continuity of care within the practice and patient experiences in the clinic. 

Overall, the report didn’t reveal much that’s new to long-term watchers of the VBC transition. But it did reinforce the fact that it’s going to take a little more momentum to get over the hump and truly dive over onto the downside slope of the industry’s evolution. 

During the next one to two years, policymakers and payers should consider putting a little extra effort into tweaking models to actually address the long-standing complaints of the PCP community if they are to motivate these groups to embrace programs like the traditional Medicare Shared Savings Program options or the new Making Care Primary (MCP) Model. 

Hopefully, in another five years, debate over the “tipping point” of value-based care will finally be over and the benefits of the transition will be clearly visible for both providers and their patients. 

Jennifer Bresnick is a journalist and freelance content creator with a decade of experience in the health IT industry.  Her work has focused on leveraging innovative technology tools to create value, improve health equity, and achieve the promises of the learning health system.  She can be reached at jennifer@inklesscreative.com.