Recently, one of our larger employer-members brought an issue to my attention that reminded me of the importance of proper primary care. This employer had a patient who required an ultrasound – which, if performed during an office visit, would be 100% covered by the plan.

The specific patient is receiving care at an office that cannot provide ultrasound services. Under the Pricing Transparency regulations many hospitals, prior to procedures, send patients out-of-pocket cost estimates. In this case, the patient who is receiving care at a provider that cannot offer in-office ultrasound services was informed by the hospital that the procedure would be billed as an outpatient service and the patient was responsible to pay approximately $730 out of pocket the day of the procedure.

This employer is part of the Alliance’s QualityPath program, and after many inquiries from the patient, (who had to decide whether or not to do the procedure,) the doctor informed them that an MRI could also provide sufficient imaging and would cost the patient nothing under their benefit plan. Inversely, an MRI means the employer would instead pay 100% for the more expensive imaging service.

As I was guiding the employer through this issue, I felt that if the patient had access to Advanced Primary Care we could have referred them to an independent Ambulatory Surgery Center (ASC) from the start – at a contracted rate of around $180.

This scenario reminds me that good primary care is at the core of our health care system and serves as the cornerstone of healthy communities. In a perfect world, primary care would be used first, most frequently, and would have built-in patient navigation.

Instead, primary care utilization has been on a sharp decline over the past few decades, so let’s dig into some of primary care’s biggest problems and how Advanced Primary Care begins to solve them.

Primary Care Problems

Consolidation

As we’ve covered in the past, consolidation remains the leading cause of the loss of independent primary care physicians and private practices; the percent of primary care physicians that worked for large health systems jumped from 28% to 44% between 2010 and 2016 alone.

Then, from 2016-2018, roughly 14,000 independent physicians left private practice to work in hospitals. (And because primary care practices rely heavily on fee-for-service payments, the pandemic has likely added fuel to the fire, exacerbating the rate of consolidation.)

We’ve also written how the health care landscape is shifting due to millennials taking up a larger share of the overall patient population; their unique and personalized needs aren’t being met within the current health system and their low primary care use reflects that.

Low or No Access

Because primary care practices are being consolidated or closed there’s a lower supply of primary care physicians, and their uneven geographic dispersal leads to an inadequate supply of appointments – especially for those that are last-minute. This also explains why emergency department utilization is steadily rising.

According to the Health Resources and Services Administration (HRSA), more than 80 million people live in what they consider a “Primary Care Shortage Area.” This designation essentially means the supply of primary care physicians does not meet the needs of the local population. (Their criteria is a based on a 3,500:1 ratio of patients per physician.)

Nearly 20% of the U.S. population resides in a health professional shortage area, which are dominated by rural counties.

Low Utilization

Despite the overwhelming importance of primary care, its utilization has been on a sharp decline; between 2008 and 2016, primary care visits dropped by almost 25%. And while spending on primary care services fell 6% between 2012 and 2016, it increased by 31% for specialty care across the same timespan.

Care avoidance could be attributed, in part, to the rise in high-deductible health plans that often require co-pays which serve as an effective barrier for patients seeking health care services. (Additionally, not having health insurance altogether certainly exacerbates care avoidance for patients.)

Fragmented Care

Not only is primary care being offered in less places and used less by patients, it’s also often organized in a way that prevents physicians from understanding and addressing the situational factors in patients’ lives. Previously, primary care physicians approached patient needs from a generalist standpoint; they addressed a broad variety of symptoms and focused on holistic care rather than seeing patients for individual health concerns.

However, today’s health care system offers more flexibility and financial opportunity within specialty care, which is partially why specialties within primary care (family medicine, internal medicine, general pediatrics, geriatrics, etc.) are growing in combination with other niche medicine specialties (sleep medicine, sports medicine, etc.).

Of course, each of these professions belong to a specific accreditation group and has its own professional organizations that further fragment primary care and add to complexity in health care.

This modern shift in primary care usage and structure is a problem because primary care is intended to establish the first line of defense against common chronic illness and facilitate solutions to complex issues that specialty care isn’t built to handle.

The Advanced Primary Care Solution

The fragmented, impersonal, and sometimes inaccessible primary care options wrought by the pandemic have highlighted our need for a new primary care solution – one that focuses on the whole person and one that places an emphasis on preventative care. Employers are ditching traditional care methods for Advanced Primary Care due to its unique benefits.

Deeper relationships

Advanced Primary Care creates long-standing, continual relationships with patients. Those trusted relationships reach patients in ways that specialized care can’t.

Physicians accumulate historical knowledge about patients over time – their work history, mental health history, and family life – which creates a better foundation to accurately diagnose health issues, recognize them earlier, and deploy the appropriate care mechanisms to help manage them.

Holistic Health Care

Advanced Primary Care treats the whole person – mind and body – and can identify and treat a broad spectrum of health concerns. This is key to preventative care; treating common chronic illnesses before they evolve into more serious (and costly) health issues.

On the other hand, this type of care allows physicians to address acute symptoms and solve complex problems or health issues for which there is no cure or ability to diagnose.

Care Coordination

In fee-for-service primary care, patients are often slotted into impersonal, 20-minute appointments. From there, the patient is sent to a series of specialists who, due to the nature of their profession, are each focused on a very specific diagnosis – there’s no “quarterback” combining diagnoses, comparing notes, and coordinating the care holistically.

Advanced Primary Care utilizes team-based primary care, where the primary care doctor serves as the quarterback and uses a team to coordinate their efforts.

Lower Costs

Advanced Primary Care ditches the fee-for-service payment model and measures success by a patient’s health status rather than the revenue generated from visits, tests, and procedures.

And by not simply treating acute symptoms and placing a larger focus on preventative health, physicians help patients become less likely to experience worsening symptoms and prevents more serious problems down the line.

Likewise, the need for costly specialty care becomes less likely as their issues are treated and managed by their primary care doctor.

Smarter Specialty Care Referrals

When a physician does have to refer a patient to a specialist, they can work with their team to make a high-value decision and help the patient navigate their in-network options.

For example, an advanced primary care clinic is more likely to refer patients who need an MRI to a free-standing clinic instead of a hospital, which can save hundreds (sometimes thousands) on a single test.

Improved Patient Access

When an employer utilizes an Advanced Primary Care clinic, monthly per-person fees replace the traditional fee-for-service model, and typically, patients’ co-pays are eliminated (or negligible). Removing that financial barrier drastically increases the patient’s utilization of high-quality care, and as a result, patient groups report higher levels of engagement and satisfaction.

Additionally, physicians spend more time with their patients and offer flexible (sometimes same-day) appointments. Not only are appointments flexible, more services are available to patients because physicians have more time to perform routine operations.

Lastly, because the clinic is typically near (or at) an employer’s worksite, the patient doesn’t need to commute to their appointment. Plus, most Advanced Primary Care clinics offer telehealth services.

Advanced Primary Care Clinics with The Alliance

Want to know more about Advanced Primary Care? Interested in learning how to create or join an Advanced Primary Care clinic for your employees? Reach out to our Business Development team by filling out this form!

Melina Kambitsi, Ph.D.

Melina Kambitsi, Ph.D.

SVP, Business Development and Strategic Marketing at The Alliance

Melina Kambitsi Ph.D. joined The Alliance in 2017 and leads the teams responsible for business development, client development, and strategic marketing. Dr. Kambitsi came from Network Health in Milwaukee and Menasha, Wis. where she was chief sales and strategy officer. In this role, she was responsible for sales and underwriting, strategic planning, product development and risk-based contract analytics. Earlier she was senior vice president of sales at Blue Cross Blue Shield in Honolulu, Hawaii and the vice president of sales, marketing, and product development at Blue Cross of Northeastern Pennsylvania. 

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