8 Steps to Implementing Advanced Primary Care
September 29th, 2022
Robust primary care is essential to the ability to transform health care in the U.S. Adults who regularly see a primary care physician have 33% lower health care costs and 19% lower odds of dying prematurely than those who see only a specialist. Additionally, every $1 increase in primary care spending produces $13 in savings, and if everyone used a primary care provider as the principal source of care, the U.S. could save $67 billion annually. As part of its pioneering work to define and promote the adoption of advanced primary care, PBGH’s California Quality Collaborative’s primary care improvement efforts led to almost 50,000 hospital bed days avoided, emergency room utilization sharply reduced and total savings of about $186 million in California.
Despite these outsized benefits, misaligned financial incentives, chronic under-investment, infrastructure barriers and a lack of integration with other elements of care — including behavioral health — continue to severely constrain primary care’s impact on the health of American workers and families.
That’s why PBGH is spearheading the development and implementation of ‘advanced primary care.’ Our approach emphasizes bolstering existing primary care to treat more health needs within the primary care practice and refer to only the highest quality specialists when appropriate, increase patient access, integrate behavioral health screening and management, improve care coordination and expand tools and systems that can support population-based care for patients.
A new report highlights eight key takeaways from a discussion with representatives of large employers and public health care purchasers based on their experiences implementing advanced primary care.
1. Changing payment is crucial
Care delivery change requires payment change. Capitated payment – with some flexible incentives – will enable practices to meet clinical and health goals. A model predominantly based on fee-for-service or volume-based payment is antithetical to the core tenants of advanced primary care. Read about how Washington State Health Care Authority is tackling primary care payment reform.
2. Update operating systems or find new ones
Health plan operations are built to pay fee-for-service and are very challenged to pay differently. Whole Foods took a bold approach by creating its own system rather than relying on health plans. Learn how.
3. Align around standardized measures
Purchasers should align to adopt a set of priority standardized measures by which to assess care and service. Through a multistakeholder consensus process, PBGH has selected a set of evidence-based clinical and outcome measures that collectively signal and reflect the desired outcomes of advanced primary care. See how Covered California is using these measures.
4. Redefine your investment priorities with payers and partners
The cost benefits of advanced primary care must be emphasized in negotiations with payers. But this does not mean paying more overall. The expectation is that total cost remains flat. Read about eBay’s perspective on investment in primary care.
5. Hone your message
Despite studies that have repeatedly shown how strengthening primary care can improve outcomes, reduce costs, enhance the patient and provider experience and improve health equity, those benefits are not always apparent to health plans, organizational leadership or even employees. CalPERS’s experience with mandatory primary care provider selection offers important lessons for other purchasers.
6. Think nationally and act regionally
Employers should take the lead in their communities and regions when it comes to enlisting like-minded purchasers in support of advanced primary care. This can include national employers with even a modest presence in the community. Read about The Boeing Company’s approach to this.
7. Identify a trusted authority that can help foster standardization and adoption
A neutral convener can play an important role in helping achieve consensus around common measures and definitions, and likewise serve as a focal point for payer, purchaser and provider discussions regarding implementation and payment challenges. Washington and California offer examples of how regional multistakeholder groups play a key and needed role in implementing national change.
8. Just do it
There is a tendency in health care to focus for too long on discussion and planning without pursuing or engaging in the practical or implementing change. It’s important to start the process of implementing advanced primary care. Read about steps The Wonderful Company is taking on behalf of its employees.
Employers Are Driving Innovations in Primary Care
February 24th, 2022
Employers know that primary care is essential for a healthy workforce and employees’ access to a high-value health care system. Evidence shows that improved primary care translates into healthier, happier patients and lower overall health care costs:
- U.S. adults who regularly see a primary care physician have 33% lower health care costs and 19% lower odds of dying prematurely than those who see only a specialist.
- The U.S. could save $67 billion each year if everyone used a primary care provider as their principal source of care.
- Every $1 increase in primary care spending produces $13 in savings.
Large employers are increasingly working with existing direct contracting partners and new vendors to enhance primary care, which includes the integration of behavioral health care among other things.
Four approaches reflect the ways large employers are currently working to improve primary care for their employees:
1. Developing a common set of advanced primary care standards to enable employers to speak with one voice. The development of the advanced primary care model is as much about streamlining the practice of primary care as it is about improving outcomes, enhancing the patient experience and reducing costs. Simple and consistent definitions of optimized primary care across all payer contracts would reduce, if not eliminate, the bewildering array of sometimes-conflicting value-based requirements contained in multiple payer contracts. That fact could mitigate clinician burnout by easing the administrative burden while allowing more time for the actual provision of care.
It is, therefore, essential that employers send a common signal to the market. For that reason, PBGH worked last year with members through an employer-led initiative to create a Common Purchasing Agreement. This enables employers to communicate their priorities and engage payers and providers to make changes to care delivery and payment that meet their priorities.
2. Integrating behavioral health into primary care. Behavioral health integration is an integral part of advanced primary care and a key feature of the Common Purchasing Agreement mentioned above. Nearly seven in 10 patients in need of behavioral health treatment seek care via primary care practices. Evidence shows that integrating behavioral health services into primary care can enhance mental health care access and coordination, improve outcomes and reduce costs. Behavioral health integration, a feature of advanced primary care, allows patients to access mental health care screening, services and treatments through their primary care provider, just like any other specialty care. Employers are highly focused on these efforts, which address an issue that has reached crisis level in this country.
3. Requiring members to choose a primary care provider. Patients benefit from an ongoing primary care relationship with improved care access, greater care continuity and better health outcomes. This in turn reduces employee absenteeism, enhances productivity and lowers overall health care spending for employers. That’s why some employers are taking additional steps to ensure their members are connected to a primary care practice. Methods to do so include mandating that members select a primary care physician and/or team, using benefit design incentives to support the use of primary care over specialty care (when appropriate) and increase education about the importance of having a primary care provider.
4. Helping employees identify and use only the highest quality primary care providers. Using quality measures, such as the PBGH advanced primary care measure set, purchasers and health plans can identify high-performing provider practices. Once those practices have been identified, employers can drive plan members to providers able to demonstrate that they provide high-value care, or the providers identified can be rewarded for their superior performance.
Employers understand better than anyone that the quality of health care their employees can access has a profound impact on their work, lives and productivity. The last few years working through the unprecedented challenges brought about by the pandemic have only reinforced the importance of continuing to strive to reduce disparities in health care and increase access to high-quality and more affordable services.
The same principles of aligning payment incentives and employer voices in primary care provides a model for other care verticals, including maternity care, oncology and musculoskeletal disorders, to name a few. Employers will increasingly work with organizations able to help design and implement the standards necessary to ensure they’re buying the best health care services available for the millions of employees, consumers and families throughout the nation who rely on their employers for health benefits.
A Little Less Conversation, A Little More Action
November 18th, 2021
“We’ve talked long enough. It’s long past time to take action. Our goal is to foster meaningful, widespread change in health care within three years.” – Elizabeth Mitchell, CEO of PBGH
Large employers and health care purchasers have increasingly begun to take actionable steps to strengthen primary care, the critical precursor to a high-quality, cost-effective health care system.
Extensive research and pilot programs over multiple decades have repeatedly shown that a robust, integrated and accountable approach to primary care—characteristics collectively defined as advanced primary care—can significantly reduce overall health care costs while improving patient outcomes and experience.
Efforts by the nation’s largest employers to transform health care reached a major inflection point this fall when nearly 200 employers gathered with their health plans and health care provider partners from across the country at the PBGH Primary Care Payment Reform Summit. The event created a platform during which employers collectively conveyed their readiness to implement tools designed to induce payers and providers to deliver the same levels of value and quality they routinely expect from other vendors, and their commitment to investing in advanced primary care with integrated behavioral health and a commitment to equity.
Here are 5 key takeaways from the summit about what large employers and purchasers want from their health care vendors:
1. Employers have long accepted poor value for their health care dollars in ways they never would for any other product or service.
Employer-sponsored health plans routinely pay 200-600% times the rates charged to Medicare and effectively provide most of the profit margin for both health plans and providers without visibility into the quality of care their employees receive. Years of provider and insurer consolidation means even the largest employers tend to lack enough employees in any market to exercise adequate leverage to compel greater transparency and accountability.
2. Purchasers feel they’ve given health care stakeholders ample opportunity to reform the care payment and delivery system.
Industry efforts to transform health care have largely failed due to a lack of shared alignment and goals, a fragmented care system, the continued reliance on fee-for-service and the industry’s resistance to change. Now purchasers are collectively taking action to improve value and quality. Read more about what purchasers are doing right now in the full report.
3. Point solutions are making fragmentation worse and threaten to further increase costs.
To better serve members and reduce costs, many employers are turning to third-party vendors for singular, or point, solutions that address specific care functions or services. While many of these new, often digital capabilities are useful in isolation, they’re collectively making worse the already substantial problem of fragmentation and complexity across the care continuum. Many are also backed by venture capital firms seeking maximum profit potential and hence have little incentive to reduce the overall cost of care.
4. Integrating behavioral health into primary care is vital.
Mental health has been a top priority for employers for many years, and the urgency has only increased during the pandemic. Mental health care is hard to access and of variable quality, but mental health care is primary care and needs to be part of advanced primary care practice. Evidence shows that integrating behavioral health services into primary care can enhance mental health care access and coordination, improve outcomes and reduce overall costs.
5. Achieving lasting change will require that purchasers pull together to achieve critical mass.
Employers today have an opportunity to leverage their immense buying power to promote fundamental change in how health care is accessed, purchased and delivered. But even the biggest purchasers in the country lack leverage in most markets. Change on this scale cannot occur unless purchasers work in concert in every region in the country. Only by collectively setting high standards and demanding change can employers hope to overcome the existing system’s enormous inertia.
The Time to Act is Now
Employers want to buy the best health care benefits on behalf of their employees. But they understand better than most how costly and dysfunctional our health care system has become. They provide the critical lifeline of health insurance to about half of Americans, and they grapple every day with ways to keep coverage affordable.
Read the full report A Little Less Conversation, A Little More Action: 5 Takeaways from the PBGH Primary Care Payment Reform Summit here.
See more about the PBGH Primary Care Payment Reform Summit here.
PBGH Chair Honored as Top Health Care Innovator
August 26th, 2020
Lisa Woods, Pacific Business Group on Health (PBGH) board chair, was honored August 24 by Modern Healthcare Magazine as one of the Top 25 Innovators for 2020.
Woods serves as Senior Director of U.S. Strategy and Benefits Design for Walmart Inc., the country’s largest employer. Her responsibilities include ensuring that 1.5 million Walmart associates and their dependents have access to comprehensive, affordable health benefits.
“We’re thrilled but not surprised that Lisa’s long-time efforts have been recognized,” said Elizabeth Mitchell, president and chief executive officer of PBGH. “Her track record of developing creative, comprehensive and effective solutions to extremely difficult problems, coupled with her genuine commitment to the health and welfare of Walmart associates, make her uniquely qualified for this honor.”
“All of us at the Pacific Business Group on Health feel fortunate to have the benefit of her experience, insight and judgment as we work to help America’s largest employers and health care purchasers reduce soaring costs without compromising quality.”|
Woods began her career with Walmart more than 30 years ago as a medical claims processer. Her duties steadily evolved and expanded to include claims auditor, architect of the retail giant’s claims processing system, and manager of the company’s research and development, fraud and abuse and customer service teams. In her current role, Woods leads the Walmart’s strategic benefit design efforts. Among her most significant innovations:
- Centers of Excellence: Walmart created a Centers of Excellence program that pays all expenses for employees and their families to have surgery at approved medical centers for transplant, heart or spinal surgery, or knee and hip replacement. The program’s results have been impressive: Walmart’s per- patient cost for joint replacements was more than $4,000 less than at non-COE facilities; one-fifth of patients avoided unnecessary procedures; all patients treated at COEs had three times fewer hospital readmissions and collectively were 70% less likely to be readmitted to the hospital. The program serves as a model which PBGH is working to replicate for the benefit of other employers nationwide.
- Increasing Access to Affordable Care: At the start of 2020, Walmart kicked off four health care benefit pilot programs aimed at expanding access to more affordable and effective health care services and lowering costs for employees and the company. The four pilots include a referral service using data analytics to steer patients to the highest-performing physicians, a free concierge service, $4 telemedicine visits and technology that enables patients to easily locate doctors with a history of providing high-quality care.
- Expanding Direct Contracting: Walmart has launched insurance products through direct contracting relationships with the nation’s top hospitals and health systems. By focusing on quality and making sure patients are directed to the most appropriate care and provider within a network, the program has saved money for the company and its employees.
Modern Healthcare noted that this year’s Top 25 Innovators championed scalable solutions being used to reshape health care in ways both big and small. While many of this year’s honorees pushed solutions that directly address the coronavirus epidemic, the magazine said, their innovations and approaches to problem-solving will be beneficial long after the crisis is over.
The full list of innovators and profiles of the winners are featured on Modern Healthcare’s site.