Jeff Chappell, M.D., is the Medical Director of the Wayne Community Health Center, a federally qualified health center located in Bicknell, Utah, the most remote health care delivery site in our state. Dr. Chappell has served in the Bicknell area for over 30 years and has a large geriatric panel. Over time, he had begun to experience a clear, disincentive need to see medically complex patients … the PA’s (physician assistants) would see lots of colds, sore throats and UTIs, and their numbers looked better – my numbers were lower.”

In 2018, Dr. Chappell’s practice started participating in an alternative payment model with Medicare that pays the clinic to focus on preventive care and deliver most care to Medicare patients in the family practice clinic setting. By investing in high quality care coordination and nursing contact with patients at risk for worsening health, the practice prevents unneeded hospital visits or expensive specialty services. These savings support payment to the health center for staff that helped Dr. Chappell and the PAs manage their Medicare patients with complex health needs more closely. The switch in focus to paying for prevention also enhanced Dr. Chappell’s experience of his leadership role as a highly-trained family physician to his system: “My value is as a resource to the mid-levels. In a few minutes of discussion [with the PA] I can avoid a $1,500 MRI or a $3,000 ER visit. My value to my organization has increased.”

What if all payers paid for primary care prevention and fostered value for the experience and broad scope of family medicine physicians leading their teams?

Background

Relative to other developed western nations, the United States underspends health care dollars in primary care. On average, the United States spends 5%-7% on primary care as a percentage of total health care spending compared to Organization for Economic Co-operation and Development (OECD) countries that average 14% spending. (Jabbarpour, et al., 2019)

Utah has historically benefitted from better health outcomes and lower than average healthcare costs compared to national averages but has been seeing rising costs in the past few years. The Kem Gardner institute reported in January 2019, “Utah’s health care expenditures are growing at one of the fastest rates in the country.” (Summers, 2019) Utah has also seen rising rates of preventable conditions like prediabetes that are now equal to nationwide rates. (Public Health Indicater Based Information System (IBIS), 2020)

Investment in delivery of primary health care will bend the curve. The National Academies of Science, Engineering, and Medicine (NASEM), arguably the most highly respected scientific body in the nation, published a report this summer (2021), “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” (McCauley, Meisnere, Robinson, & Phillips, Jr., 2021) The report says, “Primary care is the only component of health care where an increased supply is associated with better population health and more equitable outcome,” it argues for more funding, research, and development of the primary care workforce. Even though primary care provides 55% of ambulatory services in the US, it represents only 5% of total health care spending. (McCauley, Meisnere, Robinson, & Phillips, Jr., 2021) Despite the ability to manage the increasing numbers of patients with complex chronic conditions, family physicians are not reimbursed to outfit the kinds of offices and teams that proffer the best quality services. Practices like Dr. Chappell’s could do even more if private payers invested in prevention. Higher primary care payments from fee for service payers would “support our team care model and allow us to pay the wages that we need to pay to have this level of staff. We are competing with other local employers.”

The NASEM report shows that the work that family physicians do and how we are paid are getting attention at the highest levels. NASEM shares steps to advance primary care, for example, paying for teams of caregivers that deliver the long-term, high-quality outcomes our patients deserve, increasing access with an emphasis on telemedicine, and training a primary care workforce where they will practice (rural areas, underserved urban areas, and FQHCs like Wayne Community Health Center). The report also calls for health information technology systems that meet the interoperability needs of primary care, a much higher bar than the current design delivers. Primary care access is described as foundational to reaching the goals of equity and success for ALL Americans.

Utah’s Primary Care Spend

The NASEM report calls for a state-by-state measurement of primary care spending as a percentage of all health care spending — a task that has begun in Utah. Benchmarks will then be used to track the success of initiatives designed to increase the percent investment in preventive and primary care services. Last fall, the UAFP brought together multiple stakeholders and using national standards, developed our own Utah Primary Care Spending Report using 2018 and 2019 All Payer Claims Data collected by the Utah Department of Health Office of Health Care Statistics.

Using standardized methodology from the Maine Quality Forum and Medicaid, Medicare, and commercial claims data from Utah’s robust All Payer Claims Database, the Utah Department of Health Office of Health Care Statistics calculated the spending for Utah’s total, primary care and non-primary care health services for 2018 and 2019. The results show that Utah is only spending 6.5% of all health care dollars on primary care services rendered by primary care clinicians.