- The COVID-19 pandemic has further highlighted the shortcomings of the fee-for-service payment system, healthcare industry stakeholders said during a recent panel discussion.
- Initiatives to reform the payment system and improve the value of care delivery should focus on making care more equitable as well.
- Primary care should be an area of emphasis in healthcare improvement efforts.
Even amid an all-encompassing focus on controlling the COVID-19 pandemic, the Biden administration should be considering broader policy changes that can enhance the value and equity of healthcare, a panel of industry experts said recently.
At a Jan. 26 event that explored ways for the new administration to improve the healthcare payment and delivery system, much of the discussion centered on making the system more effective both generally and for underserved demographics specifically.
Deficiencies in the current system
The discussion, hosted by The Commonwealth Fund, was based in part on a task force report released late last year that includes recommendations for transforming U.S. healthcare.
David Blumenthal, MD, president of The Commonwealth Fund, noted the fee-for-service system has faltered as a reliable revenue source during the pandemic, when patients have been reluctant to visit healthcare facilities and elective procedures have been periodically prohibited.
Mark McClellan, MD, PhD, who was FDA commissioner and later CMS administrator during the George W. Bush administration, described COVID-19 as “a wake-up call” for healthcare financing.
Specifically, the pandemic has underscored the need “to move to a different mechanism of financing our healthcare … rather than trying to just keep your doors open because utilization is down, and having to lay off staff,” said McClellan, a professor and the director of the Robert J. Margolis Center for Health Policy at Duke University.
A revamped healthcare payment and delivery model would have allowed the U.S. to better respond to the pandemic and would boost population health more broadly, panelists said. Such a model would look to “move care upstream with community health workers, with assistance from apps and digital technologies to help identify people who have risk factors and meet them where they are and figuring out what’s the best way to address them — moving beyond traditional medical services to address social needs,” McClellan added.
“All of that is really hard to do without moving away from traditional fee-for-service.”
Improving healthcare value for disadvantaged communities
Promoting value-oriented care and population health management is necessary but not sufficient, panelists said. Healthcare payment reform also should include accountability for equity.
“If we had more explicit measures that were built in, and if we had designed our value-based care reforms and the payment reforms to support them, just imagine how much more progress we could make,” McClellan said.
Measures should be used to assess aspects of healthcare where inequities are evident, he said. Such measures could apply to areas as distinct as COVID-19 vaccination rates, maternal mortality rates, cardiovascular outcomes and outcomes in care of substance-use disorders.
Karen Dale, RN, market president for AmeriHealth Caritas DC, a Medicaid managed care plan serving the nation’s capital, sees an opportunity to institute those types of measures for providers.
Her organization already has process-related incentives to encourage providers to address social determinants of health. For instance, providers have financial incentives to refer patients to the health plan for issues such as food insecurity.
It wouldn’t be a stretch for health plans to then give providers data highlighting any disparities in performance on those processes across categories such as race, ethnicity and language, Dale said.
“And if we provide the tailored technical assistance — which we do today on the other [value-based payment] measures — then they're now getting the support they need, the coaching and the ability to see how they're doing with creating change,” she said.
As part of such initiatives, panelists said, health plans also should work to reduce administrative burden, giving providers more time to make meaningful process changes. The Commonwealth Fund report recommends that Congress direct federal agencies to:
- Create a uniform, national, standardized billing system for all private and public payers
- Establish a set of core quality and equity metrics that can be used by all payers and clinicians
Zeroing in on primary care
To make healthcare more equitable, panelists said, it’s vital to improve the representation of minorities in medicine. That priority especially should apply to primary care, which can serve as the gateway into the healthcare system for prospective patients.
Making primary care a more lucrative career path relative to other specialties is an important step, panelists said.
“My mantra has always been that we can significantly increase what we reimburse or how we compensate primary care providers if they are doing all the right things to help improve quality for the patients that they serve and helping to manage the health of populations,” said Julian Harris, MD, a partner in the healthcare services investment team with Deerfield Management.
“Some of the things we need to do to make primary care more attractive more broadly will also help to actually diversify who ends up selecting primary care as their chosen profession.”
New payment models should support a team approach to primary care, along with longitudinal data tracking of patients and virtual-care options, McClellan said.
“It's not just increasing the payment for primary care providers but changing the form — making it more about a partial or even fully direct-contracted model, maybe with some accountability for overall costs,” McClellan said.