With the relentless demands placed on primary care teams, they are often left without the energy to deliver on what their name promises: care.
Working to complete problem lists, address gaps in care, prioritize a myriad of patient concerns and finish documentation robs our primary care teams of actually having a relationship with their patients. This relationship is at the heart of what truly matters. Primary care teams have historically been the relationship managers in the healthcare ecosystem, and without that service, the entire patient experience suffers.
This experience has led to far fewer medical students choosing primary care than are needed, and many current primary care physicians curtailing their practice, retiring early or leaving clinical medicine altogether. Amidst these challenges to the care team, as stand-alone entities, primary care practices lose significant dollars for health systems and private practices are struggling to survive.
We have taken action to address the challenges. At MaineHealth, we have invested in more wellness programs, provided additional call relief, looked for ways to offset demand with telehealth and rolled out ambient dictation. Health systems often view primary care as a front door. Insurance companies have used primary care to improve Medicare Advantage performance, largely through improving burden of illness scores. All of these measures can help, but ultimately they are only treating the symptoms of a far bigger disease.
Fee-for-service reimbursement is simply incompatible with the practice of primary care medicine. Continuing to compensate our primary care physicians and advanced practice providers in a transactional and episodic manner for managing longitudinal relationships and chronic conditions makes no sense. It probably did in an earlier era, when acute conditions dominated the primary care schedule, but not anymore.
In a well-intended effort to move from complete reliance on fee-for-service to more value-based payments, various arbitrary and artificial incentives have been layered on, which often feel like significant, additional work to the primary responsibility. This has only increased frustration and burnout for our already strained primary care teams.
Timid incrementalism is not going to cure this affliction. We need radical change.
Capitation is a far better payment model for primary care. It puts the primary care team back in control of managing the patient relationship and the patient’s unique needs. It puts control of the schedule and how work is accomplished back in the hands of the primary care team. It better aligns economic incentives with the interests of the patient, and it enables the primary care team to focus on caring — not box-checking.
To address this at MaineHealth, we launched Trellis Health, a fully capitated primary care practice. We also started converting one of our existing primary care practices into a synthetic capitated model (in other words, we are asking providers to behave as though they are capitated, even though we are getting paid fee-for-service in the background). It is still very early, but the results are promising. The patient feedback on Trellis has been remarkable. The care team has reported tremendous satisfaction, with the ability to innovate and simply do the right thing for the patient at every opportunity without the fear of running afoul of misaligned financial incentives.
We are not alone. Other health systems are trying similar experiments, and thousands of primary care physicians have left health systems and traditional private practices to practice direct primary care. What often began as concierge medicine is looking more and more like capitated practice. So much so, that many employers, large and small, are now offering a direct primary care benefit to their employees.
MaineHealth has discovered some interesting findings in our journey to capitated primary care, primarily that the world is deeply aligned around fee-for-service payments. Navigating the payment process and attribution with a very committed payer partner has proven difficult. Working through other regulatory hurdles and ERISA has been a challenge in a world rigidly affixed to traditional payment methods. We will need fresh thinking and regulatory relief to advance capitated primary care at scale.
In addition, a significantly different EHR is needed. The large, commonly used EHRs are not designed to deliver longitudinal, relationship-based care. They are far too transactional and lack the necessary features for chronic condition management. We need the EHR vendors to reconsider their products.
It is early. We still need to see the impact of capitated primary care on patient outcomes like safety, quality and experience, and overall cost of care. But if we create an environment where our primary care teams can once again become the relationship manager, find joy in practice and have the capacity to care — I am willing to make a large wager on the outcome.
Dr. Andy Mueller is CEO at MaineHealth, the region’s largest integrated health system, based in Portland.
