‘Turn the system on its head’: Value-based payment offers benefits for rural patients, PCPs

As the demand for primary care physicians rises across the United States, people in rural areas are experiencing barriers to access that others do not — but a value-based payment system could help, an expert said.

John Gale, MS, a senior research associate for the Maine Rural Health Research Center, discussed how primary care could benefit from a new payment model at the National Rural Health Association’s annual conference.

“I will tell you upfront I don't think value-based payment is the end-all-be-all solution to our health problems,” he said. “It is layering a way of improving quality on top of the fee-for-service payment model, which we know is problematic.”

One of the issues with the current model, he said, is that it does not analyze how patients fare under the system. A value-based care model would ensure that providers’ base pay is “somewhat different and somewhat better” if they meet certain targets to improve health care outcomes.

“They’re rewarded — if it works well — for helping patients improve their health, reduce the effects and incidence of chronic disease and live healthier lives based on the best evidence that we have,” Gale said.

Quality reporting

To prepare for the transition to value-based care, Gale said that providers will need to begin implementing quality reporting in practice. The Maine Rural Health Research Center worked with rural health clinics to determine five quality measures based on National Quality Forum definitions that could be used when building a value-based system: controlling high blood pressure, tobacco use assessment and cessation intervention, childhood immunization status, hemoglobin A1c control and documentation of current medications.

Gale said these measures are consistent and “reasonably reportable by as many clinics as possible,” but advised attendees to choose quality measures that fit their practices.

“It’s time to get on board,” he said. “A lot of state Medicaid programs are requiring quality measures and quality metrics, especially if they are managed care plans. Some commercial payers [do]. Whether it’s required or not, I would just encourage [rural health clinics] to really figure that out. I know what work it is. I know how difficult it can be, but it’s important.”

‘We need to pay them better’

The benefits of primary care in rural communities are undeniable. A Harvard study showed that adding 10 new PCPs to a rural community led to improvements in mortality and general health that were two and a half times better than in communities with fewer PCPs.

PCPs are even more critical in rural areas because those communities rely on them to “pick up the slack when the specialty care system doesn’t work the way we want it to,” Gale said.

But even so, the role of primary care has declined in the past 40 years, with PCPs facing lower incomes and higher practice overheads. Gale compared PCPs to the schoolteachers of the health care system — overworked and underappreciated.

“We talk about how important they all are and we want to pat them on the back. On teacher’s day, we send cookies to the school, but do we pay them very well? Not really. Do we do anything to make their lives better?”

He also noted that, over time, the prestige of health care in the public’s eye has shifted from PCPs to specialists.

“I would argue that primary care providers don't have lowered prestige because they're paid less, but they're paid less because they have lower prestige in terms of our subjective valuation of what's important in health care,” Gale said. “I firmly believe that we've got to turn the system on its head, that we need to promote primary care. We need to pay them better.”