Effective healthcare is commonly broken down into four components known as the Quadruple Aim. More than one definition of the Quadruple Aim has been described, but my favorite includes quality and experience of patient care, patient population outcomes, costs of care, and staff satisfaction. Primary care providers play a critical role in positively impacting all four elements of the Quadruple Aim and ensuring the promise of value-based care – yet systemic challenges are threatening the very future of primary care delivery.
Training focus
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Most medical schools and residency training programs are closely tied to one or more hospitals. While this makes sense for access to patients, faculty, care experiences, and financial support of training, it skews the trainee experience toward patients of high acuity, inpatient care, and toward medical specialties. This is not a criticism of these programs since they must expose trainees to all specialties and get them comfortable recognizing and treating the sickest patients. But the unfortunate side effect is that training pushes trainees away from primary care and makes primary care seem less prestigious. In addition, it makes trainees more likely to enter hospital medicine instead of outpatient primary care where the need is most critical.
To reverse this trend, more time needs to be dedicated during training on outpatient primary care. Medicare is the largest payer of graduate medical education, so Medicare could require additional outpatient primary care training in residency to encourage Family and Internal Medicine trainees to enter outpatient primary care. Medicare could also incentivize these training programs with additional funding if outpatient primary care exposure is increased. Since specialist trainees are required to do a “transitional” or “preliminary” year prior to specialty training, requiring additional outpatient primary care exposure will help specialists understand and respect the work of outpatient primary care.
Narrow the pay gap
According to a Medical Group Management Association report on compensation data of more than 192,000 healthcare providers, there continues to be a sizable pay gap between compensation for primary care providers and specialists. Specialists train longer and there are fewer of them, so in some ways this makes sense. Again, this is not a criticism, just another disincentive for trainees to pursue and feel valued in primary care. The average medical student graduates with significant debt, so pay is a factor in career decision making. In a fee for service system, specialist visits are paid at a significantly higher rate than primary care, reinforcing the pay gap.
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Being at the bottom of the pay scale of doctors is a bitter pill for many primary care physicians. If perceived lifestyle was better or satisfaction from the work was greater, this might ease the bitterness, but this is not the case. Surveys show that primary care physicians are less satisfied with their work than their specialist counterparts, and work/life balance is a top complaint. One change that could improve satisfaction and work/life balance of the primary care physician is limiting the number of patients for whom a primary care physician is responsible, known as a panel. A 2022 article in the Journal of the American Medical Association showed primary care doctor panel sizes ranged from 400 to almost 3000. Even adjusting for the health of patients, this range is extreme. Medicare and private payers could limit panel sizes (once they are adjusted for patient health) with payment models that include these limits. Some argue that value-based care models do this, but increasing pay for care quality and outcomes does not always equate to smaller panels, especially in the employed physician model.
Align unaligned incentives
The push toward Value Based Care refocuses the approach on care, outcomes, and cost instead of number of visits. However, most primary care physicians still have very large patient panels and are rushing through patient visits in hopes of work/life balance. When doctors hear Value Based Care, they think it means more clicks in the Electronic Health Record and staying later for charting. Moreover, many physicians are still incentivized by relative value units, meaning visits and procedures, and not by patient care, outcomes, and cost.
Imagine being the physician in a group that has a risk arrangement, and your patients have the best health and quality metrics with significantly reduced healthcare costs. However, you half the number of visits to achieve this, so the physician who did twice as many visits but had terrible outcomes and high patient costs received more incentive pay. CMS has instituted rules to ensure a percentage of shared savings goes to providers, but the employer can still control panel size and base pay. Even when employers do incentivize doctors for value, there is a lag between performance measurement and pay to the employer which then filters it down to the doctor.
Much of the work needed to impact outcomes and cost happens between visits and is out of the doctor’s control. Between visit effective care includes resources like having a good Care Manager with bandwidth to do outreach, having Medical Assistants to follow up on needed tests and interventions, and having effective Disease Management Programs that support self-management. The employed physician usually has little to no control over whether these resources are available or effective. In addition to Medicare setting physician panel size maximums, staffing minimums could be set like the staffing ratios used for nurses in hospitals. Additional funding could be provided beyond risk adjustment to support Care Managers and outreach staff. These payments need to be made available as soon as resources begin, not two to three years later. Hopefully private payers would follow suit to remain competitive, at least in the Medicare Advantage market.
The future and the time factor
Time is the foundation of most primary care challenges. Interventions that preserve time for primary care doctors to see patients and supervise their care will improve care, outcomes, and satisfaction while lowering patient costs.
- Training programs should dedicate more time to primary care outside of the hospital, even for those planning to enter specialties.
- Physicians who provide care need time to be part of business decisions, especially resource allocation and risk arrangements. There are times when incentive programs fail because the agreed upon targets were unrealistic, mainly because physicians were not part of the decisions.
- The Value Based Care movement must incentivize all staff who provide care. This includes physicians, nurses, care managers, medical assistants, and all staff involved in care delivery, and rewards must include both recognition and additional pay. Tracking quality, outcomes, and cost metrics and showing this performance over time to all staff will help connect them to the Quadruple Aim and show whether efforts are making the desired impact on patients.
- Alternate models of care like Direct Primary Care that can reduce the number of patients per primary care doctor and staff member to allow a better doctor-patient-staff relationship may make primary care a more desirable field.
Finally, the esteem of primary care must be restored by reminding all doctors and patients that primary care providers are best positioned to make meaningful impacts on patients. As an industry, we must ensure that primary care doctors are regarded and adequately compensated to hit the mark on satisfaction because they are critical to addressing the most significant challenges in healthcare.
Photo: aldomurillo, Getty Images
Dr. Auren Weinberg is the Chief Medical Officer at Veradigm. He completed his residency at Children's Hospital of Philadelphia where he served as Chief Resident. He started a private practice shortly after leaving residency, which was the first in the area to embed mental health care, nutrition counseling, and exercise classes for patients. Dr. Weinberg co-founded an Independent Physicians Association which focused on supporting privately owned practices in achieving the quadruple aim of better outcomes, better care, lower cost, and higher staff satisfaction.
