Advanced primary care can help employers control costs and coordinate care, but many employers do not know how to start and scale such a solution in their employer-sponsored health plans, according to a report from the Duke-Margolis Center.
Primary care is an essential part of preventing high-cost health conditions among employees. However, only slightly more than half of all privately insured individuals have a regular source of primary care, the report noted.
Additionally, fee-for-service care remains predominant among care delivery models, stymieing care coordination and, by extension, access to preventive care services.
“Advanced primary care is patient-centered care that’s coordinated across providers and settings, most likely using a team-based approach. And at the heart of it, it’s really focused on outcomes and results rather than revenues,” Elizabeth Fowler, deputy administrator and director of the Center for Medicare and Medicaid Innovation, explained in a webinar discussion of the report.
The Duke-Margolis Center investigated how advanced primary care could help employers reduce costs as well as improve health equity, care coordination, and patient outcomes.
Employers and public payer programs have tested many strategies over the years in order to bring down costs, including wellness programming, onsite clinics, virtual care, and centers of excellence. While many of these strategies saw some success, each had its pitfalls.
The report argued that employers can use the lessons learned from these diverse strategies to build an advanced primary care model that offers comprehensive, coordinated care and greater health equity.
“As employers increasingly focus on more diverse, equitable, and inclusive workplaces, there’s also a question about how they are going to use their health plans to drive not just equal benefits but equitable benefits—that may mean programs that allow employees to tailor their healthcare and navigate the healthcare system in a way that works for them,” Elizabeth Carpenter, head of advisory services at Avalere, shared in the webinar.
“Everything about the advanced primary care model suggests that there’s opportunity there.”
Carpenter, Fowler, and other experts may not have to work hard to convince employers that this approach is worthwhile. Slightly more than half of all large employers have indicated that they plan to use an advanced primary care strategy in some manner in the next year, according to the report.
However, employers face challenges in implementing these strategies, which may prevent the model from reaching a broad enough scale to produce substantial results.
“There are a growing number of examples around the country—some in the commercial side, more probably in Medicare Advantage and some of the advanced Medicare ACOs and some even in Medicaid programs—that are treating somewhat different populations but have already made this big step at some scale to this different model of care delivery,” Mark McClellan, director of the Duke-Margolis Center for Health Policy, said in the webinar.
“There isn’t yet what we’d like to see in terms of a critical mass to do this.”
The report identified five strategies that employers can use to venture into advanced primary care.
First, employers need to gain awareness of the market’s openness to change. Not all providers will be open to adopting the advanced primary care model. Employers must isolate the regions in which they find willing and able provider partners by looking for areas in which these models have already seen success.
Second, employers can build their advanced primary care model using easily scalable and standard approaches. Performance metrics, data exchange, and other supports are primed for a standardized approach.
Third, as with any shift in healthcare, innovation and partnerships are key. Some employers will be able to develop their own tools and analytics internally, but for employers who do not have the capacity to do so, identifying strong partners will be crucial.
Fourth, employers will need to ensure that employees are aware of how to utilize the advanced primary care model. Otherwise, they will never see the benefits of this strategy. Employers have to design a strategy for employee engagement.
Finally, since so much of the industry’s current understanding of the advanced primary care model comes from public payer programs, employer-sponsored health plans will benefit from collaborating with public payer entities. The researchers suggested joining a state multi-payer initiative, an approach that has been used to further value-based care initiatives in the past.
Additionally, the report identified four outcomes that employers can use to measure success.
Employers should look for accountable provider reimbursement that supports care transformation including capitated payment model adoption and infrastructure changes that emphasize preventive care.
Metrics that would assess whether care is convenient, timely, and simple for the members include access to both in-person and virtual care and better awareness of social determinants of health.
Employers can assess whether health outcome metrics have improved and the presence of condition-specific outcome measures in order to track whether the model is pursuing improved health outcomes and overall health.
Lastly, identifying a slower rate of cost growth and lower out-of-pocket healthcare spending will tell employers whether they are pursuing affordable and equitable care in their new model.
Rising healthcare costs have become unbearable for employers. Nearly nine in ten employers (87 percent) said that healthcare spending would be unsustainable in the next five to ten years, according to a Kaiser Family Foundation survey.
In particular, employers expect that mental health and chronic disease management needs will drive healthcare spending in 2022. Most employer respondents in the Business Group on Health’s 2022 large employer survey stated that they expected to see higher claims for medical services and long-term mental healthcare in 2022.
As employers search for long-term answers, advanced primary care may help stem escalating healthcare costs.