Lawmakers push for payment reform for primary care

Photo: John Baggaley/Getty Images

U.S. Senators Sheldon Whitehouse (D-RI) and Dr. Bill Cassidy (R-LA) have introduced legislation, the Pay PCPs Act, to better support and improve pay for high-quality primary care providers by reforming how they get paid through Medicare.

The lawmakers also released a Request for Information so the healthcare industry could weigh in on the best methods for achieving this.

Whitehouse and Cassidy called primary care a "critical part" of the healthcare equation, citing evidence showing that primary care improves outcomes for patients and drives down healthcare costs.

"There are many issues to address in primary care, and we look forward to receiving feedback on our legislation through the RFI to make a meaningful difference to healthcare success," they said in a joint statement.

WHAT'S THE IMPACT?

The senators also referenced statistics showing that, while the U.S. spends more on healthcare as a share of its GDP than other countries, life expectancy is below that of peer nations – and still falling. Three in 10 people report not having a usual source of primary care, and the U.S. will likely face a shortage of between 17,000 and 45,000 primary care doctors over the next decade.

The legislation aims to head off this expensive primary care shortage, while also improving Medicare beneficiaries' health outcomes and helping primary care providers lower health costs, the senators said.

The Pay PCPs Act would task the Centers for Medicare and Medicaid Services with establishing hybrid payments to reward primary care providers who provide the best care to their patients – care that reduces patients' emergency visits, hospitalizations, excess specialist services and other big cost drivers – and reward patients with better health outcomes.

The bill would provide Medicare beneficiaries with reduced cost-sharing for certain primary care activities and services, and would also create a new technical advisory committee to help CMS more accurately determine fee schedule rates.

The senators' accompanying RFI provides stakeholders the opportunity to comment on the bill. 

THE LARGER TREND

The primary care workforce is struggling to meet the population's demands, and doesn't receive enough investment, despite diminishing supply and growing demand, a March report found.

Despite a rapidly aging population with higher levels of chronic disease, the number of primary care physicians per person has decreased, the report found. The share of all clinicians practicing primary care – including nurse practitioners and physician assistants – stagnated at around 28% between 2016 and 2021, and PCPs declined from 68.4 to 67.2 per 100,000 people between 2012 and 2021.

According to the report, demand for PCPs will only increase with time. The National Institute of Health estimates that the number of people 50 or older with at least one chronic disease will increase by 99.5%, from 72 million in 2020 to 143 million by 2050.

FAIR Health's 2023 analysis of primary care data showed people are shifting away from traditional primary care providers, with about three in 10 foregoing primary care altogether between 2016 and 2022.

That number, though, ranged from a high of 43% in Tennessee to a low of 16% in Massachusetts, suggesting significant regional variations. Of the providers who performed primary care services in that time, 56% were physicians, while 44% were nonphysicians.

Nurse practitioners constituted the largest share of primary care providers by specialty (27%), followed by family medicine physicians (20%), internal medicine physicians (18%) and physician assistants (15%). Smaller percentages were accounted for by pediatricians, obstetricians/gynecologists and others.
 

Jeff Lagasse is editor of Healthcare Finance News.
Email: jlagasse@himss.org
Healthcare Finance News is a HIMSS Media publication.