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Journal of Primary Health Care Journal of Primary Health Care Society
Journal of The Royal New Zealand College of General Practitioners
RESEARCH ARTICLE (Open Access)

Navigating payer heterogeneity in the United States: lessons for primary care

Winston Liaw 1 , Daniel McCorry 2 3 , Andrew Bazemore 1
+ Author Affiliations
- Author Affiliations

1 Robert Graham Center, Northwest, Washington, DC, USA

2 Georgetown University, Washington, DC, USA

3 Current address: McLeod Regional Medical Centre, Florence, SC, USA

Correspondence to: Winston Liaw, 1133 Connecticut Avenue, NW; Suite 1100, Washington, DC 20036, USA. Email: wliaw@aafp.org

Journal of Primary Health Care 9(3) 200-203 https://doi.org/10.1071/HC17024
Published: 15 August 2017

Journal Compilation © Royal New Zealand College of General Practitioners 2017.
This is an open access article licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Abstract

With most providers accepting private and public funding, the US exemplifies hybridization, which results in both systemic benefits and harms. While this practice stimulates innovation, encourages practices to be efficient, and increases choice, it has also been linked to gaps in patient safety and overtreatment. We propose three lessons from the US for navigating a public and private system: hybridization allows for innovation; hybridization leads to administrative complexity; and if the costs of participation outweigh the benefits, practices may undergo dehybridization.


References

[1]  Squires D, Anderson C. US Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries. Oct 2015. Commonwealth Fund: Issues in International Health Policy, Report No. 1819.

[2]  Organization for Economic Cooperation and Development. Health resources – Health spending – OECD Data. 2017. [cited 2017 March 20]. Available from: http://data.oecd.org/healthres/health-spending.htm

[3]  Organization for Economic Cooperation and Development. OECD Better Life Index. 2017 [cited 2017 March 20]. Available from: https://www.oecdbetterlifeindex.org/countries/united-states/

[4]  US Office of Personnel Management. Report to Congress on the Physicians’ Comparability Allowance Program. 2012. [cited 2017 March 19]. Available from: https://www.fedphy.org/v1/images/docs/2012%20PCA%20Report.pdf

[5]  Association of American Medical Colleges. Physician Specialty Data Book. 2012. [cited 2017 March 20]. Available from: https://www.aamc.org/download/313228/data/2012physicianspecialtydatabook.pdf

[6]  Boccuti C, Fields C, Casillas G, Hamel L. Primary Care Physicians Accepting Medicare: A Snapshot. The Henry J. Kaiser Family Foundation. 2015. [cited 2017 March 20]. Available from: http://kff.org/medicare/issue-brief/primary-care-physicians-accepting-medicare-a-snapshot/

[7]  Medical Group Management Association. MGMA Cost Survey: 2014 Report Based on 2013 Data. 2014. [cited 2017 March 21]. Available from: http://www.mgma.com/Libraries/Assets/Key-Findings-CostSurvey-FINAL.pdf?source

[8]  Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003; 138 288–98.
The implications of regional variations in Medicare spending. Part 2: health outcomes and satisfaction with care.Crossref | GoogleScholarGoogle Scholar |

[9]  Tsugawa Y, Jha AK, Newhouse JP, et al. Variation in physician spending and association with patient outcomes. JAMA Intern Med. 2017; 177 675–82.
Variation in physician spending and association with patient outcomes.Crossref | GoogleScholarGoogle Scholar |

[10]  Kanavos P, Ferrario A, Vandoros S, Anderson GF. Higher US branded drug prices and spending compared to other countries may stem partly from quick uptake of new drugs. Health Aff. 2013; 32 753–61.
Higher US branded drug prices and spending compared to other countries may stem partly from quick uptake of new drugs.Crossref | GoogleScholarGoogle Scholar |

[11]  Baker LC, Bundorf MK, Kessler DP. Vertical Integration: hospital ownership of physician practices is associated with higher prices and spending. Health Aff. 2014; 33 756–63.
Vertical Integration: hospital ownership of physician practices is associated with higher prices and spending.Crossref | GoogleScholarGoogle Scholar |

[12]  Kocher R, Sahni N. . Hospitals’ race to employ physicians – The logic behind a money-losing proposition. N Engl J Med. 2011; 364 1790–3.
Hospitals’ race to employ physicians – The logic behind a money-losing proposition.Crossref | GoogleScholarGoogle Scholar | 1:CAS:528:DC%2BC3MXlvFyqurg%3D&md5=c59e7cfc73c309dd9eac31a15266a400CAS |

[13]  Brownlee S. Overtreated. New York City, NY: Bloomsbury USA; 2008.

[14]  Baker M, Mayo J. High Volume, Big Dollars, Rising Tension. 2017. [cited 2017 April 12]. Available from: https://projects.seattletimes.com/2017/quantity-of-care/hospital/

[15]  Abelson J, Saltzman J, Kowalczyk L, Allen S. Clash in the Name of Care. 2015. [cited 2017 March 19]. Available from: https://apps.bostonglobe.com/spotlight/clash-in-the-name-of-care/story/

[16]  Bai G, Anderson GF. A more detailed understanding of factors associated with hospital profitability. Health Aff. 2016; 35 889–97.
A more detailed understanding of factors associated with hospital profitability.Crossref | GoogleScholarGoogle Scholar |

[17]  Joynt KE, Le ST, Orav EJ, Jha AK. Compensation of chief executive officers at nonprofit US hospitals. JAMA Intern Med. 2014; 174 61–7.

[18]  Kaiser Family Foundation. Hospitals by ownership type. 2016. [cited 2017 March 20]. Available from: http://kff.org/other/state-indicator/hospitals-by-ownership/

[19]  Health Resources and Services Administration. Summary of Program Requirements. 2017. [cited 2017 March 29]. Available from: https://www.bphc.hrsa.gov/programrequirements/summary.html

[20]  Han X, Luo Q, Ku L. Medicaid expansion and grant funding increases helped improve community health center capacity. Health Aff. 2017; 36 49–56.
Medicaid expansion and grant funding increases helped improve community health center capacity.Crossref | GoogleScholarGoogle Scholar |

[21]  Capital Link, Community Health Center Capital Fund. Financial and Operational Ratios and Trends of Community Health Centers, 2008–2011. 2013 July.

[22]  Centers for Medicare & Medicaid Services. Quality Payment Program Fact Sheet. 2016.

[23]  Blumenthal D, Davis K, Guterman S. Medicare at 50—origins and evolution. 2015. [cited 2017 March 20]. Available from: http://www.nejm.org/doi/full/10.1056/NEJMhpr1411701

[24]  Federal Register. Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule and Criteria for Physician-Focused Payment Models [Internet]. 2016. [cited 2017 March 20]. Available from: https://www.federalregister.gov/documents/2016/11/04/2016-25240/medicare-program-merit-based-incentive-payment-system-mips-and-alternative-payment-model-apm

[25]  Centers for Disease Control and Prevention. Quality Payment Program Executive Summary. 2016 [cited 2017 March 20]. Available from: https://qpp.cms.gov/docs/QPP_Executive_Summary_of_Final_Rule.pdf

[26]  Centers for Medicare & Medicaid Services. Innovation Models. 2017. [cited 2017 March 22]. Available from: https://innovation.cms.gov/initiatives/#views=models

[27]  Cuellar A, Helmchen LA, Gimm G, et al. The CareFirst patient-centered medical home program: cost and utilization effects in its first three years. J Gen Intern Med. 2016; 31 1382–8.
The CareFirst patient-centered medical home program: cost and utilization effects in its first three years.Crossref | GoogleScholarGoogle Scholar |

[28]  Afendulis CC, Hatfield LA, Landon BE, et al. Early impact of CareFirst’s patient-centered medical home with strong financial incentives. Health Aff. 2017; 36 468–75.
Early impact of CareFirst’s patient-centered medical home with strong financial incentives.Crossref | GoogleScholarGoogle Scholar |

[29]  Yong PL, Saunders RS, Olsen L. The healthcare imperative: lowering costs and improving outcomes: workshop series summary. (Washington, DC: National Academies Press; 2010). [cited 2017 March 22]. Available from: http://search.ebscohost.com/login.aspx?direct=true8scope=site8db=nlebk8db=nlabk8AN=414600

[30]  Smith MD, Institute of Medicine (U.S.), eds. Best care at lower cost: the path to continuously learning health care in America. Washington, DC: National Academies Press; 2012.

[31]  Himmelstein DU, Woolhandler S. Taking care of business: HMOs that spend more on administration deliver lower-quality care. Int J Health Serv. 2002; 32 657–67.
Taking care of business: HMOs that spend more on administration deliver lower-quality care.Crossref | GoogleScholarGoogle Scholar |

[32]  Casalino LP, Gans D, Weber R, et al. US physician practices spend more than $15.4 billion annually to report quality measures. Health Aff. 2016; 35 401–6.
US physician practices spend more than $15.4 billion annually to report quality measures.Crossref | GoogleScholarGoogle Scholar |

[33]  Higgins A, Veselovskiy G, McKown L. Provider performance measures in private and public programs: achieving meaningful alignment with flexibility to innovate. Health Aff. 2013; 32 1453–61.
Provider performance measures in private and public programs: achieving meaningful alignment with flexibility to innovate.Crossref | GoogleScholarGoogle Scholar |

[34]  Government Accounting Office. HHS Should Set Priorities and Comprehensively Plan Its Efforts to Better Align Health Quality Measures. 2016. [cited 2017 March 22]. Available from: http://www.gao.gov/assets/690/680433.pdf

[35]  Peikes D, Angling G, Taylor EF, et al. Evaluation of the Comprehensive Primary Care Initiative: Third Annual Report. 2016.

[36]  Rao SK, Kimball AB, Lehrhoff SR, et al. The impact of administrative burden on academic physicians: results of a hospital-wide physician survey. Acad Med. 2017; 92 237–43.
The impact of administrative burden on academic physicians: results of a hospital-wide physician survey.Crossref | GoogleScholarGoogle Scholar |

[37]  Liaw WR, Jetty A, Petterson SM, et al. Solo and small practices are a vital, diverse part of primary care. Ann Fam Med. 2016; 8 8–15.
Solo and small practices are a vital, diverse part of primary care.Crossref | GoogleScholarGoogle Scholar |

[38]  Eskew PM, Klink K. Direct primary care: practice distribution and cost across the nation. J Am Board Fam Med. 2015; 28 793–801.
Direct primary care: practice distribution and cost across the nation.Crossref | GoogleScholarGoogle Scholar |

[39]  Fernandopulle R. Learning to fly: building de novo medical home practices to improve experience, outcomes, and affordability. J Ambul Care Manage. 2013; 36 121–5.
Learning to fly: building de novo medical home practices to improve experience, outcomes, and affordability.Crossref | GoogleScholarGoogle Scholar |