Driving Improvements in Primary Care Payments

A Q&A with Rishi Manchanda, Primary Care Payment Model Work Group Member

The LAN recently spoke with Rishi Manchanda, chief medical officer of The Wonderful Company and member of the PCPM Work Group, to offer a purchaser perspective on how cultivating primary care delivery best practices can drive value and improve health outcomes. In this interview, Manchanda also shares his vision for ensuring providers are empowered to make smart decisions when it comes to writing prescriptions, making referrals, and ordering tests. This interview is the second in a short series that explores the role primary care payment can play in health care payment reform efforts:

My hope is that PCPM work will help pave the path to achieving LAN goals by helping primary care providers and purchasers better define “value.” Among other efforts, this means enumerating the key functions that “best-in-class” care delivery models can use to drive better outcomes and value (e.g. demonstrated ability to consider cost, quality and value in clinical decision-making in the spirit of “choosing wisely.”) Then, we must all work to identify which of these key functions are already performed well in existing primary care practices so they can be optimized and brought to scale. Lastly, we have to be candid about those value-driving functions that are currently missing in primary care practice and provide the necessary incentives and support to bring those to scale. For instance, many private companies now invest in coaching, navigation, risk analytics, and disease management services from third-party vendors, many of whom essentially try to measure, track and improve employees’ mastery of key self-management skills like healthy eating, coping skills, and problem-solving skills to prevent or control disease. They’re buying into the value proposition that quantifiable improvements in self-management skills can yield better outcomes at better value. Many current primary care practices aren’t configured to delivery on that value proposition. Perhaps through this PCPM work, we can spur primary care practices to consider how to leverage the relationships and continuity of care they’ve established with patients to demonstrate how they can measurably improve patients’ mastery of self-management skills.

A priority is to help control total costs of care by reducing pharmaceutical spending. Beyond reforms such as reference-based pricing, one way to do this is by supporting primary care and specialty providers to understand and make wiser choices when it comes to prescriptions (e.g. avoiding unnecessary prescriptions, making the choice of low-cost therapeutic equivalents the default, etc). Primary care reform efforts often include efforts to influence and optimize referral, lab, and radiology practices. We need to consider how payment and care delivery reforms can support providers to be good stewards of medicines as well.

We can’t expect to find a path to better value using volume-based payment models. Different payment models allow us to better understand and design systems that generate better value. I’ve seen first-hand how perverse fee-for-service incentives constrain physician’s ability to provide care in ways that make sense. For instance, I’ve seen primary care practices achieve the Quadruple Aim by applying QI (quality improvement) methods that enable the clinic, along with community partners, to identify and address “upstream” drivers of disease and overutilization among the social determinants of health. Our current volume-based payment models don’t support care redesign experiments like these and others that offer glimpses of better value. That’s why moving to different payment models is so important.