Listen up, Washington: Focus on primary care

  | December 12, 2016

When it comes to healthcare policy, this is a time of both turmoil and opportunity. It's also a time for the stakeholders to speak. As Washington mulls the status of the Affordable Care Act and priorities for the future, athenaInsight asked physicians and healthcare executives to share their advice.

Here is the first installment from Michael Middleton, M.D.


On a recent trip to Washington, D.C., I heard plenty of buzz about healthcare, most of it around two topics: the ACA (what is going to happen to it now) and MACRA (its rollout and impact). Sometimes it seems like people forget we had a healthcare crisis long before these acronyms came on the scene.

Healthcare makes up roughly 40 percent of our nation's mandatory spending. For decades, costs have been going up without bringing outcomes and satisfaction with them. Now, add another negative factor to the equation — physician burnout.

There are lots of smart people committed to making healthcare work better. But their efforts must center on the system's biggest hope and need: strong primary care.

Most would agree that good primary care saves money, improves outcomes, and increases patient satisfaction. Therefore, any solutions put forth must promote and protect good primary care while simultaneously addressing the factors contributing to physician burnout.

In the past few years, this hasn't happened. In fact, as an independent primary care provider, I see three ways current trends and regulations have been making things worse:

  • Increasing the cost of delivering healthcare by increasing the administrative burden.
  • Preventing needed innovation because the focus and resources of the industry are occupied with meeting the ever-changing regulations.
  • Disproportionately affecting small practices, which lack the administrative infrastructure to address these regulations in ways required. This leads smaller practices to feel forced to consolidate, further “institutionalizing" the doctor-patient relationship.

Here's how the movers and shakers in Washington can improve healthcare with primary care in mind:

  • Value-based reimbursements: Move forward with them, but involve practicing, independent primary care physicians in these strategies. Increasing the financial incentives for wellness and cost reduction is our best attempt to simultaneously reduce costs and improve outcomes. This is already happening with shared savings programs and patient-centered medical homes. We can't stop the progress now.
  • Transparency of costs: As primary care physicians, we already help patients navigate their healthcare options, from specialists to ancillary services. By knowing the costs involved, we can also guide patients to high-quality/lower cost services.
  • Simpler interoperability: Since primary care physicians provide the medical home for patients, we bare most of the burden of accumulating and assimilating all patient records. And the less various healthcare entities are able to talk to one another, the more “translating" and transcribing we must do. This is another administratively taxing, non-reimbursed burden of primary care.

We have an opportunity now to create meaningful change — and I hope voices from those serving patients in primary care are seen as vital contributors to the discussion.

Otherwise, we might be headed for more of the same.

Michael Middleton, M.D., is a pediatrician in Orlando, Florida.


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Thanks for your article, if you’d entertain follow-up questions, I would ask:

To what degree do value-based purchasing methodologies in MACRA and other payer systems add to the administrative burden for PCPs and/or what are some examples of more PCP-centric VBP strategies that you would promote?

You say: By knowing the costs involved, we can also guide patients to high-quality/lower cost services
What would you ideally see as a mechanism to help guide patients that they would not have through payers? Do you see an alterative model related to navigating physician networks and cost transparency than already exists in the market?

Ashley Odom

Complex regulations in general add to the administrative burden, and this disproportionately affects small independent practices, many of which are primary care. A good example of how value-based payment reforms specifically increase the administrative burden on a practice is PCMH certification. See here:


Many of those who were already best serving patients with a medical home model have been least able to achieve certification. Thankfully our practice was able to achieve certification, largely due to our EHR (athenahealth) making it easier to gather the data, but for many primary care practices this has not been the case. And at least PCMH was optional. As these systems of reimbursement become more mandatory, complex reporting requirements will make this issue more acute. I am concerned that the rules of the game are being constructed to where the survivors/victors are not necessarily the ones delivering the most patient-centric care but rather the ones best able to devote resources to playing by a complicated set of rules.

In terms of your question re: more PCP-centric VBP strategies, VBP is itself in many ways a PCP-centric strategy and I hope to see this trend continue. Again, the potential problem lies with complex regulations and onerous reporting requirements.

Re: transparency of costs, you seem to suggest that it “already exists in the market.” Practically speaking there is very little awareness of costs by either the person ordering (the PCP) or the one paying (the patient) at the time decisions are being made. As primary care physicians, we are regularly ordering healthcare (medications, tests, referrals, etc.) on behalf of our patients and choosing among options without any knowledge of the costs. One such mechanism would be cost comparisons and patient ratings available at the point of ordering, embedded in the EHR.

James Furbush
Coming from a country with a single payer system and having spent my career in healthcare I agree that the complexities of administration are excessive. In my home country citizens have a card, like a credit card, and after a consultation or procedure, the card is swiped and the office person (singular) enters the procedure code (Think HCPCS and ICD) and the billing is electronic. The reimbursement is swift with monies being deposited electronically that night. So simple and so efficient. The only people who pay by cash or check are non-citizens. This cuts out so much overhead, the validation is done online in real time.
Alan Bingham

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Listen up, Washington: Focus on primary care