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Analysis

Primary Care for All Among Proposals to Address Healthcare Disparities

By Christopher Cheney  
   July 15, 2020

Providence St. Joseph Health's Primary Care for All plan includes capitated payments, quality measures, and risk adjustment.

A Washington state-based health system is proposing a seven-point plan featuring Primary Care for All to address racial disparities in healthcare.

Racial disparities have plagued the healthcare sector for years. For example, black, American Indian, and Alaska Native women are two to three times more likely to experience maternal mortality than white women, according to the Centers for Disease Control and Prevention (CDC). The coronavirus disease 2019 (COVID-19) pandemic has highlighted healthcare racial disparities, with black Americans five times more likely to be hospitalized for COVID-19, the CDC has reported.

To respond to the problem, Renton, Washington­–based Providence St. Joseph Health (PSJH) is proposing seven ways to rise to the challenge.

1. Primary Care for All: Offering free primary care for every American would level the healthcare playing field and help ensure people of color have an equal chance to live the healthiest lives possible.

2. COVID-19 resources: Healthcare organizations and policymakers need to ensure that coronavirus testing and drug therapies are available to all minority communities.

3. Patient outreach: Healthcare organizations need to work directly with minority communities to meet social determinants of health needs and understand how to deliver services in a way that is culturally respectful and builds trust.

4. Voter education: PSJH is committed to educating voters about ballot initiatives that affect all Americans. The health system also plans to support voter registration drives in the seven states that the organization serves.

5. Promote the Census: The U.S. Census is an essential way to identify minority populations and allocate federal resources including healthcare programs appropriately.

4. Safety net programs: PSJH supports several safety net programs for disadvantaged populations, including Medicaid, the Supplemental Nutrition Assistance Program, and Temporary Assistance for Needy Families.

7. Diversity, equity, and inclusion: Earlier this year, PSJH established a social responsibility platform that features a stronger commitment to diversity, equity, and inclusion at the health system and the communities it serves.

Pushing Primary Care for All

PSJH's president and CEO, Rod Hochman, MD, recently shared his health system's perspectives on Primary Care for All with HealthLeaders.

Primary Care for All has five main elements, he says.

1. Capitated payments: "My primary care physician would be paid one fee at the beginning of the year to provide my primary care. It would be fully paid for up front. That way, the primary care office could take care of me without having to be paid every time I come into the office. They would get paid whether they talk to me on the phone or whether they talk to me on the computer," he says.

2. Quality measures: To make sure primary care physicians are taking good care of their patients, they would be held accountable by quality measures—most of which are already in place such as vaccination rates and patient satisfaction scores.

3. Increased utilization of advanced practice providers: To address an expected shortage of primary care physicians even under the current system, primary care practices would boost utilization of advanced practice providers such as nurse practitioners and physician assistants. "Under the current system, a primary care physician can take care of about 1,800 patients. Under the Primary Care for All model using primary care physician extenders such as physician assistants and nurse practitioners, that number goes up to as many as 6,000 patients," Hochman says.

4. Risk adjustment: Patients would be risk-adjusted into high-risk, medium-risk, and low-risk categories. For example, elderly Medicare patients would be categorized at higher risk than young patients because they tend to have more health issues and require more costly care.

5. Government subsidies: The government would subsidize the primary care costs of uninsured Americans. "It would not be the Medicare premium—it would just be paying for primary care. But it would ensure that every American would have a card that would give them access to primary care," he says.

How Primary Care for All would address healthcare disparities

Under Primary Care for All, every American would have a primary care coverage card, which would turn patients in every community into paying consumers of services, Hochman says.

"So, if I set up my practice in South Central Los Angeles or Roxbury in Boston or in any area that has been underserved for healthcare, all of those patients would be paying patients. It would encourage practices to set up in those communities because everyone is a paying customer, and primary care physicians would get paid up front."

Primary Care for All would encourage young physicians to go into primary care and to serve disadvantaged communities, he says.

In many countries, strengthening primary care through the Primary Care for All model has been a crucial element in improving public health, Hochman says.

"We have seen this model work in many nations that are less fortunate than the United States economically. They have put in a strong primary care net, and it significantly improves the health of the population. It provides prenatal care, preventive care for diabetes, vaccination, and all of the things that get lost in our current system because economically disadvantaged patients do not have access to good primary care."

Financial case for Primary Care for All

From a financial perspective, enacting Primary Care for All would be much more practical than more ambitious healthcare reform proposals such as Medicare for All, he says. "What we have been looking for is a solution that would do more to promote the health of Americans, but not necessarily break the bank, as people have talked about Medicare for All as a solution."

Primary Care for All would require Medicare, Medicaid, and commercial payers to carve out a modest portion of their premiums to provide primary care coverage, Hochman says. "When I think of a per member per month payment on a commercial premium, primary care is about 10 cents on the dollar."

The return on investment for carved-out primary care payments would be significant, he says. "I am getting preventive care, a safety net, and virtual care 365 days a year. I am taking care of hypertension and diabetes. And I am working on problems such as obesity and opioid addiction that have plagued the country. So, the return on investment is a pretty good one."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


KEY TAKEAWAYS

The coronavirus pandemic has put a spotlight on racial disparities in healthcare.

The Primary Care for All model would be far less costly than more comprehensive healthcare reform proposals such as Medicare for All.

Primary Care for All would generate a significant return on investment—boosting preventive care and chronic condition care at a modest cost.


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