Better Primary Care: What Will It Take to Get the U.S. to Wake Up to the Need?

Mark Masselli (00:04)
When was the last time you saw a primary care provider? One in five US residents has no usual source of
healthcare, and that means they usually end up in the emergency department. What are the policy solutions for
fixing these unhealthy and costly habits?

Ann Greiner (00:19)
We all want better health, and we have feel a sense of urgency about it. We need it now.

Margaret Flinter (00:24)
Our guest today is at the center of efforts to promote better health now by investing in person centered,
accessible and equitable primary care. Ann Greiner is the CEO of the primary care collaborative,.

Ann (00:37)
Invest in what works, and we have this incredible evidence base that primary care is the one part of our
healthcare system, if we put more money into it, it will deliver better patient, population outcomes and more
equity pay for what we want, better health. And also we need to reduce economic and social barriers to better
health, because if we don't do that, not all Americans are going to achieve better health.

Margaret (01:04)
This is Conversations on Healthcare

Mark (01:15)
Ann, welcome to Conversations on Healthcare.

Ann (01:18)
Thank you so much for inviting me. I'm delighted to be here.

Mark (01:22)
I have an obligation to say that we have a bias here, but I think our listeners know that we are primary care folks
and this is important issue to us. But more importantly, it's important issue for all Americans. the primary care,
collaborative members include both public and private organizations, and the stat really, sticks out. Our country
devotes just five to 7% of healthcare spending to primary care considerably less than those other high income
countries with better health outcomes. And can you tell our listeners how we, how do we get here?

Ann (01:58)
Hmm. Well, I do want to even update, the latest stat. We're at 4.6%, so less than 5 cents and a dollar. and I think
there are many, contributors to how we got here. But one, is the Medicare physician fee schedule and what it
values. And, many other payers, kind of take off on that fee schedule. And we're not valuing things that are
more of the cognitive services valuing, advice that primary care clinicians give related to managing multiple
chronic conditions, care integration and care coordination. Those are things that are not valued while we pay a
lot more, for, surgical interventions and drugs and many other things, but not so much, on, things that help keep
us well or restore us quickly to health when we, we get sick.

Margaret (03:00)
Well, Ann, we know that primary care, through an abundance of research, consistently delivers better outcomes
and reduces disparities. And that was highlighted, of course, in the report from the National Academy of
Sciences Engineering and Medicine. But one of the things we see, and this is just confirmed with yet another
national study, is compensation for primary care physicians, in particular, probably for everybody on the
primary care team, but particularly for physicians, is lagging behind their specialist colleagues, in medicine. But
I think the question is, is raising salaries for primary care physicians enough to fix the issue of what a small
percentage of physicians are actually choosing primary care? Or are there a host of other critical factors in your
opinion?

Ann (03:47)
Well, that is an important issue because I think when people, come to make a decision about what specialty
they'll, they're going to pursue, and they have a lot of medical debt, you know, it, it gives them pause, to pursue
primary care. And that's unfortunate because it's exactly, what we need in our healthcare system. But there are
many, many other, factors. you know, primary care is not, properly resourced beyond the salaries to actually
provide what patients need in terms of more comprehensive care. We know that we have a mental health crisis,
for example, but we don't have a financing system that supports the integration of mental health into primary

care, which is what patients want. Or we don't have the ability to, address, substance use disorder, which is also
something that many Americans, are struggling with. We, do not have the ability to really have this sort of
comprehensive team that can help patients handle diabetes and hypertension and congestive heart failure. Many
things that, accompany those chronic conditions require patients to change what they eat and how they exercise.
And a more comprehensive team could actually help patients, do better. But that's not what our current
financing allows for. So I think that there are a host of reasons that contribute, to the, lack of investment in
primary care and, and, are problematic beyond what we pay in terms of physician salaries.

Mark (05:38)
And let me, let me just say that I think that's such a good, such an important point about team-based care.
Obviously, we're from the community health center movement where that is a focus of the work that we do. It's,
it's so important and we've also wanna find out, who, what, what, brings people joy, in terms of the work that
they do. And what we found is that, nurse practitioners are, an area that we've been really focusing on the
development. But before we get to talking about sort of how all this is organized, I wanna really get back to the
heart of the dilemma that you face. And, maybe an example of when Medicare boosted payments to doctors,
who evaluate and manage patients and cut payments to those who focus on procedures, those doctors getting
less money put up a fight. You have a very diverse coalition, but not groups like the American College of
Surgeons and the hospitals. How do you cross the finish line in this very intense environment with the group
that you've organized?

Ann (06:45)
Well, we, we, just as we, are advocating for a team to provide a comprehensive set of services, we also do quote
unquote, team-based advocacy for primary care. And, we partner with, other folks like, insurance companies
and employers and consumer groups and other stakeholders that also want better health, and are very focused on
that. And that, allows us, to move policies forward. For example, we have proposed to the Centers for Medicare
and Medicaid services, a new payment model for primary care within the Medicare, accountable care
organization. the MSSP program, and we brought 30 organizations together, and they were very diverse and
said, please, we want a new way to pay primary care, and we want to invest more through this alternative
payment model within the a CO program. they took notice when 30 different organizations came and put a
proposal on the table, and we're, hopeful that that model gets introduced this year. So that's how we work. We,
we look, to partner with other stakeholders that, share, the sense that in order to improve the nation's health, we
have to, pay more attention and spend more on prevention and wellness.

Margaret (08:24)
Well, Ann, I understand you also are an advocate of hybrid payment methods with a mix of prospective and fee
for service payment. I'd, I'd love to have you share your thoughts on how this solves, issues potentially. And
also maybe distinguish between the difference between a prospective reliable payment and the value-based
rewards or shared savings that may come or may not come, at the end of a year. I think there's a lot of confusion
out there beyond the healthcare circles of what we're talking about when we talk about these things.

Ann (08:56)
Yeah. Well, Margaret, thanks so much for that question. And, you know, when I came to the Primary Care
collaborative, I came from the quality movement and I was excited about the patient-Centered Medical Home
and what it it promised. But I've turned into someone who's really focused on payment because I don't think that
we can, adequately achieve those new models of care unless we fix payment. so back, back to payment, you
know, I think that the, the National Academy of Science Engineering and Medicine, which you mentioned
previously, gave us, a set of incredible recommendations in five different domains. And one of them is payment.
And, when we had a meeting shortly after the National Academy of Science Engineering and Medicine
published their report and found that, you know, this notion of hybrid payment was something that, experts and
stakeholders across the spectrum supported, we decided that we would make that, a blueprint for our work. And
hybrid payment is a mix of fee for service and prospective payment or capitation. And it's a mix because, you
know, no payment system, is perfect, and there are, there are benefits and challenges with each. And so the
notion of hybrid is to kind of balance those out. and for example, with fee for service to pay for things that you
wanna make sure happen, and that might not be done by all practitioners, the capitated payment is for, it could
be 40 to 70% perhaps, of your, your payment comes in a monthly payment that you can anticipate, and you
manage against for your patient population. And it allows the primary care clinician to be much more flexible in
how they deliver care, and to either expand or, you know, kind of, contract in terms of the, amount of care
depending upon what the patient needs. So rather than, you know, being tied to a visit, you have this monthly
payment that would come in and you manage, you manage against. So it, you know, it is, I think, you know, on
the surface might seem a little bit complicated, but we've seen examples of how this works well, and we put a

lot of stock in the evidence that, the National Academy of Science Engineering and Medicine brought together
and in their recommendations.

Mark (11:47)
You know, when I think about payment, I think about investment. And, there's no greater advocate for
investment than the, bipartisan senate bill, the $26 billion bipartisan, legislation, that would boost their primary
care, increased training opportunities for doctors and nurses and, other providers and, and expand access to
community health centers. I know you've been tracking that Bill. what are you, what are your thoughts about it?
And, will it see the light of day or parts of it?

Ann (12:26)
Well, I think we're all waiting to see what's gonna happen. as we were on a, had a meeting this morning with,
folks on the Senate side, and they reminded us that it's hard for them to think about the year ahead because last
year's business is not yet done. And that's obviously part of last year's business, and we're all anxious, and
hopeful that this gets over the goal line by March 8th. you know, I think, that bill is very important. and it
certainly, addresses a number of issues, as you said, funding for community health centers and also for, for, for
training, very important. And, Congress's job, I would assert is not done after, you know, and hopefully that Bill
gets over the goal line because, well, community health centers serve a very important pop part of the
population, one in 11 and some of the most vulnerable. there's other things that congress needs to focus on in
terms of primary care for the other 10 and 11. And so we're hopeful, and we are having numerous conversations
that Congress will also begin to turn their lens, and, and open the aperture to look at primary care more broadly,
lift up CHCs, and think about primary care more broadly so that we can advance the health of all Americans.

Margaret (13:58)
Well, Ann, in your advocacy, you often refer to the patient-Centered Medical Home, a term that I think has
probably been around long enough that most of our audience understands what it means. But I wonder if you
could, define it for us, and also how it fits into your mission. and, you know, I, I think I might just add a third to
that. This is one of those things that, really has found resonance in the private practice community, in Veteran
Affairs, the Joint Commission Community Health Centers. When you see that kind of widespread adoption, that
usually says something, but do you think it's made a difference? Has it helped us get back to that, ideal of the
truly patient, patient centered, health home or medical home for patients?

Ann (14:42)
I think that it has, and I know, it's really helped to orient primary care practices to focus on providing care,
thinking more in a population, basis. So, you know, proactively understanding who's in your population in terms
of who has diabetes or asthma or congestive heart failure, and proactively reaching out to make sure that they're
getting the services they need, providing really good access using technology, to support care. And I know that,
in the Community Health Center movement, there's been really fantastic adoption of the patient-centered
Medical Home, and as you said in the va, the commercial sector to some extent. but I think, the financing model
has not supported the full, blown, patient-centered medical home as we had hoped for, in the, in the, in the
private sector. And so this is where we need payment reform, to be able to support the patient-Centered Medical
Home and other models of advanced primary care, which I would assert are really, you know, cousins and,
mothers and fathers of the patient centered medical home. There're, there're variants, but it's all very much in
line with, a more population based approach using technology, much better access. And it doesn't need to be a
physical home. Let's just be clear on that. I think we can take good advantage of virtual visits, patient portals, all
kinds of ways to have touches with your patient that, you know, supports them in their, in their care journey and
also provides them a home where your data is in one place where you can, get the integration and coordination
across different conditions that you might have, where you have a trusted relationship with the healer to help
guide you, when you need that kind of guidance and support.

Mark (16:52)
You know, when I look at your, four goals, one is certainly around, health equality and the, the collaborative
recently issued a brief outlining how Medicaid and the children's health insurance program chip can reduce
inequities and improve health, of the whole nation, expanding access to primary care. I'm wondering if you
could tell us a little more about this approach.

Ann (17:16)
Sure. So, I mentioned the NASA report and our excitement about, how the community came together. It is
coming together to support those recommendations. And so we are focused on payment, as I said earlier, and we
launched, in March of 2022, a campaign called Better Health Now. and I, I think most can't argue with, we all

want better health and we have feel a sense of urgency about it. We need it now. currently that campaign, has
three different planks, but it's all focused on, really, you know, some major principles that organizations have
signed on to, to really help shape the campaign. And those principles are invest in what works, and we have this
incredible evidence base that primary care is the one part of our healthcare system. If we put more money into it,
it will deliver better patient, population outcomes and more equity pay for what we want, better health. and also
we need to reduce economic and social barriers to better health. Because if we don't do that, not all Americans
are going to achieve better health. under that, those principles, we have three planks, as you mentioned earlier,
one focused on Medicare to scale these payment changes, one focused on Medicaid so that we can reduce
inequities in care. And then finally, one that addresses one of the issues that we're facing as a nation, responding
to the mental health crisis. On the Medicaid front, we did issue a report and a set of recommendations recently,
and we believe that Medicaid managed care plans need to, start paying primary care differently and more so
that, they can provide a, this broader set of services including behavioral health integration. So you're hearing
these themes in a lot of different, you know, with a lot of different populations. I think we can take also a lot of
lessons from the community health center movement and the incredible job that community health centers have
done to provide this comprehensive set of services, really meeting patients, across a diverse set of needs. and so
I think, you know, we can learn a lot from you and from, from others, in your movement about how to evolve
our delivery system provided, we can also reform payment at the same time.

Margaret (20:01)
Well, we couldn't agree with you more about the, the lessons, you know, that we had to learn about the full
integration of behavioral health, and primary care, and of course, oral health, while we're at it in the community
health center world and all, all lessons that can be adopted by primary care in any system, but, you know, we
can't overlook the power of the Centers for Medicare and Medicaid services and their influence and certainly
through, billing codes. And you've been touting the importance of a proposed CMS, add-on code that is intended
to provide patients and their primary care providers more time together to manage complex conditions. Where
do things stand, on this front? What was the origin of this, and are you optimistic about seeing that come to
fruition? Sounds like a wonderful idea from the point of view of anyone who cares for patients with complex
conditions.

Ann (20:52)
Well, it is, and, the, the code is, G-2211. and it's a very important way that, primary care can get, you know, can
be resourced for the care that it provides to those who have very complex needs. So I think it is really important.
we, the final rule came out at the end of the year. There has been efforts, to try to overturn it. and I think those
continue. We, we are hopeful that, those will not be successful, frankly, and will know, you know, in the end of,
end of, you know, the package when it, when it emerges. but I think there, there's growing recognition that, our
healthcare system is not doing a good job taking care of patients with complex needs. We see that in our life
expectancy, data, and, and in our understanding of the, you know, number of chronic conditions, we see
expanding in terms of that Americans are facing. And so, you know, we have a system that I think, does not
support the, that, you know, integration and coordination. And so patients are left kind of being their own
general contractors going to this specialist and that specialist and themselves trying to figure out how to
integrate and coordinate the various advice they're, they're receiving. They really want a partner to help them.
it's complicated. and we have a very, chaotic healthcare system. And so what I think we need to do is really
strengthen that foundation so that primary care, can support patients in these, in this journey. which is often, you
know, fairly challenging, particularly if you have two, three or more chronic conditions. And unfortunately,
more Americans are in that situation.

Mark (23:07)
And speaking of situations, Americans are in, and you talked earlier about virtual homes, health homes, and, we,
the mental health crisis we're, we're seeing a, a larger uptick of, the use of telehealth. I know that was one of the
sort of, silver linings, if you will, during the pandemic. It allowed people to really explore an area that had really
been limited. but, you know, there are some fixes that need to be made, and you're calling on Medicare to
remove its initial in-person requirement necessary to trigger payments for telemental health services. And, can
you explain what the holdup is? And it, it seems like a very practical solution. And I will certainly say for so
many working families who are working hourly, the notion that you have to take an hour bus ride to get to a
place to wait a half an hour to be seen for 15 minutes and then repeat it, sort of suggest that people aren't really
listening or understanding the practical reality that so many people face.

Ann (24:09)
Yeah, I think it might, its origins might be really around this notion of you can, you really need to establish first
a relationship in person. you know, and I think the, these last number of years have, demonstrated to us that, you

can establish relationships, over Zoom. and, and, you know, given the shortage of mental health professionals,
and also as you pointed out, you know, how time intensive it is to, you know, travel places, particularly if you're
in a rural community or you don't have access to transportation to get, you know, wherever you need to go to,
have that visit. We just think that we can be, more flexible, and, you know, move that forward. Interestingly, we
had conversations with some leading consumer groups, and, they evolved their position in conversation with us.
So we're appreciative of that and, and hopeful that this, you know, this policy will evolve.

Margaret (25:20)
Well, Ann, I'm gonna get into the weeds a little bit more about, the kind of system in which you get your care
and, and what difference does it make? So there's, some evidence, I think, that shows that, accountable care
organizations, can be helpful in terms of improving care and being attendant, to the cost issues. There is some
further evidence, that when those, ACOs are led by clinicians, and I think most of them have studied, physicians
and leadership that you may do better than in organizations that are not led, by the clinical, experts. and then
there's maybe more newsworthy stories than I've seen in the, peer reviewed literature about what's the impact of
who owns the whole health system. if you look at venture, influenced health systems, and some of this we're
reading in, in the academic literature, but mostly we're reading that I would say in the, in the news. What are
you doing in your organization around looking at this, influence on, cost and outcomes and the patient
centeredness of who owns the operation and what's its primary care, primary focus? Is it primary care or is it
healthcare writ large? You wanna try and tackle that one? I know it's a long question.

Ann (26:37)
Well, I do think governance is really important. and I think that that's something, to understand who is making
the decisions, you know, that affect, the clinical enterprise and, you know, are those being made by clinicians,
and are they shaping them or is that, are those business decisions? And I think that's a real question because as a
patient, I really want, you know, clinicians to have a lot of influence, over that, over over those set of decisions.
So, you know, whatever the financing is, I think the governance is really important to look at. I do think that, the
data that we have from, MSSP, which is the Medicare ACO, is really quite interesting. That, those that are
primary care centric are achieving twice the savings of those that are not. And I think what it begins to raise for
us is, you know, well, why, why is that? I do think, you know, it's part of the, the governance as I mentioned
earlier, but also the alignment of incentives. You know, if you have, an incentive system that, is thinking not
only about, prevention, but also has at the same time has to think about, you know, are all of our beds filled?
Those are, you know, two different, two different incentive systems and, you know, they may be canceling each
other out. you know, with, with some of the, hospital led, ACOs. Now there are hospitals that are really,
population focused and are committed to primary care and have a different approach. But I think the, these are
all, trends that we're watching and trying to understand. and there's, you know, there's a lot going on. and
disentangling what's happening is, is, is a complex business, but when we can point to the data, I think we
really, and see that over time, it's not just one year. I think we really need to, to pay attention to that.

Mark (29:06)
Well, Yeah, I think it's such a good point. I'm wondering if there's any scorecard. I'm sitting here as a consumer
seeing lots of mergers going on with hospitals. Seems like it's a sucking sound of taking away primary care
dollars ultimately across the board because there's just a large, health industrial complex here, that doesn't seem
to be slowing down. that's a pretty big fight that you've got on your hands. and how are you able to educate the
average citizen about this? And I know you're focused in on the policy and doing such a great job, but what's,
what are some guideposts for simple consumer out there trying to figure out, these large mergers? And is it it
that, what does it mean for me?

Ann (29:49)
Yeah. Well, the economists will tell you that when you have, consolidation of, of hospitals in a market that
prices go up. So that's not great for consumers. and, you know, that, that when you have, so, you know, I think
that is, that is problematic. you know, what happens for consumers when primary care, is now a part of a
hospital system. You know, I think that's an open question and you need to kind of examine that. Do I still have
the same amount of time with my primary care clinician as I once had? where are they referring me, in terms of,
you know, specialty services or acute care services? Is it within that hospital metric metric, network, or do they
consider, you know, other specialists or other hospitals that might be able to meet my needs? So the, as a
patient, you might ask those kinds of questions. so, you know, I think, the administration is also examining these
kinds of issues around consolidation and competition. do we have less competition? And so that means, with
consolidation, and that means prices are gonna go up, and that's not good for consumers. These are all, you
know, very important questions for us to be watching. but not to just watch forever. if we see in markets that

consolidation is not turning out to be good for consumers, then, you know, I think the, the regulators and others,
should be concerned and, and take action.

Margaret (31:38)
Ann Greiner, CEO of the Primary Care Collaborative, we want to thank you for joining us today on
Conversations on Healthcare. And thanks to our audience for being here. Be sure to subscribe to our videos on
YouTube. Find us on Facebook and X with our account name, CHC Radio. As always, you can go online to
chcradio.com to sign up for our updates, and please share your thoughts and your comments about this program
with us. And thank you so much again for joining us today.

Ann (32:07)
Thanks so much for the invitation. I'm a big fan of your program.

Mark (32:10)
That's great. Thank you so much.

Margaret (32:16)
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