Policy Brief: Strengthen Primary Care Relationships, Strengthen Health Equity
April 26, 2022
By Caroline Smith, Sr. Analyst, Policy
In October 2021, Broome et al. described using the Medicare Shared Savings Program as a “chassis” for innovation. This chassis could test new innovations with only a fraction of the effort required to build a new model from the ground up and establish the MSSP infrastructure as the starting point for many providers, not a competitor to new Innovation Center models. To further demonstrate this idea, the Aledade policy team developed a series of blogs describing how this would work for four innovations: primary care capitation, value-based insurance design, addressing inequity in health care, and incorporating desired elements from the Next Generation ACO Model.
The Urgency of Equity
As the nation reckons with the difficult truths that the COVID-19 pandemic has brought to light, there is now a ubiquitous urgency from all health care actors to prioritize the reduction of health disparities through patient-centered, population health initiatives. Aledade applauds the Center for Medicare and Medicaid Innovation (CMMI) Strategy Refresh report for the intentional focus on addressing health disparities. Ensuring equitable access to quality health care is defined as a primary pillar of action in the Center’s next decade of innovation. Aledade has been actively taking steps to increase health equity with efforts that include forming the Aledade Center for Health Equity, partnering with community health centers (CHCs) to improve care to underserved populations, and working to elevate the collection and operationalization of social determinants of health (SDoH) data. 
We are proposing a feasible and simple solution that will drive more equitable and quality care to vulnerable populations through value-based bonus payments that reward physicians for establishing relationships with patients who need care most. Patients without primary care relationships should be identified, prioritized, and targeted for establishing a medical relationship. 
To encourage this relationship, we recommend that for every new eligible patient a physician sees for an annual wellness visit (AWV), the physician is guaranteed a standard payment that will be either bonused or credited to their practice or clinic at the end of the calendar year or set as a Per Member Per Month (PMPM) payment. For every year the relationship is maintained, additional enablement funding should be awarded. 
This model accurately reflects the need for additional resources to care for this unattributed, high-need patient population, and it affords physicians and clinics the autonomy to use funds appropriately and at their discretion, such as dedicating more time for administrative tasks associated with caring for high-need patients under a value-based care model.
Incentivizing longitudinal primary care relationships through accurate and population-reflective funding is a promising solution to combating health inequity because it establishes access to health care. This solution is best positioned to impact independent primary care physicians, as this group is currently disincentivized to see underserved patients that are in higher need, and are either uninsured or underinsured. With an enablement mechanism in place, an appointment with an underserved patient will have a payment value that is on par with the payment for seeing other, already attributed patients.  
For Medicare and Medicaid beneficiaries that are attributed to Accountable Care Organizations (ACOs) in the Medicare Shared Savings (MSSP) program, CMMI must prioritize value-based primary care in order to not only address health equity in the present but also minimize health disparities in the future. While we recognize the complexity of achieving health equity, it is our goal to utilize this brief to present a feasible solution to address health equity that can be implemented by January 2023. 
The Case for Equity Enablement Funding through Primary Care Relationships
Regarded as the centerpiece of effective primary care, longitudinal clinician-patient relationships provide an opportunity to increase education and prevention services, mitigate distrust rooted in societal marginalization, and mobilize coordinated social and health need services, all of which contribute to improved health outcomes and reduced health disparities. 
Primary care physicians are an optimal relationship to highlight as a resource for achieving improved health equity, as they are the most likely clinician to know a patient’s health history in the context of the community where they are living. This is paramount to the effective reduction of disparities, as understanding the socio-ecological context of one’s environment is essential to care. In a value-based model, this long-term physician-patient relationship is much more likely, as primary care physicians are more financially incentivized to address the total cost of care and holistic health of their patients, rather than the individual services they are providing. 
Value-based primary care models, primarily ACOs, have been proven effective in improving the quality of health care while simultaneously lowering the cost. This proposed model is particularly valuable in furthering health equity as underserved populations can arguably benefit the most from these outcomes. As mentioned, two potential solutions to incentivize primary care relationships that drive health equity and reduce the total cost of care are to either establish a new benchmarking methodology that is reflective of patient populations or incentivize physicians through enablement funding mechanisms outside of the existing benchmarking methodology.
The former requires a substantial and accurate patient information database and re-benchmarking formula, both of which have an infrastructure that is not yet developed, and therefore is long from being implemented. The latter requires a much lighter lift as the proven successful benchmarking methodology in MSSP can be used as a chassis, and the only new system to be developed is the standard, flat rate physicians will be awarded.
Equity Enablement in 2023
Defining and identifying patients
Our solution is rooted in simplicity and direct applicability. For this reason, we recommend CMS identify patients as eligible if they are located within a geographic or provider-based Health Professional Shortage Area (HPSA). 
In the long term, we recommend vulnerability be directly associated with health needs SDoH screening assessments. This will require a large enough foundation of accurate data that has yet to be standardized, collected, and operationalized. 
Additionally, we propose that data on Medicare beneficiaries who have not yet seen a primary care provider in the current calendar year be collected and shared on a quarterly or twice-annual basis.
Formula for payment
Enablement funding could take the form of either a bonus payment credited to the physician at the end of each calendar year, similar to Advanced Alternative Payment Models or monthly PMPM payments. We recommend that payments be standardized to further emphasize the guarantee of these incentives and that, for every Medicare beneficiary who is newly established, CMS credits a flat rate to the practice or clinic. This bonus payment or PMPM will increase for every year thereafter that the primary care relationship is maintained.
Beginning in January 2023, CMS will produce data highlighting vulnerable patients who have not yet sought a primary care visit. A federally-qualified health center (FQHC) is able to access this data, identify Medicare beneficiaries within twenty miles of their clinic and launch an outreach campaign. This clinic identifies ten vulnerable patients, eight of whom they are able to successfully contact and schedule for an AWV from March to June of 2023. The FQHC submits claims data to CMS, and the newly established relationship is cataloged for equity bonusing or PMPM payments. 
Special Considerations
We present this solution with the understanding that its implementation will present differently depending on the environment and whether it is an independent practice or an FQHC. While the solution would be relatively direct for independent practices, we suggest additional resources and opportunities be made available for HRSA-designated FQHCs. These additional considerations include that bonus payments would be credited to the institution, not specific physicians. Equity enablement funds could be designated to further SDoH and care coordination efforts, including funding additional staff and services. 
Additionally, we do not aim to present these solutions in a manner that would increase the level of work required for an already-burdened staff. For this reason, we recommend that Community Health Workers (CHWs) be the primary resource for outreach and establishing care for previously unattributed patients. Funding for CHWs should be specifically provided for FQHCs outside of the PMPM or bonus payments.
The First Step on a Long Road to Equity
We acknowledge that to effectively close health disparities a substantial amount of data collection, workflow realignment, and payment reform will be necessary. To address these concerns, Aledade plans to propose future opportunities for effective and implementable model components that will include expanding the patient panel in value-based care models to be more inclusive of Medicaid beneficiaries, tech-enabled workflows that advance the collection and application of SDoH data, and additional means to incentivize more physicians participating and succeeding in value-based care activities. 
When addressing the issue of health equity, it is essential to put the perspective of those most impacted by these solutions at the forefront. Minority groups and CHC leaders should always be consulted when working toward achieving health equity. To improve the equity of this framework between independent primary care physicians and community-based primary care physicians, future propositions to improve the structure of value-based care within CHCs should be diligently considered and prioritized. Aledade is conducting an ongoing request for information to propose such solutions in the near future by speaking directly with CHC representatives and experts.