The U.S. primary care delivery model is far from perfect. Access to traditional in-person primary care is often poor, and new models are still unproven. Yet, the stakes are too high for employers to sit back idly.
Why is primary care important? Primary care has been shown to improve population health and lower costs. Better access to primary care has even been associated with lower death rates. Primary care providers (PCPs) are a key source of mental health support and prescribe more psychiatric medications than psychiatrists.
Nonetheless, primary care generally represents less than 5% of the medical budget. Increased access and clinical personalization will not lower the cost of primary care itself, but may lower total medical expenses through improved patient management. By developing a strategy to improve access to primary care, employers can take advantage of innovative approaches and improve the value of care for their employees and work community.
Types of primary care services
Primary care services are now offered through an increasing number of venues and providers, including:
- Traditional community PCPs generally offer in-person visits, and can perform laboratory and other tests, although their hours are often limited to the business day. Many also now offer virtual visit options. They are usually paid through the health benefit plan, and the payment model is usually fee-for-service.
- Virtual primary care (VPC) is increasingly offered by health plans and by third-party vendors, and allows for patient care anywhere in the country. Virtual primary care providers are often licensed in multiple states; they are generally paid through a combination of population fees (a per-participant, per-month cost) and fee-for-service for services delivered. While VPC is gaining traction, state regulations affecting licensure, prescribing practices and payment could impact access over the coming years.
- Direct primary care is offered by PCPs who do not participate in insurance. Patients or their employers pay a monthly or annual fee that covers all PCP professional services and can cover a limited set of laboratory tests. Members still need a health insurance plan because over 90% of medical expenses would not be covered by a direct primary care plan, including diagnostic tests, specialty care and hospitalizations.
- Membership practices charge a modest annual fee (around $200 per participant) and provide virtual care nationwide and in-person care in cities where they have offices. They generally bill an access fee to employers and fee-for-service for care delivered.
- Concierge practices charge a substantially higher fee (often $2,000 or more per participant per year), and each clinician takes care of a small number of patients and offers enhanced access, often including a physician’s cell phone number. They generally bill fee-for-service to health insurance for care delivered in person at their offices, and their fees are rarely subsidized by employers.
- Onsite/near-site clinics can offer primary care to employees at high-density worksites, although they usually do not provide care for dependents or children. Onsite clinic vendors also offer virtual primary care, providing a hybrid model with in-person and virtual options. These clinics usually charge the employer for operating costs and do not charge for individual patient encounters.
- Retail clinics generally offer acute care, although some also offer primary care and mental healthcare. Some also provide ongoing care for chronic diseases. Most are staffed by advance practice clinicians, are paid fee-for-service and participate in employer-sponsored health insurance.
- Executive physicals are generally offered only to executives, and sometimes include tests that are not evidence-based. They can cost from $2,000 to over $10,000 per year, and generally do not provide ongoing primary care.
Steps to design a primary care strategy
Assess population need for primary care services
Employers can ascertain employee pain points through surveys and in-person and virtual focus groups, and tailor new offerings to their members’ needs. As employers develop their primary care strategy, they should recognize employees’ life stage needs, dependent needs, the prevalence of chronic conditions, and diversity, equity and inclusion factors. Employers can also incorporate population demographics and PCPs’ geographic footprint as they consider potential approaches to enhance primary care offerings.
Encourage primary care utilization through plan design and/or new offerings
Employers can encourage the utilization of primary care through a plan design with low out-of-pocket costs for primary care. Some plans even offer non-preventive primary care visits without cost sharing, although patients must first meet deductibles in high-deductible health plans.
Employers can also promote new primary care offerings. For instance, virtual primary care through telemedicine allows providers to have frequent touchpoints with their patients and can give patients access to providers with desired attributes, including gender, race and sexuality. Employers with large groups of onsite workers can also offer an onsite or near-site primary care clinic. Newer health plan offerings focus on high-quality PCP selection and may incorporate value-based payment.
Require new primary care models to coordinate with traditional care and other programs
Even as virtual and other alternative providers of primary care become more available, some patients will continue to see in-person community primary care providers. Members who have built strong relationships with their PCPs are often older or sicker, and the value of their longitudinal relationship is high.
Many members will access both new forms of primary care as well as pre-existing community primary care. Virtual and other new providers should have clear plans to communicate with community primary care physicians to promote care coordination and eliminate duplicate tests and conflicting instructions.
Employers have access to dozens of vendor programs, which focus on aspects of primary care, including chronic conditions, mental health and family building. New primary care offerings should integrate with these programs by informing members and offering navigation support.
Integrate with mental healthcare
As many as three-quarters of primary care visits include a behavioral health element, and unresolved mental health issues are a major cause of distress in patients and their families as well as a professional challenge for PCPs. Employers can work with their carriers to identify PCP networks that have substantial behavioral health supports built into them.
Many employers use virtual care companies to augment or create mental health access for their employees. These systems should ideally collaborate, with either virtual or in-person PCPs to help make care as seamless as possible. Virtual primary care should include mental health resources and professionals, and virtual primary care companies should have explicit processes for managing patient suicidality and addressing opioid use disorder.
Use primary care to support the company’s diversity, equity, and inclusion strategy
Researchers have shown that patients are more satisfied with physicians of their race or ethnicity, and patients on average have more visits when their physician is of their race or ethnicity. Physician-patient race concordance is also associated with lower use of emergency departments and lower overall healthcare costs. Virtual primary care can increase access for patients in rural and underserved areas, and can increase the diversity of the pool of providers from which members can choose.
Design a monitoring and evaluation plan before initiating a new program
It’s easier to justify continued investment, or to explain program changes, when you effectively measure the results of a new program. We recommend a combination of:
- Structural metrics (the program has the promised providers and infrastructure),
- Process metrics (percentage of employees who have had a primary care visit) and
- Outcome metrics (such as net promoter score, blood pressure control and preventive care metrics).
Performance guarantees that align with these metrics can help concentrate a vendor’s attention on the needs of the employer’s population.
Accessible primary care clinicians can improve the value of care delivered to employees and their families. The new primary care models available today can also increase access and improve quality of care, while delighting employees and their families.
The evolving landscape of primary care offers many new options for employers and for plan members. Careful curation of primary care resources can improve care and meet employee and dependent needs, while demonstrating the employers’ genuine concern for employee and family wellbeing. Employers have more primary care options than ever and can build a strategy to take advantage of the benefits of this fast-changing landscape.
Patricia Toro, MD, MPH, contributed to this article. Toro is a senior director in the Health Management Practice of WTW. She is trained in infectious diseases and works with payors, providers, and employers to improve the quality and outcomes of health care delivery.