The American Academy of Family Physicians offers more than one definition of primary care. There is little controversy about two service lines in most versions: health screening and the management of chronic conditions. The same cannot be said for the third component, “first contact care” of new or unknown conditions.
As with other aspects of “shirts and skins,” or the differentiation of medical specialties into hospital or community settings, the defining question becomes whether first contact care can only be provided in the office settings by primary care providers. Alternatively, should some new illnesses and injuries that may represent emergency medical conditions be cared for in hospital settings, or at least by a subset of primary care physicians who specialize in acute care?
The short answer is that 136 million consumers per year agree that first contact care should be provided in America’s emergency departments. The more serious their new illness or injury is, the more likely their primary care physicians are to agree with them. The same is true for first-contact ED encounters at night or on weekends. Yet private and public sponsors of health coverage are less and less likely to agree.
For policy makers and health plans, controlling the location and type of provider giving first contact care is crucial to their ability to control resource utilization and referrals. This primary care paradigm is fundamental to systems of care in Europe and the Commonwealth, where cultural and legal factors are better aligned with robust primary care networks and universal access to coverage. In the US, the type of physician delivering first contact care is far more likely to be driven by the patient’s payer class. While two thirds of first contact care is rendered in office settings by primary care specialties, the picture looks very different for consumers without private insurance coverage. For the uninsured, two thirds of first contact care is provided in emergency departments.
In our reforming system, it has been difficult to reconcile the important goals of expanding access to coverage and the primary care workforce with the 24/7 reality of first contact care. One such effort is a portion of the Affordable Care Act known as the “bump rule”, where the definition of primary care is at odds with the differentiation of medical specialties between office and hospital settings. While President Obama is the nation’s highest-ranking player of pick-up basketball, market trends in “shirts and skins” were not sanctioned in his administration’s new rule on primary care payment for Medicaid.
Thousands of physicians trained in family medicine, internal medicine, and pediatrics have opted to practice full-time in EDs. This has proved to be confusing to rule-writers for the Medicaid program translating the statutory requirement in the ACA. The intent of Congress and the first-term Obama administration was clear enough: to strengthen community-based networks of primary care providers during 2013 and 2014, before many [if not all] states ramp up Medicaid coverage for low-income adults. The incentive was also compelling: federal funding of cognitive services by primary care providers at Medicare rates, rather than at the paltry amounts usually paid by Medicaid.
The claims data defining the scope of primary care to Medicaid rule-writers in Baltimore reflected the marketplace, in which the ED is the point of service for half of first contact care and the Evaluation and Management codes for ED services to Medicaid beneficiaries are firmly established in statute within the scope of primary care. In both the proposed and final versions of the bump rule, physicians trained in primary care specialties and practicing in EDs would have been paid at the higher Medicare rate. The rationale for higher payments would be compelling, since physicians without formal residency training in emergency medicine are far more likely to practice in rural hospitals and other hard-to-staff EDs, serving disproportionate numbers of Medicaid patients, as well as the uninsured.
More recently, CMS appears ready to send states implementing the primary care payment rule additional guidance, warning them not to pay Medicare rates to any providers who practice in EDs. Meanwhile, dozens of other specialties based on primary care residencies followed by fellowships, such as pulmonary medicine or cardiology, will still be eligible for payment at the higher rate for Medicaid consults. Many of these consultations will undoubtedly be provided in hospital settings. And tens of millions of Medicaid visits to EDs for urgent and emergent conditions – most too serious for rapid evaluation and management in office settings – will fall outside the final version of the bump rule.
The bump rule provides a window into the current policy challenges in the delivery of both primary care and emergency care services. The front line for acute care advocates in federal policy making circles today is only a reflection of the deeper challenges ahead for a society attempting to expand access to health coverage at the same time it reins in healthcare costs. It is unlikely that we will succeed in achieving both goals in the future US healthcare system without resolving a number of inaccuracies and inequities surrounding access, delivery, and valuation of primary care versus emergency care. Fortunately, some of the solutions are to be found in understanding the dynamics of how first contact care is being delivered, and how acute care providers support the larger goals of strengthening the primary care workforce. This support allows the primary care workforce to focus on meeting the needs of our citizens for health screening and chronic disease management that can be safely done in community settings.