This spring, a gauntlet landed at the feet of healthcare experts.


Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care, a 450-page report by the prestigious National Academies of Sciences, Engineering and Medicine (NASEM), doesn’t simply gather the mountains of data that reveal the gaping accessibility and affordability problems of the US healthcare system.


Report authors, members of NASEM’s Committee on Implementing High-Quality Primary Care, go on to identify what needs to change – and how to make those changes.


And they are crystal clear about their key call to action. In the final line of the report’s preface, the authors state that “the committee firmly believes that primary care should be a common good, available to all and sufficiently valued and resourced to repair health equity in the United States.”


If primary care is a common good, they also argue, then the strength and quality of the country’s primary care services is a public concern.


Here’s a look at three key areas for change that the report’s authors identify – and how to address them.  


Re-focusing on primary care


According to the NASEM report, the United States is plagued by a disjointed healthcare system. It creates inequities in care, misallocates resources between primary and specialty care, burns out clinicians, generates financial pressure on primary care practices, limits the relationships that clinicians and patients can develop and produces suboptimal care for too many U.S. residents.


The report goes on to explore five implementation objectives to turn all of that around.


  • Pay primary care teams to care for people, rather than paying doctors to deliver services.
  • Ensure that high-quality primary care is available to everyone in every community.
  • Train primary care teams where people live and work.
  • Design information technology that serves the patient, family and the interprofessional care team.
  • Ensure that high-quality primary care is implemented in the United States.


My take – These are laudable objectives and honestly, the US should be further along in making them happen. After all, primary care is the only part of healthcare where an increased supply is associated with better population health and more equitable outcomes. The US chronically overspends on healthcare yet underinvests in primary care compared to other countries in the Organization for Economic Co-operation and a Development (OECD). In fact, primary care represents just 5-7% of the total healthcare spend in the United States, whereas other OECD countries spend on average 14%.1


Where do all those overspent dollars go? Most of US healthcare spending goes toward hospital care (38%), all other physician and professional services (20%) and prescription drugs and medical nondurables (14%).2  If we increase the spend on primary care so that primary care doctors can holistically manage their patient’s health, quarterbacking to specialists and coordinating care as needed, we can achieve lower overall spend on healthcare.3


Redesigning payment and benefits systems


The report authors say creating a payment system that supports and encourages high-quality primary care is fundamental to improving the health of the nation. They then offer a spectrum of options for improving payment for primary care. These options are not mutually exclusive, and the authors recognize it will likely be necessary to employ multiple levers to produce the changes necessary to support primary care.


  • Option 1 builds incrementally on the existing physician fee schedule (PFS) to value primary care services more accurately.
  • Option 2 provides overarching models to blend fee-for-service (FFS) and fixed payments.
  • Option 3 puts forth global payment models for practices prepared to take on more financial risk.
  • Option 4 discusses creating a societal goal for the proportion of health care spending that goes to primary care.


My take – All of these options are an improvement on the current system, which skews toward rewarding specialists more than it does primary care providers. What we need is a system that makes practicing primary care more rewarding and economically feasible.


In addition to paying primary care doctors more for what they do, another important step is for payers, including self-funded employers, to do more to recognize and incentivize the delivery of high-value primary care. This means using the right technologies and metrics to separate those who consistently provide high-value primary care at a fair price from those who don’t in order to direct patients to them. It also means incentivizing activity that coordinates care, such as appropriate referrals and prescribing, as well as performance, such as health outcomes.


Demand customers select a Primary Care Provider (PCP) – or the payer assign them one


The most intriguing recommendation of the report? If patients fail to select a PCP, then payers assign them to one.


Payers use two processes to assign patients to clinicians: voluntary alignment and attribution. In voluntary alignment, health plan members select their primary care providers. This comes with the advantage of the patient making an informed choice and engaging with a health plan and a provider based on their own preferences and needs.  


Alternatively, with the attribution approach, the health plan matches a patient to a PCP based on the best data available, such as claims patterns, location, and PCP availability.


My take – Insisting on matching members with PCP teams aligns squarely with the points made earlier that primary care is critical to better health outcomes. The really important point made by this report recommendation is that members must be assigned to a PCP BEFORE care is needed. This means that the member knows right away who to turn to not only for immediate needs, but also has a trusted coach to help navigate if the need for further specialty care arises.   


So, what’s the hold up?


As important as these recommendations from the NASEM report are for fixing what ails primary care in the US, they really are just another example of what we in the ecosystem have known (but sadly few have acted upon) for years if not decades. I would even say that pretty much everyone in the healthcare ecosystem conceptually agrees with the primacy of primary care in making us all healthier and less costly to treat.


So, if there is this radical agreement, why aren’t we making more progress? How do we actually put these insights to work?


A big part of the answer lies in self-funded employers endorsing the need for primary care-centered, high-performing health plans, and then actually putting these plans in place for their employees. The barrier, of course, is that the big traditional insurance carriers have so much conflict of interest in making the tough calls needed to build these plans that they simply do not do so. And that’s where we step in.


At Centivo, we have built a health plan for self-funded employers that is anchored around providers of value-based care. And in line with the NASEM recommendations, employees who select that plan must choose an in-network PCP. They then get a plan with free primary care (not just wellness visits and screenings), no deductibles or coinsurance, and an easy-to-understand copay schedule. In other words, we have not only taken down the financial barriers that prevent great primary care, but we have also actually built a plan that incentivizes it.


Does this sound like primary care progress to you? Reach out to Centivo to learn more.


1 BenefitsPRO, July 26, 2019. U.S. Spending Less Than Other Countries on Primary Care.

2 Primary Care Collaborative, December 2020. Primary Care Spending: high stakes, low investment.

3 “The impact of a regional patient-centered medical home initiative on cost of care among commercially insured population in the US,” DovePress, May 2016.

Wayne Jenkins