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New York’s delivery system suffers from a severe lack of investment in primary care. As a result,
the state has not done well in preventing, managing or caring for the growing number of New Yorkers
with chronic illness. While spending more than any other state on Medicaid, New York State
ranks 50th in “avoidable use of hospitals and costs of care” according to the Commonwealth Fund
Scorecard on US Health System Performance. New York ranks 45th among the 50 states in Medicaid
spending on primary care.
As the population ages and demand for services grows, we must recognize that the more New York
State invests in its primary care system, the less it will spend overall on healthcare. To achieve
affordable, appropriate healthcare coverage for all, it is essential that we enhance, support and
sustain primary and preventive care services in New York State.
The Primary Care Coalition has identified five actions required to build a strong, effective
primary care sector. These constitute “the primary care agenda” for New York State:
- Reform the payment system for primary care
- Preserve and expand primary care workforce capacity
- Build New York’s primary care infrastructure
- Transform the current model of care into a patient-centered medical home
- Aggressively promote the use and adoption of health information technology
among providers of primary care services
1. REFORM THE PAYMENT SYSTEM FOR PRIMARY CARE
Investment in primary care begins with reimbursement
policy. If primary care providers do not receive adequate
payment, they will be unable to afford the significant
ongoing cost of providing essential health care services.
Payment reform is essential to accomplish all other items
on the primary care agenda.
PROBLEM:
Currently, reimbursement for primary care services is
inadequate, often inequitable and often pays for episodic
visits rather than the services needed for prevention and
care management.
WHERE ARE WE NOW?
While New York State took some steps toward Medicaid
primary care payment reform, full implementation of these reforms has been slowed by the
severe fiscal crisis confronting the State. Federal payment reforms will help but New York
still must continue its own investment in primary care to achieve the potential in savings and
quality improvements inherent in the transition to a primary care based health care system.
Specific payment reforms in the package of federal health care reform laws include:
- 10% incentive payments to primary care physicians whose Medicare charges for office,
nursing facility and home visits comprise at least 60% of their total Medicare charges.
- 5% incentive payment for mental health services.
- Reinstitution of the geographic payment differential that will benefit primary care physicians
in rural and low cost areas.
- Increase Medicaid payments to primary care physicians for evaluation and management services and immunizations to at least Medicare levels in 2013 and 2014 with the Federal government paying for the full cost of meeting this requirement.
NEXT STEPS:
- Fully implement and fund primary care payment reforms included in the 2008-09 State Budget.
- Expand support offered by the Patient Centered Medical Home (PCMH) incentive pool and implement a blended reimbursement schedule for medical homes that incorporates a fee-forservice
(per visit) component, a per-member per-month care management stipend, and an incentive for meeting and reporting quality performance goals.
- Assure that all primary care reforms are reflected not only in Medicaid fee for service but also in managed care contracts.
- Encourage New York State to pay Medicaid primary care fee for service rates at Medicare levels in 2011 and 2012. While the federal government will pay these added costs in 2013 and 2014, encourage it to continue enhanced Medicaid primary care payments beyond 2015. Be prepared to fund these payments with State revenues if the federal government does not extend its investment.
- Encourage implementation of comparable payment reforms by commercial payers and use insurance regulation to achieve increased investment in primary care among commercial payers.
2. PRESERVE and EXPAND PRIMARY CARE WORK CAPACITY
PROBLEM:
Many communities currently lack the primary care workforce capacity
needed to ensure that all New York residents have access to primary care.
Expansion of the primary care workforce will require years of effort
to achieve.
WHERE ARE WE NOW?
The Doctors Across New York program funds loan repayment and
practice support for physicians willing to practice in underserved areas.
Additionally, incentives for training in ambulatory care settings have
been planned.
Federal health care reform reauthorized and expanded many existing
federal health professions training programs for primary care disciplines.
It also established new training programs to increase the primary care
workforce, including Teaching Health Centers (to establish new accredited
or expanded primary care residency programs) and the Primary Care
Extension Program (to provide technical support and assistance to primary care practices in quality
improvement and system redesign, patient-centered medical home implementation, and evidencebased
practices).
NEXT STEPS:
- Fully fund the Doctors Across New York loan repayment, physician practice support, and ambulatory care training programs.
- Continue to expand Area Health Education Center (AHEC) and other community-based initiatives to recruit and train health professionals in primary care and in communities of need.
- Expand scholarship programs and create a New York State public service corps to pay medical school and nursing school tuition for students who commit to practicing primary care in medically underserved areas of New York for five years after completing their professional education.
- Encourage and support those eligible within New York to apply for federal grants under health care reform provisions that will build primary care workforce and capacity.
3. BUILD NEW YORK"S PRIMARY CARE INFASTRUCTURE
PROBLEM:
Lack of capital resources to expand, renovate or build new provider
sites seriously inhibits the expansion of primary care capacity.
WHERE ARE WE NOW?
The State has made available modest funding through its HEAL
grant program for primary care expansion among health centers
and hospitals. These resources are insufficient. Moreover, they
have been unavailable to private practitioners seeking to expand,
renovate or set up new practice sites.
NEXT STEPS:
- Continue State capital investment in the primary care infrastructure. Assure that capital resources for private practitioners are included.
- Assure that communities experiencing the downsizing or closing of hospitals retain or build adequate primary care capacity to meet their needs.
- Augment State efforts by inducing private investment to provide primary care providers with greater access to needed capital. This can be done by establishing a Primary Care Access Fund offering low-cost financing to build New York’s primary care infrastructure.
4. TRANSFORM THE CURRENT MODEL OF CARE INTO A
PATIENT-CENTERED MEDICAL HOME
PROBLEM:
The rapid growth of chronic disease coupled with costly rates of avoidable
hospitalizations and readmissions has led to exorbitant healthcare
costs in New York State. Studies show that, organized into a Patient-
Centered Medical Home (PCMH) model, primary care can reduce costs,
improve patient outcomes and reduce disparities. This model addresses
care that is now often fragmented, episodic and subject to access barriers,
such as long waits for appointments. These changes in practice are
difficult and expensive to implement, however.
WHERE ARE WE NOW?
The New York State Medicaid program has taken significant steps— most in early stages—to encourage reorganization of primary care into
the patient-centered medical home model. Federal health care reform will
support additional PCMH implementation, and statewide demonstrations
of the patient-centered medical home are underway. Federal health care reform also offers funding
for Primary Care Extension Program State Hubs and local Primary Care Extension Agencies
offering technical assistance to support providers in transforming their practices.
NEXT STEPS:
- Assure that PCMH standards and supportive payment methods are adopted by all payors and are adequate to pay for the additional expenses of providing a patient centered medical home.
- Provide technical assistance to primary care providers to transform their practices into patient centered medical homes.
- Assure that New York State applies successfully for federal Primary Care Extension Program funds or otherwise supports PCMH implementation. Expand State incentives already underway.
- Monitor and assess the implementation, progress and evaluation of PCMH demonstrations occurring throughout the state.
5. AGGRESSIVELY PROMOTE THE USE AND ADOPTION OF
HEALTH INFORMATION
TECHNOLOGY AMONG PROVIDERS
OF PRIMARY CARE SERVICES
PROBLEM:
Investment in health information technology (HIT) is expensive yet essential to providing effective
primary and preventive care. Introduction of HIT into a practice can be time consuming and
disruptive. These barriers have delayed the adoption of
HIT by providers.
WHERE ARE WE NOW?
New York has allocated significant grant funding to support
HIT adoption in communities across the State. Much of
this support has been targeted to institutional and hospital
providers as well as to building the State’s HIT infrastructure.
Only a small portion of this money has supported community
health centers and small medical practices.
At the federal level, the stimulus program provides incentive
funding from 2011 through 2015 for physicians and
hospitals that adopt electronic health records and show they
are meaningfully using them. It also funded two Regional
Extension Centers (one for New York City and one for the
rest of the State) to provide technical assistance in EHR adoption and use to community health
centers and small primary care practices, especially those located in underserved communities.
NEXT STEPS:
- Assure that all primary care providers receive capital resources for HIT acquisition and maintenance.
- Assure that all primary care providers continue to receive technical assistance in implementation and use of HIT.
Click here to download a pdf of the 2011 Primary Care Agenda.
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