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Primary Care
What is Primary Care?
Multiple definitions of primary care (PC) exist. The American Academy of Family Physicians defines primary care as: "A provision of integrated, accessible health care services by physicians and their health care teams and networks who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of the community. The care is person-centered, whole-body care, team-based, community-aligned, and designed to achieve better health care and outcomes, and lower costs associated with this care. The care provided to patients, the system delivering that care, and the clinicians providing PC form a framework where patients can access efficient, equitable, and effective PC services of the highest quality leading to better care, better health outcomes, and lower costs".
According to the American Academy of Family Physicians, "Primary care physicians are trained for and skilled in comprehensive, first contact, and continuing care for persons with any undiagnosed symptoms, or health concerns not limited by problem origin (biological, behavioral, or social), organ system, or diagnosis. Additionally, primary care includes health promotion, disease prevention, health maintenance, counseling, patient education, diagnosis and treatment of acute and chronic illnesses in a variety of health care settings (e.g., office, inpatient, critical care, long-term care, home care, schools, telehealth, etc.). Primary care is performed and managed by a personal physician who often collaborates with other health professionals, and utilizes consultation or referral as appropriate. Primary care provides patient advocacy in the health care system to accomplish cost-effective and equitable care by coordination of health care services. Primary care promotes effective communication with patients and families to encourage them to be a partner in health care".
Source: https://www.aafp.org/about/policies/all/primary-care.html
Hawaii Med-QUEST Division (MQD) & Primary Care
Better PC is associated with improved health outcomes, lower health care costs, and reductions in health disparities in populations thus essential to managed care. PC is the foundation supporting other state health care priorities, such as value-based care and health equity. Primary care is central to a high-functioning healthcare system and thus, there is an urgent need to preserve and strengthen primary care as well as a need for support of preventive care and illness care services for Medicare beneficiaries.
Source: https://www.chcs.org/resource/strengthening-primary-care-through-medicaid-managed-care/
Key working definitions:
Primary Care Visits, which are the setting for preventive care provided by primary care providers, often serving as the first point of care for an individual.
Primary Care Services, or services provided or, in some cases, recommended in the outpatient primary care setting. Primary Care Services are parsed into:
2a. Beneficial Primary Care Services, defined as preventive care with a focus on high-value care services such as screenings, immunizations and vaccinations provided in the primary care setting; and
2b. Low-Value Primary Care Services, defined as services that are typically considered unnecessary and known to result in wasteful spending.
Primary Care Supports, defined broadly as the set of care services that engage, support, stabilize, and improve management of the member in the outpatient setting, so as to reduce excessive and inappropriate inpatient utilization.
Local and Federal Initiatives
Hawai‘i ‘Ohana Nui Project Expansion (HOPE): MQD is building the Hawai‘i ‘Ohana Nui Project Expansion (HOPE) program, a five-year initiative to develop and implement a roadmap to achieve a vision of healthy families and healthy communities. QI will be the vehicle for the HOPE program, which includes an emphasis on health promotion, prevention, and primary care.
Primary Care Innovation in Medicaid Managed Care Profile: Hawaii 2019: Includes Hawai'i MQD PC vision, advanced PC goals, PC initiatives (existing and finished), and quality measures.
Primary Care First (PCF): "Primary Care First is a voluntary alternative five-year payment model that rewards value and quality by offering an innovative payment structure to support the delivery of advanced primary care. In response to input from primary care clinician stakeholders, Primary Care First is based on the principles underlying the existing Comprehensive Primary Care Plus (CPC+) model design: prioritizing the clinician-patient relationship; enhancing care for patients with complex chronic needs, and focusing financial incentives on improved health outcomes. Primary Care First aims to foster practitioner independence by increasing flexibility for primary care, providing participating practitioners with the freedom to innovate their care delivery approach based on their unique patient population and resources. PCF participants may receive additional revenue based on their performance on easily understood, actionable outcomes".
Primary Care Physician (PCP) Reimbursement Enhancement: PCP reimbursement enhancement in accordance with Section 1202 of the Affordable Care Act (ACA), the Department of Human Services (DHS) MQD extends its enhanced reimbursement rate for certain primary care services provided by eligible primary care physicians (PCP). The initial two-year provision ended December 31, 2014. This ongoing provision increased payment rates for certain primary care services such as smoking and tobacco use cessation, immunizations, and preventive medicine to at least the level of Medicare.
Relevant Evaluation of PCP: RAND Corporation. Examining the Implementation of the Medicaid Primary Care Payment Increase Report. (2017): "To better understand differences in approaches and potential challenges in implementing the policy from the perspective of Medicaid officials, providers, patients, and health plan administrators, ASPE commissioned the RAND Corporation to conduct an independent case study into stakeholder experiences before, during, and after the policy’s implementation. During the summer and fall of 2016, RAND held discussions with these stakeholders to elicit their experiences planning for, implementing, and evaluating the impact of the policy. This report describes the results of this work".
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