How Evolving United States Payment Models Influence Primary Care and Its Impact on the Quadruple Aim

J Am Board Fam Med. 2018 Jul-Aug;31(4):588-604. doi: 10.3122/jabfm.2018.04.170388.


Introduction: Prior research has demonstrated the associations between a strong primary care foundation with improved Quadruple Aim outcomes. The prevailing fee-for-service payment system in the United States reinforces the volume of services over value-based care, thereby devaluing primary care, and obstructing the health care system from attaining the Quadruple Aim. By supporting a shift from volume-based to value-based payment models, the Medicare Access and Children's Health Insurance Program Reauthorization Act may help fortify the role of primary care. This narrative review proposes a taxonomy of the major health care payment models, reviewing their ability to uphold the functions of primary care, and their impacts across the Quadruple Aim.

Methods: An Ovid MEDLINE search and expert opinion from members of the Family Medicine for America's Health payment and research tactic teams were used. Titles and abstracts were reviewed for relevance to the topic, and expert opinion further narrowed the literature for inclusion to timely and relevant articles.

Findings: No payment model demonstrates consistent benefits across the Quadruple Aim across a limited evidence base. Several cross-cutting lessons from available payment models several recommendations for primary care payment models, including the following: implementing per member per month-based models, validating risk-adjustment tools, increasing investments in integrated behavioral health and social services, and connecting payments to patient-oriented and primary care-oriented metrics. Along with ongoing research in emerging payment models, data systems integrated across health care and social services settings using metrics that can capture the ideal functions of primary care will be critical to the development of future payment models that most optimally enhance the role of primary care in the United States.

Conclusions: Although the ideal payment model for primary care remains to be determined, lessons learned from existing payment models can help guide the shift from volume-based to value-based care. To most effectively pay for primary care, future payment models should invest in a primary care infrastructure, one that supports team-based, community-oriented care, and measures the delivery of the functions of primary care.

Keywords: Delivery of Health Care; Family Medicine; Health Expenditures; Primary Health Care.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Fee-for-Service Plans / statistics & numerical data
  • Fee-for-Service Plans / trends
  • Health Expenditures*
  • Health Services Accessibility / economics*
  • Health Services Accessibility / trends
  • Humans
  • Medicare
  • Primary Health Care / economics*
  • Primary Health Care / statistics & numerical data
  • Primary Health Care / trends
  • Reimbursement, Incentive / statistics & numerical data
  • Reimbursement, Incentive / trends*
  • United States
  • Value-Based Health Insurance / statistics & numerical data*