Advancing Primary Care Through Alternative Payment Models: Lessons from the United States & Canada

[摘要] The United States and Canada share high costs, poor health system performance, and challenges to the transformation of primary care, in part due to the limitations of their fee-for-service payment models. Rapidly advancing alternative payment models (APMs) in both countries promise better support for the essential tasks of primary care. These include interdisciplinary teams, care coordination, self-management support, and ongoing communication. This article reviews learnings from a 2017 binational symposium of 150 experts in policy and research that included a discussion of ongoing APM experiments in the United States and Canada. Discussions ranged from APM challenges and successes to their real and potential impact on primary care. The gathering yielded many lessons for policy makers, payors, researchers, and providers. Experts lauded recent APM experimentation on both sides of the border, while cautioning against the risk of “pilotitis,” or developing, implementing, and evaluating new payment models without plan or ability scale them into broader practice. Discussants highlighted the power of “learning at scale,” highlighting large-scale primary care payment innovations launched by the US Center for Medicare and Medicaid Innovation since 2011, and called for a similar national center to drive innovation across provincial health systems in Canada. There was general consensus that altering payment models alone, absent incentives for innovation and continuous learning as well as increased proportional spending on primary care overall, would not correct health system deficiencies. Participants lamented the absence of more robust evaluation of APM successes and shortcomings, as well as more rapid release of results to accelerate further innovation. They also highlighted the importance of APMs that include flexible and upfront payments for primary care innovations, and which reward measuring and achieving global rather than intermediate outcomes, to achieve utilization goals and patient and provider satisfaction. Near neighbors and sibling nations in history and trade, the United States and Canada also share a history of poor health system performance, resulting in part from the limitations of fee-for-service (FFS) payment. ^{1 ⇓ ⇓ ⇓ ⇓ – 6} Favoring volume over quality of care, such systems are also thought to limit primary care effectiveness, and have given rise to calls in both nations to move toward alternative payment models (APMs). ^{7 ⇓ ⇓ – 10} In March 2017, approximately 130 Canadian and US leaders from policy and academia assembled in Washington DC to discuss lessons in improving primary care effectiveness that might be disseminated across borders (See Appendix for Attendee list). The invitation-only gathering included provincial and state health ministers and leadership, academic and thought leaders, as well as leadership from many federal and provincial agencies that finance health care and evaluation in both countries. Dyadic panel presentations featuring experts from both countries were followed by rich audience discussion, with taping and careful notetaking used post hoc by conference planners to thematically organize and distill seminal lessons for broader dissemination. The authors of this commentary specifically reviewed all notes from sessions on APMs, which revealed binational agreement on the importance of advancing APMs capable of improving primary care effectiveness. This article summarizes expert opinions on the current state of APMs in the United States and Canada, as well as key lessons and implications for policy makers, payors, researchers, and delivers with interest in supporting primary care to advance health in both nations.

[学科分类] 过敏症与临床免疫学