Value-Based Care Necessitates Shift in Primary Care Staffing Model

August 13, 2019 - The medical assistant-only model for primary care staffing may be the most cost-effective for practices relying on fee-for-service revenue, but the model will not be able to support value-based care and other sophisticated revenue arrangements, Premier recently reported.

In a new analysis of 2018 data from 257 family medicine and primary care practices, the healthcare improvement company found that 22 percent of practices used a medical assistant-only primary care staffing model, while 54 percent staffed with a combination of registered nurses or licensed practical nurses along with medical assistants, and 24 percent staffed with all three of the provider types.

While primary care practices tended to use a combination of provider types, the analysis showed no correlation between employing a richer skill mix and higher levels of productivity, making the medical assistant-only staffing model the most lucrative for practices.

Employing a medical assistant-only model cost about half of as much as hiring a combination of providers with a higher skill mix, Premier reported.

But the medical assistant-only primary care staffing model may not be able to support new models of care that aim to address complex health and behavioral health needs, explained Chris Smedley, vice president of physician enterprise services at Premier.

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“As the industry moves toward value, participating in risk-based models will become a more viable option for many to ensure financial success. Providers will need to layer on staff with more specialized skill sets in order to more proactively address patient needs in value-based models,” he said. “The key is to appropriately evolve staffing models as organizations shift to managing the health of their populations.”

Primary care practices should employ a higher skill mix as the organizations transition away from fee-for-service, including registered nurses and licensed practical nurses alongside medical assistants.

Practices should also hire behavioral health specialists and even social workers, nutritionists, and pharmacy support staff as the practice takes on risk-based models that share financial responsibility with health systems, the company suggested.

The primary care staffing models key to value-based care and risk-based model success will be an investment, costing practices significantly more compared to a medical assistant-only model. However, investing in the right staffing model should pay off as practices qualify for incentive payments, shared savings, and other value-based reimbursements.

Determining the best staffing model for a practice will hinge on the organization’s readiness to take on value-based care and financial risk.

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For example, medical groups and practices satisfied with remaining in fee-for-service should reconsider their staffing models if they employ a richer skill mix. The mix “may only be contributing to higher practice expense and ineffective use of resources relative to licensed staff,” Premier stated.

Many medical groups are currently at this place in the transition to value-based care, or only slightly further along. According to AMGA’s most recent risk readiness survey, federal and commercial fee-for-service revenue among medical groups fell by 20 percent and eight percent, respectively, from 2015 to 2018.

Furthermore, 61 percent of physicians in a 2018 poll conducted by the Doctors Company said value-based care will have a negative impact on their practice. Another 63 percent said the transition away from volume will also negatively influence their earnings.

In the early stages of the value-based care transition, hospitals and health systems focused on the acute setting, which represented the largest savings opportunity. This left medical groups and their practices on the outskirts of the value-based care transition, leading to wide variation in operating models and gaps in value-based care capabilities, Premier explained.

But more value-based care models are starting to target primary care practices. For example, Medicare’s Quality Payment Program now attributes patients to providers participating in Advanced Alternative Payment Models using primary care.

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CMS also recently announced Primary Care First, a program that rewards practices for delivering advanced primary care services, which are broader than the traditional primary care skillset and emphasize patient-centered, coordinated, team-based care.

Medical groups and associated practices will have more opportunity to meaningfully participate in value-based care models as the shift away from volume evolves. Therefore, assessing the practice’s staffing model as soon as possible is key to value-based and risk-based care success.

Premier advised practice leaders to use business intelligence solutions to assess the staffing model and provider performance. Solutions are able to integrate data from a variety of sources (e.g. billing, scheduled, payroll, general ledger) to create peer comparisons.

Automating the collection and analysis of information also gives leaders more time to manage data and glean actionable insights.

“Primary care is one of the highest priorities for health systems as they move to value-based care and payment models,” said Smedley. “However, many primary care clinics are still operating under fee-for-service and lack the insights necessary to effectively adjust their operating models as they transition to value.”