Shift to value-based payment will require new staffing mix for primary care, analysis finds

As they shift to value-based payment, primary care practices will need staff with a higher skill mix aimed at keeping patients healthy, according to a new analysis.

Practices will need to add new staff such as behavioral health providers, social workers, nutritionists, and pharmacist support, according to a white paper from Premier Inc., a healthcare improvement company.

While many primary care practices and clinics are still operating under fee-for-service payment models, those that want to transition to value-based care will need to adjust their operating models, including staffing, Chris Smedley, vice president of physician enterprise services at Premier, said in an interview with FierceHealthcare.

Practices will need to add staff that support physicians in focusing on preventive care for patients, Smedley said. “It’s really a mental switch between dealing with the recurring visit or the problem-of-the-day to more proactive and integrated care.”

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Chris Smedley (Premier)

While higher skill staff will cost practices more in salaries, under a value-based payment model that will balance out as practices are paid more for keeping patients healthy and out of hospitals and emergency rooms. Practices will need to focus on everything from patient wellness to nutrition.

Using its database of detailed physician practice information, Premier analyzed 2018 data from 257 family medicine and primary care practices to look at variation across staffing models and identify opportunities for improvement. The analysis found wide variation in staff models and productivity.

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For practices that are fee-for-service revenue-based, the most cost-effective staffing option is a medical assistant-only model with the highest performing models having a larger number of support staff per provider. But that changes in a value-based system.

The Centers for Medicare & Medicaid Services (CMS) is moving practices to value-based care with its Quality Payment Program, established under the Medicare Access and CHIP Reauthorization Act, or MACRA. 

The best staffing model depends on where practices are in the journey to value-based care, Smedley said: “As you shift to value-based care and population health, the key here is to be intentional about what staffing you are using and why.”

The analysis found that 22% of family medicine and primary care clinics used a medical assistant-only model; 54% were staffed with a combination of registered nurses (RNs) or licensed practical nurses (LPNs) along with medical assistants; and 24% were staffed with RNs, MAs, and LPNs.

In a fee-for-service model, practices with medical assistant-only models and comparable staff were just as likely to achieve top performance as those with higher skill mix models with registered nurses, the analysis found. Those were also almost half the cost of higher skill mix models, with no discernible differences in productivity or output, the report found.

“People always ask the question, what’s the ideal primary care staffing model. What we learned from this analysis is it depends where you are in your transition to value,” Smedley said. Adding staff with a higher skill level and having those employees work to the highest level of their licensure is important. Practices need to ensure they use their staff to better coordinate and manage care.

“The idea is if you are shifting toward value and introducing a richer skill mix, ultimately you should be helping them drive down the overall total cost of care. While you might invest more in staff, you’re focused more on preventive care,” Smedley said.