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A Primary Care Physician was considered a “Gatekeeper” because originally under most managed care arrangements, PCP’s coordinate patient care from various providers and in various settings within a system, thus helping to ensure appropriate care and resource use.

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The Affordable Care Act encourages the utilization of all types of primary care providers in innovative care models and increases support for primary care.

The term “primary care provider” as used in the Affordable Care Act means a clinician who provides integrated, accessible health care services and who is accountable for addressing a large majority of personal health care needs, including providing preventive and health promotion services for men, women, and children of all ages, developing a sustained partnership with patients, and practicing in the context of family and community, as recognized by a State licensing or regulatory authority, unless otherwise specified in this section.

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The Affordable Care Act states that the “National Strategy for Quality Improvement in Healthcare” (124 STAT. 378) includes:

• NATIONAL STRATEGY FOR QUALITY IMPROVEMENT IN HEALTH CARE.
• ‘‘(a) ESTABLISHMENT OF NATIONAL STRATEGY AND PRIORITIES.—
• ‘‘(1) NATIONAL STRATEGY.—The Secretary, through a transparent collaborative process, shall establish a national strategy to improve the delivery of health care services, patient health outcomes, and population health.
• ‘‘(2) IDENTIFICATION OF PRIORITIES.—
• ‘‘(A) IN GENERAL.—The Secretary shall identify national priorities for improvement in developing the strategy under paragraph (1).
• ‘‘(B) REQUIREMENTS.—The Secretary shall ensure that priorities identified under subparagraph (A) will—
  • ‘‘(i) have the greatest potential for improving the health outcomes, efficiency, and patient-centeredness of health care for all populations, including children and vulnerable populations;
  • ‘‘(ii) identify areas in the delivery of health care services that have the potential for rapid improvement in the quality and efficiency of patient care;
  • ‘‘(iii) address gaps in quality, efficiency, comparative effectiveness information, and health outcomes measures and data aggregation techniques;
  • ‘‘(iv) improve Federal payment policy to emphasize quality and efficiency;
  • ‘‘(v) enhance the use of health care data to improve quality, efficiency, transparency, and outcomes;
  • ‘‘(vi) address the health care provided to patients with high-cost chronic diseases;
  • ‘‘(vii) improve research and dissemination of strategies and best practices to improve patient safety and reduce medical errors, preventable admissions and readmissions, and health care-associated infections;
  • ‘‘(viii) reduce health disparities across health disparity populations (as defined in section 485E) and geographic areas; and
  • ‘‘(ix) address other areas as determined appropriate by the Secretary.

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In addition the national strategy shall include a comprehensive strategic plan to achieve the priorities described in the national strategy.  The Strategic Plan shall include provisions for addressing, at a minimum, the following:

• ‘‘(A) Coordination among agencies within the Department, which shall include steps to minimize duplication of efforts and utilization of common quality measures, where available. Such common quality measures shall be measures identified by the Secretary under section 1139A or 1139B of the Social Security Act or endorsed under section 1890 of such Act.
• ‘‘(B) Agency-specific strategic plans to achieve national priorities.
• ‘‘(C) Establishment of annual benchmarks for each relevant agency to achieve national priorities.
• ‘‘(D) A process for regular reporting by the agencies to the Secretary on the implementation of the strategic plan.
• ‘‘(E) Strategies to align public and private payers with regard to quality and patient safety efforts.

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Under the Affordable Care Act, Title IV, “Prevention of Chronic Disease and Improving Public Health”, Subtitle A, “Modernizing Disease Prevention and Public Health Systems”, states that the President shall establish, within the Department of Health and Human Services, a council to be known as the ‘‘National Prevention, Health Promotion and Public Health Council’’.  After obtaining input from relevant stakeholders, this Council is to develop a national prevention, health promotion, public health, and integrative health care strategy that incorporates the most effective and achievable means of improving the health status of Americans and reducing the incidence of preventable illness and disability in the United States.  The Council is to provide recommendations to the President and Congress concerning the most pressing health issues confronting the United States and changes in Federal policy to achieve national wellness, health promotion, and public health goals, including the reduction of tobacco use, sedentary behavior, and poor nutrition.

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Generally PCPs are:

• Family Practitioners
• General Internists
• Pediatricians
• Obstetricians and Gynecologists

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Managed care arrangements generally classify physicians into two categories – Primary Care Physician (“PCP”) and Specialist. PCP’s generally have oversight responsibility for coordinating the total spectrum of healthcare services for a given patient.

The definition of who is a PCP varies. PCP’s usually include: family practitioners, general internists, pediatricians, and sometimes obstetricians and gynecologists. PCP’s are usually the means by which patient’s access and navigate a healthcare system.

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Under the traditional managed care system a PCP is considered a “Gatekeeper” because under most managed care arrangements, PCP’s coordinate patient care from various providers and in various settings within a system, thus helping to ensure appropriate care and resource use. PCP’s are usually paid a capitated rate by HMO’s for each patient in their panel that they are responsible for. Under a capitated arrangement the PCP usually receives a fixed payment per panel member no matter what services are provided. Also, PCPs may be required to pay for referrals and tests from this fixed sum of money.

Some states require HMO’s to provide certain minimum services, or to have certain terms/provisions in their managed care agreements. Other than certain laws and regulations that may exist, most of the terms under agreements between Managed Care Organizations (“MCO’s”) and physician’s are negotiated. Once the MCO’s and physician’s (or physician networks) have negotiated and agreed upon terms, then these terms are usually put into a written agreement. The agreement between physicians and MCO’s typically deal with such issues as to: the definition of Primary Care Physician (who is a PCP under that agreement), what services the PCP is to provide and to whom, the dollar amount the PCP is to receive, and when payment to PCP is to be received.

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Patient Rights Laws

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Consider: If a HMO in Michigan says it will no longer consider internists as PCPs, members would have to choose among the network’s Family Practitioners and General Practitioners.  Internists would be considered specialists and patients would need a referral to see them.  In protesting this move, the American College of Physicians-American Society of Internal Medicine (ACP-ASIM) claimed the new policy would disrupt continuity of care and ultimately increase health costs.  Since Internists typically treat older patient populations, ACP-ASIM questioned the HMOs motives, such as was the HMOs motive to reduce costs by encouraging these patients to disenroll from the network by denying patients with chronic diseases the coverage to see the doctors who are trained to treat them. The HMO admitted its mistake and acknowledged that the policy change was prompted to make money due to the high incidence of chronic disease in the community. The HMO restored internists as PCPS.

The Affordable Care Act references the value of motivating patients to maintain a healthier diet, engage in more exercise, stop smoking, manage their medication and live overall healthier lives.

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[Source: HealthCare.gov]

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