This editorial describes several key lessons about the development of effective value-based care delivery.
The American Journal of Accountable Care. 2023;11(3):33-35. https://doi.org/10.37765/ajac.2023.89436
In this issue of TheAmerican Journal of Accountable Care, Daugherty et al1 describe a large-scale initiative to transform primary care practices across the Allegheny Health Network. Transformation efforts were implemented in waves, with 10 to 12 practices launching the process every 6 to 9 months. Practices went through 3 stages of transformation, including optimizing staffing, initiating continuous process improvement, and integrating new clinical team members to enhance primary care delivery. Several key lessons about development of effective value-based care delivery emerge from this account.
First, the article acknowledges the important point that effective teams are necessary to support modern primary care. The value of robust primary care teams has been demonstrated in an extensive literature. Delivery of team-based care as part of a medical home to a general primary care population has been associated with improved patient experience, reduced costs, and improved quality.2 Receipt of team-based care by chronically ill patients has been associated with reductions in hospitalizations, overall emergency department visits, and ambulatory care–sensitive emergency department visits.3 Moreover, team-based care is associated with lower burnout among primary care employees.4
Yet even since this literature was developed, the practice of primary care has substantially changed. The role of the primary care physician (PCP) has expanded to include a significant amount of work not directly tied to face-to-face visits. This includes addressing gaps in ambulatory quality, coordinating care for high-risk patients, and managing chronic diseases between visits. In fact, one recent study estimated that PCPs would require more than 26 hours a day to deliver all the recommended preventive care, chronic disease care, and acute care needed for a hypothetical panel of 2500 adult patients.5 Additionally, since the passage of the Health Information Technology for Economic and Clinical Health (HITECH) Act, which encouraged adoption of electronic health records in clinical practice, the role of electronic documentation and communication has markedly increased. Our research demonstrates that PCPs spend a significant proportion of their days on the electronic health record—and several-fold more time than clinicians in other specialties.6 Although this time—especially after hours—may be associated with emotional exhaustion,7 it is also associated with better quality of care in some circumstances,8 so ideally, it would be supported by a team rather than eliminated. Thus, in the modern care delivery landscape, the traditional 1:1 medical assistant to physician ratio is even less adequate than it was when the original studies demonstrating the benefits of team-based care were conducted. Additionally, existing research suggests that there is continued room to expand team-based care delivery in primary care compared with other specialties.9
The authors describe how they successfully augmented existing care teams with advanced practice providers, registered nurses, and health coaches who can help PCPs comanage panels, see urgent visits, triage and address patient questions, and help support patients toward their health goals. The 2.5 full-time equivalents of clinical support for every 1.0 physician full-time equivalent described by the authors are roughly similar to or slightly higher than ratios described in research regarding optimal patient-centered medical home staffing.10,11 Ultimately, it was further supplemented by extended care teams consisting of behavioral health consultants, clinical pharmacists, and dietitians. Future research may benefit from formal assessments of how the combination of these care team enhancements affects physician time expenditure, physician experience, and how diverse clinical team members spend their time.
It is worth noting that the scaling up of teams described in this article is not an easy feat from either a logistical or a financial perspective. A central transformation team guided practices through principles of staffing optimization, continuous process improvement, and integration of new team members. This also enabled sharing of best practices and a consistent staffing approach across the network. However, the presence of this type of transformation team and additional infrastructure ultimately requires substantial investment. It is notable that financial outlays for the program were ultimately justified by a positive return on investment via value-based contracts. Because most organizations function in a predominantly fee-for-service (FFS) environment, garnering support for enhanced primary care teams has remained a consistent challenge. As previously noted by Basu et al,12 clinics typically operate near maximum net revenue levels under traditional FFS payments. Increased FFS payments would not alone be expected to produce enough additional revenue to incentivize enhanced staffing to meet patient-centered medical home requirements. However, this outlay could be more feasible under arrangements in which FFS payments are supplemented by additional per-member per-month or adequate pay-for-
performance payments,12 or under high levels of capitation.13 Along this line, the authors note that their efforts resulted in an improvement in the aggregate Star ratings for primary care practices in the Allegheny Health Network, resulting in a superior performance bonus of $983,000 that, when combined with base value-based reimbursements, exceeded investments made in staffing and transformation. Ideally, the expansion of value-based care arrangements would facilitate the ongoing sustainability of these investments via financial streams not tied to care delivered directly in visits.
Perhaps most importantly, the successful initiative described by Daugherty et al requires leadership buy-in and development of incentives to motivate diverse team members regarding transformation. Although changes in value-based reimbursement can make the financial case for transformation, frontline leaders, physicians, and staff in large and diverse health care organizations such as the Allegheny Health Network face competing demands. These could include demands related to enhancing FFS revenue, expanding the organization’s geographic footprint, or advancing an academic mission. Given the ownership of the Allegheny Health Network by Highmark Inc, an insurance carrier, it is likely that the orientation toward transformation and the direct benefits of succeeding in value-based care derive from the very top of the organization. Sustaining this transformation and extending successes made to date in depression screening, postdischarge calls, and other key performance indicators will require continued commitment to this workand value-based care both at the top of the organization and throughout the organization’s matrix. In the longer term, diverse players continuing to feel motivated about this work may require monetary incentives that flow directly to individual practices or clinicians and demonstrated investment of returns from value-based contracts back into the clinics engaging in transformation and quality improvement efforts.
Although the idea of team-based care has been present for some time, its importance is as great as ever in 2023. Transformation centered on team-based care, such as that described by Daugherty et al, is highly relevant in a primary care environment increasingly wrestling with delivery of care via multiple modalities and the potential of value-based care. For those primary care leaders seeking to enhance teams and advance quality and outcomes in predominantly FFS environments, this work provides a road map for transformation as incremental resources become available. Ultimately, as demonstrated in this article, effectively deploying such an effort requires a carefully crafted combination of leadership support, infrastructure, and a favorable financial framework, all of which may become increasingly feasible with the growth of value-based care.
Author Affiliations: Primary Care Center of Excellence, Brigham and Women’s Hospital (LR, RG), Boston, MA; Harvard Medical School, Boston, MA (LR, RG).
Source of Funding: None.
Author Disclosures: Dr Rotenstein reports receiving research grant funding from the American Medical Association. Dr Gitomer reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.
Authorship Information: Concept and design (LR, RG); drafting of the manuscript (LR, RG); and critical revision of the manuscript for important intellectual content (LR, RG).
Send Correspondence to: Lisa Rotenstein, MD, MBA, MSc, Primary Care Center of Excellence, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02215. Email: firstname.lastname@example.org.
1. Daugherty H, Hahn K, Johnjulio W. Primary care transformation: a team-based care model. Am J Accountable Care. 2023;11(3):28-31. doi:10.37765/ajac.2023.89435
2. Reid RJ, Coleman K, Johnson EA, et al. The Group Health medical home at year two: cost savings, higher patient satisfaction, and less burnout for providers. Health Aff (Millwood). 2010;29(5):835-843. doi:10.1377/hlthaff.2010.0158
3. Meyers DJ, Chien AT, Nguyen KH, Li Z, Singer SJ, Rosenthal MB. Association of team-based primary care with health care utilization and costs among chronically ill patients. JAMA Intern Med. 2019;179(1):54-61. doi:10.1001/jamainternmed.2018.5118
4. Helfrich CD, Dolan ED, Simonetti J, et al. Elements of team-based care in a patient-centered medical home are associated with lower burnout among VA primary care employees. J Gen Intern Med. 2014;29(suppl 2):S659-S666. doi:10.1007/s11606-013-2702-z
5. Porter J, Boyd C, Skandari MR, Laiteerapong N. Revisiting the time needed to provide adult primary care. J Gen Intern Med. 2023;38(1):147-155. doi:10.1007/s11606-022-07707-x
6. Rotenstein LS, Holmgren AJ, Downing NL, Bates DW. Differences in total and after-hours electronic health record time across ambulatory specialties. JAMA Intern Med. 2021;181(6):863-865. doi:10.1001/jamainternmed.2021.0256
7. Adler-Milstein J, Zhao W, Willard-Grace R, Knox M, Grumbach K. Electronic health records and burnout: time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. J Am Med Inform Assoc. 2020;27(4):531-538. doi:10.1093/jamia/ocz220
8. Rotenstein LS, Holmgren AJ, Healey MJ, et al. Association between electronic health record time and quality of care metrics in primary care. JAMA Netw Open. 2022;5(10):e2237086. doi:10.1001/jamanetworkopen.2022.37086
9. Rotenstein LS, Apathy N, Edgman-Levitan S, Landon B. Comparison of work patterns between physicians and advance practice practitioners in primary care and specialty care settings. JAMA Netw Open. 2023;6(6):e2318061. doi:10.1001/jamanetworkopen.2023.18061
10. Patel MS, Arron MJ, Sinsky TA, et al. Estimating the staffing infrastructure for a patient-centered medical home. Am J Manag Care. 2013;19(6):509-516.
11. Magill MK, Ehrenberger D, Scammon DL, et al. The cost of sustaining a patient-centered medical home: experience from 2 states. Ann Fam Med. 2015;13(5):429-435. doi:10.1370/afm.1851
12. Basu S, Phillips RS, Song Z, Landon BE, Bitton A. Effects of new funding models for patient-centered medical homes on primary care practice finances and services: results of a microsimulation model. Ann Fam Med. 2016;14(5):404-414. doi:10.1370/afm.1960
13. Basu S, Phillips RS, Song Z, Bitton A, Landon BE. High levels of capitation payments needed to shift primary care toward proactive team and nonvisit care. Health Aff (Millwood). 2017;36(9):1599-1605. doi:10.1377/hlthaff.2017.0367