Getting Your "Value-Based Care House” in Order by Embracing Primary Care

Oct. 2, 2017
Regardless of what becomes of the Affordable Care Act, industry experts agree that value-based care (VBC) initiatives will likely remain. Here are five key VBC-oriented questions to ask regarding your primary care offerings.

Regardless of what becomes of the Affordable Care Act (ACA), industry experts agree that value-based care (VBC) initiatives will likely remain, since VBC has considerable momentum and positive underlying drivers. It is impossible to get to VBC without a strong foundation of primary care accessible to consumers. Yet many primary care strategies have fallen short because health systems have focused on the old “heads in beds” mentality: build a primary care network so that you can generate referrals into specialists and hospitals. Instead, in today’s VBC world, we need primary care to keep patients out of the hospital.

Here are five key VBC-oriented questions to ask regarding your primary care offerings.

Improving Primary Care: 5 Key Questions

Question 1: Do you have a comprehensive strategy and action plan to sustain and grow your supply of primary care providers?

To build and sustain your primary care “network,” you need an adequate and easily accessible supply of providers to serve the unique needs and current and expected service demands of your patient population. If you have not implemented a plan to ensure an adequate supply of primary care providers, you will not survive the transition to value. Ask yourself:

  • Do we have a well-defined strategy to recruit new primary care providers to our organization?
  • Do we have a succession plan to replace primary care providers slated to retire or leave over the next several years?
  • Have we developed a plan to fully optimize the use of mid-level providers such as nurse practitioners (NPs) and physician assistants (PAs) in the primary care setting?
  • Do we have an adequate supply of trained geriatricians?
  • Are our primary care providers appropriately dispersed throughout our communities to provide geographic access to primary care to current and future populations?

Question 2: Has your organization deployed team-based care in the primary care setting?

When properly designed and deployed, team-based care has been shown to reap significant benefits in practices of all sizes and result in increased patient satisfaction and improved health outcomes. Consider the success of San Francisco-based One Medical in offering patients easily accessible, team-based primary care.

Common shared responsibilities in team-based care include pre-visit planning and expanded intake activities, including reconciling medications, updating the patient’s history and collaborating with the patient to set the visit agenda. Post-visit, services can include referral tracking and follow-up with community providers, health coaching, and even personal check-ins. Ask yourself:

  • Have you redesigned and redistributed work among all clinical and non-clinical members?
  • Are all team members working at the “top of their licenses”?
  • Are your team members the correct mix? Does the team include physicians, nurse practitioners, physician assistants, and nursing staff as well as non-clinical staff?
  • Are you investing in training of existing staff, redesigning workflows and instituting collaborative internal partnerships to keep personnel costs down?

Question 3: Has your organization implemented patient-centered access to team-based primary care services for both routine and urgent visits?

When patients can’t see their personal primary care provider and instead seek an alternative provider, we know that care quality and patient satisfaction suffers. We also know that costs increase when patients use the emergency department as an alternative to primary care. While urgent care has its place, it is not a substitute for a patient’s primary care provider—especially for those needing complex care management. If you are experiencing overutilization of your emergency department, look immediately to your primary care accessibility.

Being available to patients when they need and want is a key driver of value. If your patients can’t be seen same-day for urgent visits, or need to wait more than 10 days for a routine visit, you have access problems that will likely cause serious repercussions if not remedied.

If you don’t know whether you have access problems, perform an accessibility assessment now to understand whether patients can access their primary care providers when they want and need to do so. Improving accessibility to primary care will have a significant impact on cost, health outcomes and patient satisfaction. Ask yourself:

  • How long does a new patient have to wait to be seen by a primary care provider?
  • Do your primary care providers have policies and procedures in place to provide same-day access for those needing to be seen urgently?
  • Can patients see their primary care provider outside of normal business hours for both routine and urgent needs?
  • Do patients have the ability to schedule appointments online via a secure portal, whenever they want, as opposed to when someone is available to answer phone calls?
  • Are routine visits scheduled on evenings or Saturdays?
  • Can patients reach their primary care provider (or covering provider) by phone or secure email 24/7?
  • Do providers or their representatives taking calls have access to the patient’s medical record?
  • Do you track and report against access standards, and determine changes that need to be made?

Question 4: Has your organization implemented a population health strategy starting at the primary care practice level?

By better understanding the unique risk profiles of your patient population, you can deploy a population health strategy to meet the needs of your population. A comprehensive population health strategy begins at the primary care level, focuses on preventive and complex care management, uses current population health technology and clinical analytics, and is executed within a team approach to improve the quality of service delivery and health outcomes.

Your primary care practices should objectively assess your patient populations to identify which chronic conditions are most prevalent, then tailored their programs to meet the needs of these high-risk patients. For example, a practice with a large percentage of diabetic and/or pre-diabetic patients should consider including a certified diabetes educator (CDE) as a member of the patient care team, which has been shown to improve patient self-management and positively impact health outcomes. Similarly helpful can be linking diabetic and pre-diabetic patients to community resources for weight loss, nutrition counseling, and exercise. Ask yourself:

  • Have you deployed and optimized using disease registries so that primary care has a complete picture of the risk profile of the patient population?
  • Can your primary care providers objectively cite the most common chronic conditions of their patient population, including behavioral health conditions?
  • Can your primary care providers identify their highest-cost patients? How can you help them identify those patients?
  • What specific primary care programs have you deployed to address the needs of the most at-risk and high-cost patient populations?

Question 5: Have you integrated behavioral and physical health at the primary care level?

Forward-looking primary care providers line up resources to meet their patients’ complete needs, in both body and mind. Whether that is embedding behavioral health specialists into the primary care practice (or vice versa) or establishing stronger relationships and care coordination infrastructure between behavioral health specialists and primary care, the result is a greater likelihood of positive patient outcomes.

For decades, behavioral health has been treated separately from primary care. This is no longer the standard of care. One in four Americans has multiple chronic conditions, according to the Centers for Disease Control, and nearly one in five (18.5 percent) U.S. adults experience mental illness each year, according to the National Alliance on Mental Illness. Thus, many of your patients will have both physical and behavioral health issues.

With primary care becoming the “default” mental health system for behavioral health conditions, it’s critical that primary care for physical and behavioral health be integrated. Addressing physical and behavioral health in a coordinated, comprehensive fashion can improve health outcomes and reduce costs through reduced admissions and emergency department visits. Ask yourself:

  • Are you routinely screening for behavioral health and substance use disorders at the primary care level?
  • Do you have a process in place for routinely consulting with and facilitating patient access to psychiatry and other behavioral health specialists?
  • Have you established a communications process with your patients’ treating behavioral health specialists so that you can better coordinate care for these at-risk patients?


It’s difficult to predict exactly how changes to the ACA might impact primary care. However, we can be certain that the underlying drivers of VBC will not go away. Providers and health plans should double down on their efforts to expand VBC for those they serve and adopt “best of” VBC practices starting at the primary care level. Through VBC, providers and health plans can deliver better and more cost-competitive care to help patients achieve improved health.

Sylvia Dochterman is a consultant at Freed Associates, a major healthcare consultancy in California that has worked for more than 20 years with a wide array of healthcare organizations requiring specialized knowledge in healthcare and IT.