In value-based payment models, the importance of continuity—longitudinal relationships with patients—and coordination of care is heightened. For example, a study of more than 3 million Medicare beneficiaries showed that more primary care continuity was linked to fewer preventable hospitalizations. The primary care team’s responsibility as the “quarterback” for a patient’s health needs also becomes more significant. Respecting patients’ values and preferences, resolving conflicting opinions among specialists, and communicating with professional and family caregivers all fall within the purview of primary care.
Flowing from this foundation of continuity and coordination, a growing consensus is emerging around what the key elements of high-quality primary care should be:
Patient-centered medical home model with team-based care delivery
The Joint Principles of the Patient-Centered Medical Home (PCMH) describe the delivery of comprehensive primary care by a physician-led team: an orientation around treating the whole person, integrated care, quality and safety monitoring, enhanced access, and value-based payment. The American College of Physicians recently endeavored to further define team-based care, advocating for a cooperative interprofessional approach involving doctors, nurses, physician assistants, pharmacists, and other health care professionals. In practice, the patient-centered medical home has begun to demonstrate modestly improved quality and cost results. For example, the CareFirst BlueCross Blueshield PCMH initiative, showed overall savings of 2.7 percent over two years—while improving global quality outcomes for the one million patients enrolled in the initiative.
Population health management with patient risk stratification
Taking responsibility for population health means managing the health outcomes of a group of individuals. Often, one primary care team will be assigned to take care of a population of 1500 to 2000 patients. The startup Evolent Health seeks to blur the boundaries between insurers and health care providers by risk-stratifying these patient populations and customizing interventions to specific risks. Based on longitudinal health record data, a statistical model can reliably predict a patient’s risk for adverse outcomes, such as hospitalization. Appropriate care management services can then be tailored based on the patient’s risk.
High-risk patient management
Nationally, just 10 percent of the population is estimated to account for about 64 percent of health care expenditures, often because of the overuse of hospital-based resources. By addressing care coordination, targeting intensive interventions, and ensuring greater clinic access, concentrating on this segment of the population improves their health while reducing costs. Many primary care practices are now testing methods of high-risk patient management, such as an “ambulatory intensive caring unit.” Preliminary evidence from programs for high-risk elderly patients shows modest reductions in hospital and emergency department use.