Who is Leading the Value-Based Care Transition in Primary Care?

Most primary care physicians (PCPs) are engaging with value-based care, with 69 percent participating in some type of alternative payment model. But a new report from Chartis Group has identified the PCPs leading this transition away from fee-for-service.

Value-based care “Leaders,” according to the report, are PCPs who report participating in at least a partial-risk capitation agreement. Only about one-fifth (21 percent) of the over 300 PCPs surveyed for the report say they are in partial- and/or full-risk capitation agreements.

The other 28 percent of value-based PCPs are considered “Experimenters.” Experimenters acknowledge having a value-based agreement, with accountable care organization (ACO) and patient-centered medical home (PCMH) being the most common agreements among all PCPs.

Notably, 31 percent of PCPs say that they do not participate in any value-based arrangement or are unaware if their practice has a value-based agreement. The report classified these PCPs as “Abstainers.”

The report shows that Leaders have distinct characteristics, including longer tenure in their roles as PCPs and a larger panel compared to Experimenters and Abstainers. Leaders see an average of 22 patients a day, which is two more than Experimenters and four more than Abstainers.

“Conventional wisdom is that capitated providers (Leaders) can see fewer patients per day and fund the lower productivity through risk margin,” the report states. “However, the data show that daily patient volume progressively grows with degree of value-based care alignment. This throughput explains how Leaders can manage comparatively larger and more senior panels.”

Leaders also treat a disproportionately higher number of Medicare-eligible patients despite the thought that more older adults on a panel usually translates to smaller panels given the population’s greater health needs.

Additionally, Leaders are most likely to seek panel growth. Only 5 percent of Leaders are not accepting new patients versus 10 percent of Experimenters and 13 percent of Abstainers.

Despite differences in panel composition, throughput, and capacity, the majority of PCPs (57 percent) agree there is an organizational focus on financial costs for their panel. But with cost containment being a core tenet of value-based care, Leaders are more likely to focus on the financials compared to Abstainers (65 percent and 50 percent, respectively).

Leaders are also more likely to see costs as an organizational focus in the future, with 78 percent seeing the focus increasing over time. Just 61 percent of Abstainers say focus on costs will increase.

While PCPs are moving in the direction of value-based care, they also identified major opportunities.

First, an accompanying report from Chartis Group finds some misalignment between which specialists PCPs have strong relationships with and those who are most impactful to value-based care. For example, PCPs say that current relationships with oncologists and radiologists are not that important for managing costs today but their importance will increase. Meanwhile, cardiologists retain their high level of importance.

Leaders more closely manage their referral networks, according to the report. They also have a better understanding of the “dynamics at play” for the specialists they refer to, meaning they are more likely to know how much specialists cost, are willing to refer based on cost, and proactively monitor out-of-network usage. On the other hand, Abstainers focus more on clinical quality and outcomes of the specialists with whom they have relationships.

Notably, the report also shows that Leaders, Experimenters, and Abstainers all lack at least some understanding of how much specialists charge for service. Only about a fourth (24 percent) of PCPs say they know how much specialists charge. But value-based care alignment does seem to correlate to a greater knowledge of specialist costs, the report says.

Second, PCPs need practice capabilities to deliver against value-based care. These capabilities include EHR integration for key services and utilization (59 percent of PCPs have today, but 79 percent say it is important), adjacent or on-site clinical services (34 percent have today and 73 percent say it is important), notification or reporting on care outside of the practice (27 percent have today and 67 percent say it is important), and notifications for treatments (25 percent have today and 67 percent say it is important).

Among the largest capability gaps though are patient segmentation, clinical documentation support, and treatment notifications.

“While the reasons for differences are likely to be multifactorial, the overall trend is clear: PCPs continue to perceive a significant lack of infrastructure across the board to manage against value-based care,” the report states.

Third, PCPs who are more engaged with value-based care tend to use more advanced practice practitioners (APPs), including nurse practitioners (NPs) and physician assistants (PAs). APP to PCP ratio improves significantly as value-based care alignment increases, the report shows. For example, Leader staffing ratios are one to two compared to 1 to 2.5 for Experimenters and 1 to 3 for Abstainers.

“This ratio allows the practice to treat more patients and its PCPs to practice at the top of their licenses,” the report says.