Finding the Bright Spots in Value-Based Care


Taking one small step at a time, primary care practices can lead the way as the health care system begins to reward value.

Fam Pract Manag. 2017 Sep-Oct;24(5):21-27.

Author disclosures: Drs. Brull, Lilly, and Navarro all participate in ACOs that contract with Aledade, which was founded by Dr. Mostashari.

Family physicians have always been the quarterbacks of our health care system. Today, they're increasingly under pressure. Across the country, our health care system is going through a transformational shift, from rewarding volume to rewarding value. This shift, which bases reimbursement on the quality of care provided rather than just the number and type of services, can feel overwhelming, but it may ultimately give family physicians new opportunities to prosper. It may also enable family physicians to finally be able to offer patients the kind of care that drew them to medicine in the first place – personal, proactive care that provides true value for patients without wasting resources.

Family physicians face some headwinds. Many still have a difficult time accessing their patients' data from outside their practices, making it difficult to measure and improve quality, and in some cases larger players in the system are actively blocking it. All too often, reporting requirements are duplicative or burdensome. Even high-performing practices are questioning whether they have what it takes to succeed in value-based care.

The paradox of primary care is that, despite these challenges, small practices have some advantages in this new world. Smaller practices have a lower average cost per patient,1 cause fewer preventable hospital admissions,2 and have lower readmission rates when compared with larger practices.3 That's because big systems often find themselves with their feet in two different canoes; they may want to reduce total costs, hospitalizations, and high-cost procedures, but their financial incentives are still aligned with the old fee-for-service system. For example, if they prevent emergency room (ER) visits or preventable admissions, they lose a major revenue stream.

This is why, as we move toward a health care system focused on quality and value, small primary care practices are in the driver's seat. Primary care doctors account for only 6 percent to 7 percent of health care spending, but they can influence up to 85 percent of downstream costs.4,5 They set the course for how patients navigate our entire health care system.

They're also motivated. A recent survey from the American Medical Group Association found that 86 percent of practices with fewer than 50 physicians say they're ready to take on risk in the next two years.6

So where can family physicians start? With simple, specific steps that other family physicians are taking today, steps open to any physician willing to take a chance on them. This article will highlight four:

  1. Identify high-risk patients using annual wellness visits (AWVs), the hidden gem to assessing risk and knowing which of your patients need more outreach from you and your staff.

  2. Manage that critical juncture when a patient leaves the hospital, also known as transitional care management (TCM).

  3. Gather data on your patients' outside care so you can identify major areas of ineffective – or even counterproductive –

About the Authors

Dr. Mostashari is the former National Coordinator for Health Information Technology at the U.S. Department of Health & Human Services and is currently CEO of Aledade, a company that partners with primary care physicians to build and lead accountable care organizations (ACOs). Dr. Brull is an independent family physician in Plainville, Kan., and a former member of the FPM Editorial Advisory Board. Dr. Lilly is an independent family physician in Dunbar, W.Va. Dr. Navarro is an independent family physician in Newark, Del.

Author disclosures: Drs. Brull, Lilly, and Navarro all participate in ACOs that contract with Aledade, which was founded by Dr. Mostashari.



show all references

1. Robinson JC, Miller K. Total expenditures per patient in hospital-owned and physician-owned physician organizations in California. JAMA. 2014;312(16):1663–1669....

2. Casalino LP, Pesko MF, Ryan AM, et al. Small primary care physician practices have low rates of preventable hospital admissions. Health Aff (Millwood). 2014:33(9):1680–1688.

3. McWilliams J, Chernew ME, Zaslavsky AM, Hamed P, Landon BE. Delivery system integration and health care spending and quality for Medicare beneficiaries. JAMA Intern Med. 2013;173(15):1447–1456.

4. Mostashari F. The paradox of size: how small, independent practices can thrive in value-based care. Ann Fam Med. 2016:14(1):5–7.

5. Goroll AH, Berenson RA, Schoenbaum SC, Gardner LB. Fundamental reform of payment for adult primary care: comprehensive payment for comprehensive care. J Gen Intern Med. 2007;22(3):410–415.

6. Fisher D, Speed C. Obstacles on the road to risk. Health Affairs Blog. February 15, 2017. Accessed July 12, 2017.

7. Blanchard K, Bowles S, Carew D, Parisi-Carew E. High Five! The Magic of Working Together. New York; Harper-Collins; 2001.

8. Heath C, Heath D. Switch: How to Change Things When Change Is Hard. Waterville, Me: Thorndike Press; 2011:27–48.


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