TEAM-BASED CARE – The future (and present) of Primary Care
by Dr. Jon Hart
At the Reimagining Primary Care (RPC) Forum this spring, a prevailing theme about how primary care can and should be done in the future was one of team-based care. Our current paradigm of primary care comes with some mismatches, even conflicts to the notion of care delivered by a team, and this leads to challenges in transforming care. We’ll look at some statements made by primary care experts at RPC and explore ways to apply those to the primary care world of today and tomorrow.
Despite the decline of rural healthcare, we’ve continued to use an agrarian analogy for healthcare, calling it siloed. For those unfamiliar with farm life, a silo is a vertical tube-like structure where you store a single type of grain (or silage if airflow can be limited) to keep it contained and dry until you use or sell it. This cloistering of the product is essential to its drying (or fermentation), and until the grain is ready to be removed and taken to a larger silo (grain elevator), it doesn’t leave its cylindrical home.
Why am I being so detailed in the description of an agricultural building? To accentuate the silo concept versus one of relationship, partnership, cooperation, and a big-picture view. We’ve stuck with the silo analogy for healthcare because it’s so accurate – confined spaces with limited or no outside contact, keeping things to themselves, until someone forcibly moves it to another silo.
At RPC, Kameron Matthews, MD JD of CityBlock stated, “Healthcare systems need to move away from siloed efforts to a collaborative, communicative model. Payers, academic centers, and health systems are currently not set up to be focused on wholistically caring for patients.” Her point was that, in addition to there being little to no collaboration and communication between insurance companies, medical academic centers, health systems, and the rest of the medical world, there are also silo walls built within these healthcare entities, blocking internal teamwork and communication as well.
The basic structural design of our legacy health systems is one that promotes wall construction rather than bridge building, closed hatches rather than open doors.
Beyond structure, the function of primary care has not set us up well for a viable future with team-based care either. Erin McNeely, MD of Corewell Health West Michigan made an interesting observation about our changing landscape of digital information now available to patients. “Physicians are no longer here simply to diagnose and treat,” she said. “We have a responsibility to connect patients to knowledge, care, and resources.”
She went on to speak to the interconnectedness needed in primary care as we hurtle into the future with technology, “If we’re not able to increase our human impact through connections, things will get worse rather than better with AI.” In other words, remaining in our own siloes will cause an accelerated problem in healthcare as tech like AI becomes more prevalent in everyday life – especially for medical information.
Staying in the vein of function as a mismatch point in primary care, Lisa Rotenstein, MD MBA of Brigham and Women’s Hospital added, “Primary Care has expanded in how we define it and deliver it. Who should be delivering this care – who should be on the team?” The primary care doc can no longer do everything needed on their own to provide high quality primary care. This is especially true when we consider that “Traditionally, a PCP job has already been well over 1.0 FTE,” as noted by Dr. Rotenstein. We will need to adjust to that reality as well as the concept of working as a team.
Perhaps the biggest incongruity to be faced was articulated by Priscilla Wang, MD MPH of Mass General Brigham when she said, “We have long known that 80% of health and outcomes are influenced by SDOH, but 100% of the medical industrial complex is dedicated to biomedical model of care.” Dis … Connect.
In addition to these variances between conventional and needed primary care, there are some other headwinds PCPs face.
Dr. Rotenstein pointed out that PCPs get 5 times the number of patient messages and 15 times the prescription messages compared to their counterparts in other medical and surgical specialties. Without better designed teams, workflows, and processes to address this deluge of messages (and prior authorization requests), primary care will continue to struggle in meeting the needs of its patients. This will lead to both worse outcomes for patients as well as a decreased PCP workforce from professional frustration and burnout.
Usable, actionable data is also a challenge faced by primary care practices, one that hamstrings their ability to perform. Erika Pabo, MD MBA of Humana emphasized the need to give actionable data to docs: “Without it, it’s next to impossible to manage Total Cost of Care as well as close gaps around access and SDOH issues.”
It can’t just be a spreadsheet of discrete fields, though. Docs’ time needs to be better spent in ways other than analyzing raw, nonclinical data for actionable items. Through initial collaboration with clinicians to discern what’s important, an analytics team can find the pertinent insights and deliver specific actions to the clinical team that need to be acted upon.
So, what should a team-based approach to primary care look like?
Throughout the day of the RPC Forum, the experts floated a few opinions on this question. Dr. Rotenstein started the thoughts flowing by saying, “Well-designed teams, workflows, and tech can be combined to set up and to improve how we deliver care and how we expect physicians to function.” Dr. Matthews went on to say that the disconnected nature of medical care (due to its siloed nature) needs to be tackled by “addressing the fragmentation of what happens outside the walls, optimizing services post-discharge and in the home. We need to improve handoffs and communication – building true co-management of patients.”
Dr. McNeely noted that PCPs need to develop partnerships with all the stakeholder in primary care. She then put it all together for us by revealing her own success story.
She shared that she was burnt out in RVU system of conventional primary care medicine, buried in an inbox, drowning in paperwork, etc. Now, after just a year or so, she is working in a VBC-style clinic (value-based contracting), serving very high need patients, and she loves her work.
Why is she more satisfied while caring for needier patients? She is now supported by a Psychologist, Social Workers, therapists, two Community Health workers, and four RNs – all in a 6-physician group using AI ambient dictation. They have fully embraced team-based care, and even make the time each week to have a couple of 60-minute huddles to discuss quality improvement efforts and patient issues.
Additionally, they are creating a position of “In-Boxologist” to take point on the inbox message flow. This announcement brought both cheers and envy from the audience!
A question was posed to Dr. McNeely about how they were able to make the switch from conventional medicine to a team-based approach incorporating VBC.
“Analytics and pilots,” was her answer. She also echoed a common theme from numerous BoPC articles and podcasts: “In addition to improving outcomes for patients, value-based care has a promise of improving your financial situation, but over time.” It’s not a switch to be flipped.
This is why her organization has run numerous pilots on specific patient cohorts in their high-risk geriatric population, their high-risk Medicaid patients, and in rising risk commercial patients. With each of these, they diligently analyze the robust data they have collected in their efforts and tweak and scale – or set aside and try something else.
This approach of pilot and analyze has helped them move their medical loss ratio from 186% to 82%. They are still a hybrid practice, too, with only about 30% of their patients currently in VBC payment models.
The other special sauce part of their process is they have laid a foundation of People Connections for their patients. They assign the patients humans from the team that they can reach out to and can trust to connect them to the right resource(s) to meet a need or solve an issue. Buy-in from other clinicians and administrators has been full, as well. “When you do the right things and have the analytics to back it up,” she said, “it’s hard for people to say ‘No.’”
As they scale and spread their practices within and between practices, they are being sensitive to the differences between locations in setting things up, and, possibly more importantly, they fine tune the workflows and processes based on meaningful metrics.
Beyond a replication of Dr. McNeely’s story, many of the RPC experts dropped some gems on where the future focus of primary care should lie. Many of them came from the same playbook or built on the others.
Focus on care integration – find your partners
Make meaningful metrics that matter
Design systems around the whole-person experience
Prioritize relationships and human connectivity, especially with patients, but also within the team
Dr. Wang summed it up by saying, “We need to create a truly integrated health ecosystem, with communities of care that can address SDOH in addition to medical issues, including closed-loop referral system. Get to know your neighbors and know your health neighborhood. As PCPs, we always feel so alone, and we need to understand all the help available out there to us and our patients.”
Don’t go it alone. Find your teammates and build a team that will help optimize the health and well-being of the people you serve.
Reimagining Primary Care Forum
Kameron Matthews, MD, JD, FAAFP. Chief Health Officer, Cityblock Health
Erin McNeely, MD, FACP. Division Chief for QSE, Primary Care, Corewell Health West Michigan
Lisa Rotenstein, MD MBA MSc. Director of the Physicians Foundation Center for Physician Experience and Practice Excellence, Brigham and Women’s Hospital
Erika Pabo, MD, MBA. Chief Transformation Officer & Central Operations, Humana
Priscilla Wang, MD, MPH. Associate Medical Director for Primary Care Health Equity, Mass General Brigham
