Team-Based Care: Strategies to Improve Your Health Practice

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By Dr. Ashok Roy, MD, MPH, MBA

Team-based high-quality primary care is the cornerstone for improving population health. Medicare ACOs are built on the notion that advancing primary care can lead to better health care outcomes and lower costs. This patient-centered approach has proven effective in treating patients with complex conditions and reducing health disparities and is an essential principle in all value-based care work. 

We are at a turning point in the value-based care movement. In the last eleven years since the Affordable Care Act authorized the Medicare Shared Saving Program and alternative payment models, tens of millions of Medicare beneficiaries have enrolled in these alternatives to traditional fee-for-service Medicare. In October 2021, CMS pledged to include all Medicare beneficiaries and most Medicaid beneficiaries in accountable care or other total cost of care arrangements by the year 2030. This is an ambitious goal that underscores the importance of these cost-saving and care quality programs for the future. In short, accountable care will soon be a reality for many more patients. 

This push for accountable care gives new importance to building out primary care delivery systems. CMS has prioritized primary care’s coordination of care in recent years, including the launch of the Primary Care First and Direct Contracting models. Both alternative payment models are based on advanced primary care initiatives that have saved money and advanced patient care, as well as increased payment for certain primary care evaluation and management (E/M) services. 

Team-Based Care and Pandemic-Era Care Delivery 

This primary care focus has not let up during the COVID-19 public health emergency. Health providers participating in ACOs found that their population health focus helped better understand and anticipate their patients’ needs. They had established chronic care management (CCM) teams and stayed connected to their high need patients, especially during the early months of the pandemic. They were much more prepared for the pivot to virtual care during a time when many patients were avoiding in-person appointments. 

Robust primary care can help achieve the quadruple aim of advancing quality of care, reducing costs, improving the patient experience, and reducing provider burnout. The National Academy of Medicine (NAM) recently articulated a vision of person-centered, family-centered, and community-oriented primary care in their report, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care.” NAM offers this definition, “High-quality primary care is the provision of whole-person, integrated, accessible, and equitable health care by interprofessional teams that are accountable for addressing the majority of an individual’s health and wellness needs across settings and through sustained relationships with patients, families, and communities.”

NAM makes policy recommendations to further their vision of holistic high-quality primary care. Among those recommendations is to “Pay for primary care teams to care for people, not doctors to deliver services.” This is absolutely aligned with the goals of population health-based accountable care work. Our primary care system must evolve from delivering reimbursable specific services intended to combat diseases to a focus on preventive care. A person-centered, integrated approach is more effective if delivered by a team of providers that can address the mental and physical sides of health in the context of the patient’s community.

Team-Based Care Can Combat Physician Burnout in ACOs

A team-based care approach can build lasting partnerships that lead to consistently positive results in care quality and cost savings. For many practices, this philosophy starts with focusing on services such as CCM, which provides regular check-ins with patients with serious chronic health conditions. CCM establishes a strong relationship between providers and patients and can prevent hospitalizations or worsening disease. 

As an example of the effectiveness of a team-based approach, between 2018 and 2021, Caravan ACO participants nearly doubled the rate of CCM services from 2.8% to 4.8%. Not only was there an increase in CCM, but advanced analytics also enabled providers to prioritize patients who were most vulnerable. Along with this impressive increase, the ACOs also increased advance care planning from 8% to 14% from 2018 to 2021. This focus on population health services led to a measurable decrease in inpatient admissions and emergency department visits. 

Caravan has also brought team-based care to non-traditional value-based payment participants, such as the federally qualified health centers (FQHCs) that provide a health safety net. Between 2017 and 2021, these FQHC clients made strides on key population health metrics, increasing the rate of annual wellness visits (AWVs) from less than 20% to over 30%. These FQHCs also more than doubled chronic care management participation, moving from 2.2% to 4.7% in this time period. 

At the same time, these safety net facilities reduced overall Medicare spending on their attributed patients. In 2017, these patients averaged $11,199 annually and that number fell consistently over the years of participation, with 2021 annual spending projected at $9,888. This is accompanied by reductions in inpatient days, skilled nursing days, and emergency department visits. 

Primary Care Must be a Team Sport 

Our country’s health care leaders and government have invested a tremendous amount of money and effort into improving primary care. This patient-centered approach can prevent costly hospitalizations and help people to live longer. As we come through the COVID-19 public health emergency, this is the perfect time to regroup and reinvest in practice transformation to engage the entire clinical team in improving patient care. 

Dr. Ashok Roy, MD, MPH, MBA is Chief Medical Officer, providing overarching clinical leadership and shaping the clinical vision for participating physicians and ACOs, at Caravan Health. He is also a practicing board-certified internal medicine physician. He has more than 20 years of experience in population health, working as a consultant, administrator, and provider for health care systems, payers, outpatient clinics, and government and military organizations.