Practicing the 4 C’s of High-Quality Primary Care with a Value-Based Care Team Model

Vivek Garg, M.D., MBA
Chief Medical Officer
Humana’s Primary Care Organization

According to a report from the National Academies of Sciences, Engineering and Medicine, “primary care is the only health care component where an increased supply is associated with better population health and more equitable outcomes.” And yet we dramatically underinvest in robust primary care.

What makes primary care so impactful is its focus on clinician-patient relationships and comprehensive, longitudinal care. Unfortunately, our current fee-for-service (FFS) payment model is indifferent to relationships and long-term health. That is why value-based payment, such as full-risk and capitated payments, allow for care models that actively foster relationships and align patient care, population outcomes, and economic sustainability.
Successful primary care is rooted in what’s known as the “4 C’s.” In practice, this is defined as the primary care team being available for first contact when there is an issue, providing continuous and comprehensive care, and coordinating the care of the patient across different stakeholders and needs. These are the elements necessary to enable a deeply trusting relationship between patients and their primary care team and lead to individual behavior change, one of the goals of effective primary care.

Primary care in the U.S. falls far short of fulfilling the 4 C’s and much of that failure is due to our reliance on the FFS model. Rather than fostering engagement, FFS payment systems reward transactions and services provided, leading to impossibly large patient panels and extremely limited time spent during patient visits. The result is a formula that is not conducive to building the strong patient-clinician bonds needed for identifying the underlying issues impacting the patient’s health and working together to make changes to improve their health.

On the flip side, when practices implement a value-based care model and move to full risk, the 4 C’s become the North Star, reinforced by more robust teams and systems.

For example, CenterWell Senior Primary Care facilities and Conviva Care Centers, which are Humana’s senior-focused primary care centers, utilize a value-based care team approach that has allowed us to reduce patient panels to 400 to 600 patients, compared with the normal 2,000 or more patients at FFS practices. Recognizing the importance of regular touchpoints with patients and that building trusting relationships takes time, patients are seen an average of 4-6 times per year and PCP visits typically last as long as 40 minutes. Supporting the PCP is a care team that includes care management nurses, care coordinators, social workers, pharmacists and behavioral health specialists to treat not only patients’ physical and mental health needs, but also to identify and address social service gaps impacting their health.

To support a patient, the care team meets regularly to discuss the resources and treatment plans required for each individual. Our model also requires that we look beyond the walls of our own practices and collaborate with the other clinicians and services our patients utilize, forging deeper partnerships and coordination mechanisms across specialty care, acute, and post-acute care, so that we can holistically guide our patient’s health with their goals front and center.

While this model embodies the care that every senior deserves, you’re likely asking where the resources are coming from to fund this comprehensive, team-based approach. Humana has shown that value-based groups that have taken on full risk deliver 15 to 17% of health care dollars to the primary care practice, compared to the usual 4 to 7% for traditional primary care. That differential investment goes a long way to fund the comprehensiveness care team, as well as the technology and analytics that enable this type of care.

Practicing primary care according to the 4 C’s and with a value-based, care team approach also delivers improved clinical outcomes, as illustrated in a recent JAMA study that showed primary care practices adopting this approach reduced emergency department visits by over 13% and hospitalizations by almost 6%.
Providing first contact, continual, comprehensive and coordinated primary care is necessary to radically improve the health of our population, deliver the kind of patient care that seniors deserve and expect, and create sustainable practice models for clinicians. If we keep the 4 C’s as our North Star and reorient around a value-based care team approach, we will go much further in improving population health and equity.