Reimagining Primary Care Service Lines to Drive Growth and Value

Daniel Marino:  

Welcome to Value-Based Care Insights. I am your host, Daniel Marino. I'm really excited about this program and some of the future ones that we're going to have in place. We are going to spend the next few episodes talking about a series that we've put together around different service lines, specialty service lines. So over the next couple of episodes, you're gonna hear some great information, great insights, where we'll dive into primary care, other specialty services such as cardiovascular services, gastroenterology, orthopedics, and maybe a few others as well, we'll see. Certainly, as we conclude 2025 and move into 2026, the service line growth and development, is something that is really top of mind for physicians, for healthcare executives, really for the entire industry. So, in today's episode, I'm really excited to dive into primary care. Primary care is an area near and dear to my heart. I started my career in primary care managing, internal medicine practices, managed about, I don't know, I think there was around 20 or 25 internal medicine, and then slowly brought on family medicine as well. And when you think about where primary care has gone over the last, really, 4 or 5 years since COVID, it's changed quite a bit. There's been a lot of pressure on primary care physicians. There's certainly a shortage on primary care physicians or on providers in general. We've seen a lot of burnout, a lot of physicians, primary care physicians, just really getting tired of all of the administrative burdens that are being placed on them, whether it's with the EHR, or assisting with new referrals, or just managing all of the patient concerns and the patient challenges. So, as well as the shortage of primary care providers, it's also forced us to kind of exasperate into these new issues around patient access, and it's extremely difficult for many patients to get into their primary care physician timely, and many of them have looked at different alternatives, and the industry has evolved into expanding access. That would include virtual health, telehealth, and so forth. And then, along with that, in managing primary care services. What we've started to see is that behavioral health has really expanded into, a primary care role, where many primary care physicians now are having to work with patients on a lot of their behavioral health concerns and challenges that they might have. 

 Well, I am really excited today to have two experts in primary care. First is Dr. Sarita Soares. Dr. Soares is the program director for the Yale Primary Care Internal Medicine Residency Program, and is also a Primary Care and Addiction Medicine Physician at Yale. My second guest is Dr. Brad Richards. Dr. Richards is the Executive Director of the Yale Primary Care Internal Medicine residency program, and also an associate professor of medicine at the Yale School of Medicine. Brad, Sarita, welcome to the program. 

Brad Richards:  

Thanks for having us. 

Sarita Soares:  

Thanks, Dan. Glad to be here. 

Daniel Marino:  

Well as I mentioned, you know, primary care, I just have such a… I value it so much. It's the entry point of care. If really done well, it's the gatekeeper, it provides the oversight, and it's just such a strong component of our overall healthcare system, but we have so many challenges that we're faced with. And really, I think the biggest one is really around the shortage of primary care physicians, and then some of the corresponding issues that we've talked about, access being one of them. Dr. Soares, when you look within your own practice and within your own organization, I'm sure you're experiencing some of those same challenges with shortages. What are you seeing as some of the biggest challenges that are impacting primary care, and in particular, say, physicians or new folks wanting to get into primary care? 

Sarita Soares: 

Yeah, thanks, and I think this is something that we've been, we as a country have been dealing with for decades, and, yet the problem is getting worse as we have an aging population. And honestly, as you said, primary care is the gatekeeper, but I like to think of it a little bit more as… ideally, it should be the foundation, right? Like, a strong foundation that is broad-based, and is supportive. And should not be a narrow door. And yet, as you've mentioned, access to primary care has become a really huge challenge. I think part of that is resources, and traditionally, they were primary care physicians that were providing primary care. And we just don't have enough, young doctors who want to do primary care anymore, partially because it's incredibly challenging to be the master of you know, a variety of, medical issues, mental health issues, insurance, navigation, social work, evolving pharmaceutical agents, and, and, you know, there's just, like, a multitude of things that you need to be an expert of to be a primary care doctor. And yet, it's long hours with a lot of administrative burden, and a relatively low reimbursement in terms of pay, compared to, other specialties. And as a medical educator, I'll say, most people want to go into medicine for the right reasons. Most people really want to provide excellent patient care, and so, payment is not really top of mind for those who start their journey, but as we have graduates, who come out of medical school with $250,000 to $500,000 of student loans. Finding a field that's gonna allow them to pay the bills, and pay back those student loans is important. So I think part of the access is, it's a tough job that's undervalued and underpaid, and we have an aging population, and in general, even if we have enough primary care physicians in a practice and such, we just have an older population that's more complicated, and so there's certain patients that just need more of our time. 

Daniel Marino:  

Yeah, I agree, I agree. All of those factors, I think, are really contributing to a lot of challenges and burnout, higher burnout in primary care, and the compensation, I think, isn't really keeping up with it, especially when you see all the amount of time that… and the responsibility that primary care physicians have. Brad, let me turn to you. I can't help but think access is a major problem. It's a problem all over the place. In a recent study that we had assisted with, we found that the average time to get into a primary care physician, certainly for a brand new visit, could be… could be 3 to, in some cases, even 6 months for that new visit. Even for return follow-up, unless you have, like, a, you know, a high-acuity visit, or condition, rather, I mean, it could be 4 to 6 weeks before you get into a primary care physician. How are you addressing some of the access concerns within your organization to kind of keep up with the needs of the patients? 

Brad Richards:  

Yeah, it's a great question, and one thing that we've implemented is, you know, we have a resident faculty practice, and we have an urgent care clinic as part of our practice where we only see our own patients. And, you know, we call it urgent care. It's really anything goes. We are embedded in a federally qualified health center. We see a majority Medicaid patient population, though we have a lot of people who are both Medicare and Medicaid, dual eligible, and we do have some commercial and also uninsured individuals. But really, if someone needs something, we want to get them in as soon as possible. They're, you know. I will say, from a financial model, we're still very much a volume-driven organization, but usually we fill up all of those, for the most part, those slots. And so that… that does work. And, you know, the… the downside is we don't always have… for folks who are showing up for urgent, we get them into care, but we don't always have continuity of care, which obviously is a core tenet. You know, there's some continuity. It's within our practice. The people they're seeing are doctors of our practice, but it's not you know, their same PCP. So, that's one way. I've seen other places, you know, they'll open up, they'll have slots that will only open up 24 hours in advance. You know, you can do triage via telehealth. I think there's a lot of ways of addressing, kind of, urgent needs and providing access, but I think, to your question, the incentive to do that in a traditional, I think, or traditional fee-for-service model is not always there, because it's more about just making sure you fill up all the slots, as opposed to saying, getting people the access they need. And so you're not necessarily as incentivized as an organization to say, gosh, we gotta make sure we can get someone in within 24 hours, or even a week for their blood pressure follow-up, because we already are filled out, and, you know, operationally, that's… that's what we are mostly concerned about. 

Daniel Marino: 

Well, and it's a balancing act, right? So, you know, ideally, what we're seeing a lot is trying to deliver the care to the patient really where the patient needs it. And ideally, if you have patients who are high acuity, higher risk, if you're managing the comorbidities, all the responsibility of primary care, you know, there's different access components, different ways of delivering that care, right? You know, you can do it, obviously the traditional way of having patients come into the office, but I think telehealth and virtual health could also come into play as well. One area, and I would be interested, Sarita, in hearing your thoughts on this. Many large organizations, particularly academic organizations, have adopted a team-based approach of care, where they've included with the physician, potentially advanced practice providers, but really even expanding that to include social workers, diet, dietitians, even care managers and nurse navigators. That allow each of those care team members to really perform at the top of their license, if you will, but really create more of a comprehensive approach to primary care services to the patient. Can you comment a little bit on that? Where do you see the care teams kind of fitting into that whole primary care delivery system? 

Sarita Soares: 

I think that's the gold standard. I think that's the right way to provide primary care. I think the, you know, the amount of, really, challenging social determinants of health, barriers to wellness that a lot of our primary care patients have is incredibly overwhelming for that patient, and certainly for a primary care physician. And having a strong team of social workers, patient navigators, pharmacists, the dietitian who's able to translate what we might prescribe in terms of a diabetic diet into what someone can actually afford in the food desert in which they live. That's the secret sauce of success in primary care. And, having, you know, advanced practice providers has been phenomenal. Our practice has a small cohort of them, and they have been the glue that have just been able to have, tremendous, continuity with patients, and also just have their year to the ground, because they are dedicated, embedded in our clinic, as opposed to many of our physicians who are practicing, primary care, but also a number of other… they wear a number of other hats, and so it's a little bit harder to, be able to be that longitudinal continuity of the needs that patients, have. And so, I agree, I think team-based care is amazing, and I think the organizations that have really invested in team-based care are actually seeing much better health outcomes. The team doesn't need to be employed for every patient, but having the flexibility to prescribe the right team member for the right needs of the patient is, I think, the best way to personalize care. 

Daniel Marino:  

That's really the key. Right, because you're meeting… you're meeting the needs of the patient, right? Not everybody has those same needs. If you're just joining us, we are talking about primary care, and some of the challenges, and as well as then the changing model of primary care services. I am joined today by Dr. Sarita Soares and Brad Richards, both executives, physician executive at Yale School of Medicine and Primary Care. Brad, let me turn to you, and let's talk a little bit about value-based care and how that is coming into play. Value-based care, obviously, and primary care, is a… is a huge driver. And it's… it's no secret for many organizations primary care contracts and reimbursement is somewhere in the range of 90% of what they… that's embedded within the organizations, and If you're successful in value-based care as an organization, you have to have a robust primary care service line that looks at comorbidities, that's really managing the care, coordinating the care with the other specialties and the other physicians. But you also have to begin to track some of your outcomes. In your opinion, what's been the influence on value-based care, on primary care as you've seen it within your group? 

Brad Richards:  

So value-based care is, you know, a pretty wide spectrum of payment models that can be kind of grouped underneath there, all the way from, you know, taking full risk, where you're fully at risk for the total cost of care of a population, including 100% upside and downside, where, you know, you can, get all of the dollars that you might save, compared to a baseline, or you're going to lose a significant amount if you're at If you have downside risk. Versus, you know, you might have a pay-for-performance program, which is really dipping your toe in a value-based payment arrangement. And so, you know, if you're dipping your toe into the value-based pain arrangement, it's hard… you're not going to make a lot of changes, because you're, you know, most of your revenue is still going to be coming in through volume of service delivery, versus if you're really a total cost of care, you're really going to be looking much differently at your population, because your financial risk is really steep. And your volume-based service delivery may be inconsequential or very small in terms of your actual revenue as a practice. And so, really, where you sit in the value-based payment framework makes a huge difference with how you're going to actually, you know, shape your practice and change it. Where we are, there actually is, at least for Medicaid, and then obviously Medicare has the Medicare ACO program, MSSP. We have a Medicaid program that does have a cost of care component, but interestingly, because we're in an FQAC, they actually don't have much capital to make investments to manage the population in a way that you might think, partially because that payment doesn't come until 18 months later, because it's a, you know, you're getting a shared savings payment, much, much down the line. So it's hard to make those investments and capital up front on the care team. 

Daniel Marino:  

So are you seeing in that particular program, sorry to interrupt you, but are you seeing in that program, though, are there… is there more pressure being placed on the primary care physician because they don't have the right level of investment and resourcing? 

Brad Richards:  

You would think so, but we don't really even talk about the program because it's an upside-only program. So I think this is an interesting example when there's not really any downside risk, so there's no financial risk to the organization for not performing. 

Daniel Marino:  

So they're not performing any differently than what they would normally. 

Brad Richards:  

And it's a pretty small amount of dollars as a… it's not like a full risk contract where you're getting a lot, it's pretty small, and so most of the revenue is still volume-based, and so no one really even talks about that program, even though all of our patients are actually part of it. So I think it's a really interesting example of, yeah, actually, there is a value-based payment arrangement. We don't really talk about it very much, and we're not really focused on the outcomes that you might expect I think partially because of the undercapitalization that you would… that we don't have in terms of the outcome we would need to do. 

Daniel Marino:  

Well, I tell you, the undercapitalization for primary care, I think is a major issue. And I've said for the longest time, if, matter of fact, I recently was talking to another senior leader in an organization, and I said, you know, if value-based care was the car, t he engine to that car is care management. The more you invest in care management the more that it helps to support your physicians, and in particular, primary care. Because without this, and this was kind of the basis of my question, without strong primary care, without having that investment in there, all you're doing is creating more work for the primary care physicians. And their heart's in the right place, right? And they want to do a good job, and getting back to, Sarita, what you said, I think all physicians, I believe, get into medicine because they really want to help patients, they really want to help people and make a difference. But, you know, we all have limits, right? And without having the right support, we can only do… we can only do so much. 

Brad Richards:  

When you want to make a difference, you're often limited by the model with which you're working in, and if you're working with a really high-risk population, it's really hard to make the time and effort and investment to make a difference for someone that's really struggling with significant and persistent mental illness, and maybe housing insecurity, or other things. And, you know, and you, like you said, you see this pressure, you know, we work in a large academic system. We often have, you know, patients that we see in the hospital, we work both in the hospital and in the outpatient setting, you know, that transition of care, there's very poor transition, right? And if you talk to folks in the hospital, they're like, well, primary care will help manage this, but you're seeing patients all the time. If someone's going out to live in their car, how, you know, or they don't have a phone, like, we're not going to be able to reach them. We're not resourced. As you said, we are undercapitalized, and unless you actually invest, it's really hard to make an impact, so I always… I always think of, like, the value in primary care is, like, the is that relationship and then that long-term ability to have an impact on people's health and well-being, but you have to have the resources to do it well, and often for underserved patient populations, we don't, because the payment model is really such a volume-based service that is really more for people… it's more of a population that's in the middle, right? It's not for people who have, who don't have housing. Like, we're not going… it's really hard for us to go out to the street and find people there. It's… or homebound populations, we're older populations. Gosh, it's really hard to scale a home-based primary care program that's based on fee-for-service. People do it. It's very hard. It's much easier in a value-based payment arrangement because of that downside, you know, of preventing hospitalizations, ED visits. 

Daniel Marino:  

But you have to have the investment that's included in there, otherwise you're going to be really challenged. Sarita, I want to turn to you and get your opinion on a couple things that you mentioned earlier. You know, and as I watch primary care, you know, I've seen it evolve over, you know, my 25 years in healthcare, and as I mentioned, primary care when I was managing my office, primary care physicians and offices are very different than what it looks like today. And one of those big differences is behavioral health as a component of primary care. And I know a lot in your practice, and as the program director, addiction medicine is an area that, you know, you're really focused on. How has behavioral health, how has it changed primary care? How has it impacted primary care? I mean, I can only imagine that it's just putting even more stress on the primary care physicians to take all of those elements into consideration. Thoughts there? 

Sarita Soares:  

Yeah, I mean, I think we… we practice a very biopsychosocial model of medicine, so I think we, in primary care, very much feel that we need to take care of the mind, the body, the spirit of the patient. And a lot of times the… we can't take care of the physical body until we're doing a really great job with the mental health care needs of a patient. 

Daniel Marino:

Great points, absolutely. 

Sarita Soares:  

And, you know, I think, you know, we are… we train our future clinicians to care for mental health, but the amount of time that that takes, and the amount of resources, and the frequency in which, patients need to be seen, can kind of overwhelm them, right? And so that can be one of the other things that blocks up the access. And so I love the fact that we're now seeing more co-located, or ideally even, integrated behavioral health care teams. 

Daniel Marino:  

Me too. I think it's a game changer, and I think it's something that's been missing for a long time. I think having that as a component, it's the only way you're really going to really, you know, fully take care of the patient, both in terms of their mental health and their contributing conditions, such as, you know, diabetes and BMI and some of the other factors that are there. 

Sarita Soares: 

The other, another thing that is important that we're starting to see more of is a destigmat cessation, of, mental health. I mean, I think, you know, growing up, even, like, a couple decades ago, talking about going to a therapist or, you know, talking at all about depression or anxiety was somewhat taboo, and, and… Yeah. 

Daniel Marino:  

Nobody did it. 

Sarita Soares:  

And no one did it, right? And so, and there are still some populations where, you know, people would feel a little concerned about saying, I'm going to my psychiatrist's office, but if I'm going to my primary care doctor's office, and I'm having… I'm seeing another team member who's helping me with my overall health, I think that's amazing, right? It's a one-stop shopping, and I think we're caring for our patients the right way. 

Daniel Marino:  

Yeah, I absolutely agree. Brad, thoughts? 

Brad Richards:  

Yeah, I was just gonna say, I think, tying it back to payment a little bit, so we… we exist, Sarita and I both practice where we have co-located behavioral health, and it's great. I mean, honestly, it's… it is really, really helpful, but, the challenge in tying… again, tying it back to payment is in a fee-for-service or volume-driven, we still often don't communicate that well, right? I, don't often talk to any of the behavioral health providers about our patients all the… as much as I think we should, which comes back to payment. Not all of our patients need that, right? Some people just need to get referred. We can do warm handoffs, and that's great. But some people are really complicated. They have a lot of biopsychosocial complexity, as Sarita alluded to. And it can be hard to communicate, because we're tasked with seeing as many people as we can, and we don't have time to do these touchdowns or touchpoints, and so you're messaging people, you're hoping to catch them. 

Daniel Marino: 

Well, and the only way to get ahead of the game is, you know, you have to have, to your point earlier, the right level of investment, the right level of support services, because it is complicated. And what you end up finding is it's… I feel like, and this has been my personal opinion for many for many years, I think the primary care physicians take on too much responsibility, because there's nobody else to really be able to do it. Well, I want to thank you both for coming on. I feel like we just barely scratched the surface in some of these conversations, but I really appreciate your opinions. I'd love to hear your perspectives. Certainly with… with… on value-based care and access and… and the whole behavioral health piece, I think these are just key issues that are… that are so important. Thanks again for coming on the program. 

Brad Richards:  

Thanks for having us. 

Sarita Soares: 

Yeah, thank you, Dan. 

Daniel Marino:  

And to any of our listeners, if you're interested in finding out a little bit more about this topic, or others for that matter, please visit luminaHP.com/insights. I want to thank all of our listeners for tuning in. Until our next insight, I am Daniel Marino bringing you 30 minutes of value to your day. Take care. 

About Value-Based Care Insights Podcast

Value-Based Care Insights is a podcast that explores how to optimize the performance of programs to meet the demands of an increasingly value-based care payment environment. Hosted by Daniel J. Marino, the VBCI podcast highlights recognized experts in the field and within Lumina Health Partners