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With our recent blogs on August 3 and August 17 focused on innovative care models, it seems appropriate to pause and review the historical context that served as the foundation for many current innovative efforts. While the focus of today’s article is primary care, many of the learnings have broad applicability.  

A Definition of Primary Care

Interestingly, much of the groundwork for current innovations to improve care was provided in  1978. At that time the Institute of Medicine (IOM) proposed a definition of primary care as “…the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

Dr. Starfield’s Legacy

In her seminal book published in 1992, Dr. Barbara Starfield made the case for primary care driving improved quality and lower costs across the globe.1  She was able to show that primary care availability positively correlates with improved health outcomes and lower cost trends. Perhaps less well known from that same book is her delineation of the four pillars of primary care. 

Building on the definition created by the IOM, she described four essential elements of primary care as: 

  1. First contact 
  2. Continuity of care 
  3. Comprehensive care 
  4. Care coordination 

It wasn’t until 15 years later, in 2007, that the American Academies of Pediatrics (AAP) and Family Practice (AAFP) together with the American College of Physicians (ACP) and American Osteopathic Association(AOA) published their “Joint Principles” document that embedded Dr. Starfield’s four pillars into their definition of a patient-centered medical home.

The Power of Teams

Building on this work, Dr. Tom Bodenheimer studied the attributes of health care providers that were particularly successful in establishing and maintaining those four capabilities. In the March, 2014 Annals of Family Medicine he published, “The 10 Building Blocks of High Performing Primary Care”, which can be roughly sorted into three categories:  leadership,  structure, and function.

Bodenheimer delineates key leadership attributes including knowledge and experience in change management, driving a culture of “leading from where you are” and data driven decision making.  At the structural level, he focuses heavily on the important role of teams in efficiently and effectively supporting their patients’ needs. At the core of the team is a clinician with a dedicated panel of patients. That clinician is then paired with one or more support staff that serve as a “teamlet” that owns the relationship with every patient in their panel. In most practices, several “teamlets” come together to form a team that shares administrative and clinical support needed to ensure that all operational requirements of the practice are met. At the functional level, Bodenheimer starts with Dr. Starfield’s four pillars and adds to them the importance of population health capabilities. His final building block was a “template of the future” that foresaw virtual visits, group visits and visits with non-clinicians when appropriate.  

Many current attempts to adopt innovative clinical models are built on the foundation described here. As practices look forward to a post-COVID world that will have even greater emphasis on value-based contracting, they would do well to study the work of Drs. Starfield and Bodenheimer for guidance in building efficient and sustainable accountable care capabilities.  

1 Starfield, B, (1992). Primary care: concept, evaluation, and policy: Oxford University Press

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Dr Lustick

Dr. Martin Lustick

Senior Vice President, NextGen Advisors

Dr. Martin Lustick is a principal and senior vice president with NextGen Healthcare focused on supporting provider organizations in their successful transition from volume to value-based care.

Dr. Lustick earned a BA in History from Cornell and an MD from Columbia. After completing his pediatric residency at Children’s Hospital National Medical Center in Washington, DC, he was in clinical practice for 17 years with Kaiser Permanente of the Mid-Atlantic States. While there, Dr. Lustick held various management and leadership roles, including chief operating officer for the 800-physician medical group. He oversaw development of their hospitalist program, population health capability, and open access delivery model.

Dr. Lustick then served as chief medical officer for ThompsonHealth—a small health system in Canandaigua, NY—where he provided clinical oversight for hospital, SNF, nursing home, IT, and out-patient physician practices.

In 2005, Dr. Lustick assumed the role of SVP & CMO for Excellus BCBS which covers 1.6 million lives comprised of Medicare, Commercial, and Medicaid. In his 13+ year tenure there he led a variety of strategic initiatives, including a patient-centered medical home program which served as the foundation for the plan’s value-based payment strategy. He also led the implementation of an automated authorization program for care management services, development of a clinical quality improvement strategy, and creation of innovative programs in management of low back pain, screening and prevention, opioid addiction, and chronic disease management.

Dr. Lustick has also been very active in the community, serving on boards and committees confronting issues such as: healthcare capacity planning, Health Information Exchange, mental health, substance use disorders, social determinants of health, and childhood obesity.