Managing Patient Demand in a Value-Based System

Abstract

The transition to value-based care requires primary care physicians develop new capabilities in managing health services demand in ambulatory care settings. This narrative draws from clinical experience in a value-based, capitated system to examine how traditional fee-for-service incentives and changing patient expectations increase health care utilization. The essay introduces a practical “3D” framework—Delegate, Defer, Direct—for managing health services demand while maintaining quality care. Clinical examples demonstrate how primary care physicians can leverage team-based care models, implement evidence-based visit frequencies for chronic conditions, and develop systematic approaches to guide appropriate care-seeking behavior. Successfully managing demand requires physician practice innovation and patient partnership, supported by policy changes enabling team-based care delivery. As health care systems increasingly adopt value-based payment models as part of health care delivery reform, skillfully managing demand will become crucial for delivering high-quality, sustainable primary care.

RETHINKING DEMAND IN A VALUE-BASED WORLD

“What do you mean I don’t need to come back for 6 months? You just want me to go to the laboratory to check my HbA_1c in 6 months?” My new patient, transferred from another fee-for-service health care system, stared at me in disbelief. For years, he’d faithfully returned every 3-4 months for “diabetes check-up,” despite his hemoglobin A_1c holding steady below 7%. He had managed his diabetes well for years, making appointments merely out of habit. Prolonging the follow-up interval in patients with well-controlled diabetes does not decrease the quality of care and can save costs.¹ Eventually, he trusted my advice that he had “graduated” and that he had the skills to manage his diabetes without quarterly visits with me.

It was a skill I’ve had to learn as a salaried primary care physician working in a value-based, capitated system: managing demand. Managing demand may seem reminiscent of 1990s managed care restrictions and “rationing” care.² But there’s a difference between payer-restricted access for cost containment and physician-led demand management for resource stewardship. While my diabetic patient’s “graduation” to less frequent visits might appear as gatekeeping to some, it exemplifies clinicians partnering with patients to determine appropriate care frequency. Health care demand encompasses morbidity, perceived need, patient preference, and non-health motives.³ Through trusted relationships, clinicians can influence perceived needs and preferences rather than simply restricting access. Clinicians must learn to carefully steward health care resources while maintaining the quality of care— a challenge that requires new skills in managing patient expectations, delegating care appropriately, and identifying opportunities to safely defer or redirect care requests. Although many primary care clinicians associate value-based care with juggling countless quality metrics across multiple contracts, being salaried freed me from the current procedural terminology (CPT) coding treadmill.⁴ This freedom allowed me to focus on a fundamental question: given finite resources under a capitated, value-based care model, how could I best serve my patient population?

Clinician’s Role in Managing Demand

Today’s health care landscape faces unprecedented pressure: by 2030, 1 in 5 Americans will be at retirement age, chronic illnesses are more prevalent than ever, and the pandemic has led to unprecedented mental health needs.^5-7 Compounding these challenges, expanded access through telehealth and broader insurance coverage under the Patient Protection and Affordable Care Act has also led to health care utilization climbing steadily.^8,9

Payment models have partly shaped the health care system’s response to this increasing demand. Under fee-for-service, where payment is tied to volume, providers and health systems actively expand capacity to meet—and sometimes generate—additional demand. While individual clinicians might be at capacity in today’s overwhelmed primary care landscape, health systems typically respond to increased demand by expanding supply—adding hours, hiring more clinicians—which increases total visits rather than examining whether all demand for care is necessary.^10,11 Value-based care systems fundamentally change this dynamic by removing volume-based incentives. Examining my practice, I identified several routine practices that may drive unnecessary utilization, leading me to develop systematic approaches for distinguishing between necessary and discretionary care.

Strategies to Address Demand

Like most clinicians, I was looking for a practical way to approach this challenge of “managing demand.” I found inspiration in a productivity concept called the “4 Ds” —Do, Defer, Delegate, and Delete. I adapted the familiar productivity framework to the “3 Ds”—Delegate, Defer, and Direct— to address demand management in primary care. This approach provides a practical structure for evaluating and redirecting health care demands while maintaining quality of care.

Delegate—Matching Care to the Right Provider

The first strategy, delegate, involves identifying opportunities for other health care team members or community resources to effectively deliver care. This is a well-known strategy for many clinicians, but here, we use an active lens of demand management. For example, how can we better address our patient population’s mental health needs without physician visits, particularly with anxiety and depression? While behavioral health integration has proven successful—therapists providing counseling alongside physician medication management—there were opportunities to go further.¹² The Collaborative Care Model enables social workers to lead ongoing care through systematic registry review and discussing routine medication.¹³ Social workers cannot prescribe medications but can play a vital role in medication management by monitoring adherence, discussing patients’ experiences and concerns, and coordinating care with the primary care physician as needed.¹⁴

Delegation extends to other conditions and includes community organizations. For example, the National Diabetes Prevention Program (NDPP) consistently delivers superior outcomes¹⁵ yet although many patients schedule appointments with clinicians to discuss lifestyle changes for prediabetes, only 5% of prediabetes patients are referred to NDPP.¹⁶ With physician oversight, medical assistants can introduce the program and facilitate enrollment, allowing community partners to handle the ongoing lifestyle coaching and goal setting that would have required physician visits.

Defer—Personalizing Visit Frequency

The defer strategy involves personalizing visit frequency by challenging arbitrary follow-up requirements for chronic illnesses and routine yearly visits for stable conditions. Building on my experience with diabetes care, I looked at other chronic conditions like hypertension. We empowered nurses to handle medication refills based on validated home blood pressure readings and laboratories for stable hypertension patients, eliminating unnecessary annual visits. We applied similar principles to depression management, using automated Patient Health Questionnaire-9 (PHQ-9) screening to guide care frequency—patients with stable scores and symptoms could maintain their selective serotonin reuptake inhibitor (SSRI) prescriptions without routine visits. Like my diabetes patient who “graduated” to less frequent visits, these patients learned to monitor their conditions and understand when to seek care.

Direct—Guiding Patients to Appropriate Care Pathways

The final strategy, direct, focuses on providing clear guidance about appropriate care-seeking behavior. In my practice, I’ve observed a trend: patients increasingly schedule appointments before attempting basic self-care, reflecting both a loss of traditional community health knowledge and the paradoxical effect of online health information—which often drives care-seeking behavior.¹⁷

To address this trend, I use a 3-pronged approach. First, I provide specific rather than vague guidance during visits. For upper respiratory infections, I outline precise red-flag symptoms that warrant medical attention while reassuring patients that common symptoms like lingering coughs typically resolve without intervention. This strategy also requires robust investment in an after-visit summary to ensure patients understand the next steps clearly. Second, I aim to create standardized educational resources to address health concerns trending on social media. For example, amid rising self-diagnosed conditions like attention deficit hyperactivity disorder (ADHD) on platforms like TikTok, these resources help patients understand diagnostic criteria and appropriate care pathways before scheduling appointments.¹⁸ Lastly, we reimagined preventive care delivery through population health approaches. By consistently mailing fecal immunochemical test (FIT) tests for colon cancer screening and human papillomavirus (HPV) self-collection kits for cervical cancer screening, we maintain high-quality preventive care while avoiding clinician visits.^19,20

CONCLUSION

Managing health care demand requires balancing resources with patient centeredness while health care needs grow increasingly complex. Features that increase satisfaction and engagement—virtual visits, online scheduling, open access—can drive up demand. In practice, demand management continues to face significant hurdles: staffing constraints limit team-based care models, patient engagement with community partnerships remains inconsistent, and social determinants create barriers and higher utilization.²¹

Value-based care, as a model, also faces several critical challenges that can affect demand management. First, while reducing unnecessary visits can improve access, it requires robust infrastructure—including adequate staffing, reliable patient monitoring technology, and intervention systems—which many practices lack. Second, organizations face conflicting incentives, operating under both value-based contracts and fee-for-service payments where compensation depends on visit frequency. This “foot in 2 canoes” problem impedes full commitment to either model.²² Third, health equity concerns emerge as patients with limited health literacy, language barriers, or social needs often require more frequent in-person support, and “Just want to see my doctor.” The primary care relationship, especially in terms of continuity of care, remains irreplaceable—patients want their suffering and questions attended to by their doctor. These practical barriers necessitate careful consideration of local context and resources when transitioning to value-based care and addressing demand. Looking ahead, AI tools offer promising approaches to address some of these demand management challenges. AI-based systems have shown potential for monitoring disease progression and guiding follow-up care timing, as demonstrated in age-related macular degeneration management.²³ These applications, however, require careful evaluation to ensure they enhance rather than replace the patient-clinician relationship.

The 3D framework—delegate, defer, direct—provides clinicians with a path toward high-value care that respects patient preferences, utilizing traditional or emerging tools. Success requires systematic changes and policy support: expanding team-based care models, reforming payment systems to support patient education, and improving access to reliable health information. While no single family physician can solve health care’s demand challenges, we play a crucial role in leading conversations about appropriate utilization while maintaining trust and ensuring vulnerable patients receive needed care.