Value-Based Care Education in Family Medicine Residency Programs: A CERA Study of Program Directors

Value-based care (VBC) is a type of health care model that measures and incentivizes quality outcomes and cost efficiency rather than volume of services. VBC integrates interdisciplinary teamwork, proactive panel management, and cost measurement to improve quality and reduce overall health care costs. ^1-4 The Centers for Medicare and Medicaid Services aims for 100% of traditional Medicare and the majority of Medicaid beneficiaries to be part of accountable care relationships for quality and total cost of care by 2030.⁵ Many residents ultimately will practice in VBC settings, making training on its principles essential. However, literature on how VBC is taught in primary care residency programs is limited.^6-8 This study explores the current state of VBC education in family medicine residency curricula.

The research team, consisting of experts in graduate medical education and VBC, developed a six-item, cross-sectional survey to assess VBC education in family medicine residency programs. The survey asked program directors to assess the presence and content of VBC curricula, teaching methods, and barriers and facilitators to VBC education. This survey was part of the 2024 Council of Academic Family Medicine Educational Research Alliance (CERA) national survey. ⁹ Invitations were sent to all Accreditation Council for Graduate Medical Education-accredited US family medicine residency program directors. The CERA steering committee evaluated questions for consistency with the overall subproject aim, readability, and existing evidence of reliability and validity. Pretesting was done on family medicine educators who were not part of the target population. Questions were modified following pretesting for flow, timing, and readability. A total of 767 programs existed at the time of the survey; after removal of invalid responses, the sample size was reduced to 705. Upon review of the 382 responses received, we found a total of 320 respondents who completed the entire survey. We analyzed the data with SPSS (IBM) using descriptive statistics and association tests, including univariate χ² tests and Spearman’s ρ. The American Academy of Family Physicians Institutional Review Board approved this project in April 2024, with data collected from April 30 to June 7, 2024.

The overall response rate was 45.39% (320/705). Program characteristics and director demographics are described in Table 1. Of the respondents, 92.2% agreed on the importance of teaching VBC, and 26.9% of programs had a formal VBC curriculum. However, 95% of programs taught some VBC elements, with the most commonly taught topics being “evaluation and management of quality outcomes” (80.9%) and “working effectively with interdisciplinary teams” (80.0%; Table 2). Other topics, such as managing patient care costs (40%) and VBC’s intersection with health equity (24%), were less commonly taught. VBC elements were predominantly taught through didactics (79.7%) and administrative experiences, such as participation in care management meetings (55.9%; Table 3). The most common barriers to VBC education included lack of time and competing priorities (37.5%) and insufficient content expertise (29.7%). A positive institutional climate and the presence of faculty experts were seen as facilitators for including VBC topics in the curriculum.

This study highlights a significant gap between the perceived importance of VBC education and its actual implementation. While most program directors acknowledged the importance of VBC education, fewer than 30% had a formal curriculum in place. Despite the lack of a formal curriculum, many programs incorporated at least some VBC elements. However, comprehensive VBC education is not yet widespread, suggesting that family medicine residency programs have not fully adapted to the evolving health care landscape.

The shift to value-based care models requires an expert workforce trained in VBC principles. While the National Family Medicine Residency Graduate Report asks graduates about their current clinical practice and to rate satisfaction with aspects of their training, ¹⁰ no existing data are available on how well family medicine graduates are prepared for VBC settings, nor how many practice in such environments. Beyond panel management and interdisciplinary collaboration, primary care residency curricula should include core VBC elements like managing hospitalization and emergency department costs, addressing health-related social needs, and integrating behavioral health. While didactic teaching is common, fewer programs incorporate clinical practice or administrative experiences, which are essential for residents to apply VBC concepts in real-world settings. Academic and community-based programs that lack value-based care environments could consider partnerships with VBC organizations to provide relevant training.

The primary barrier to VBC training is time and competing curricular priorities. To address this barrier, the development of a standardized VBC curriculum could help residency programs integrate and assess VBC education more effectively. For example, Holtzman et al ¹¹ created a value-based health care elective for undergraduate medical students to introduce VBC concepts, including patient-centered outcomes, cost assessments, reimbursement models, and teamwork. In graduate medical education, the Association of American Medical Colleges’ Teaching Residents Population Health Management report¹² offers 10 key components for a successful population health system, such as data infrastructure, social determinants of health, team-based care, and care management strategies. Incorporating these elements into residency curricula could better prepare residents for value-based care settings.

The survey sample appeared representative of the regional program demographics we could access, despite limited data on all programs and directors. However, given these limitations, we were unable to conclude that this survey sample was representative of all programs. The experiences of program directors from other primary care specialties, other faculty and staff, and residents themselves were not directly represented. The survey gathered perceptions of VBC education but did not assess specific VBC skills or evaluate educational outcomes. Additionally, in our survey question, “How are VBC topics being taught?” (Appendix), one potential response combination was omitted, and the recoding of our data may have introduced a source of methodological bias.

This study underscores the need for more comprehensive integration of VBC education into family medicine residency programs. The gap between the importance of VBC and its implementation in curricula calls for standardized training materials and clinical opportunities. To ensure that graduates are equipped for value-based care settings, future efforts should include the development of curriculum guidelines, assessment tools, and postgraduate surveys to measure the effectiveness of VBC training. Ongoing evaluation will help tailor curricula to meet the evolving demands of health care delivery.

Ashley Chou and Deborah Edberg are employed by CVS Health Corporation and may own stock and/or equity but have no conflicts germane to this study. Jefferson and CVS are not affiliated, and CVS did not pay Jefferson for this work.