Independent primary care practices often turn to third-party companies to handle value-based care, but a new guide suggests they might be giving away too much money in the process. The nonprofit Ten Ten Ten has released the Value-Based Care Playbook, a free, open-source operating manual designed to help doctors keep more of their shared savings instead of handing them over to intermediaries.
The organization argues that physician enablement companies take a large cut of the savings that should belong to the practice. “Unfortunately, what’s happening is that they take a very large portion of the shared savings, so it does not truly help the primary care practice in the end,” said Jenn Block, PhD, MBA, who leads the value-based care initiative at Ten Ten Ten. She noted that practices are losing funds they could otherwise reinvest into their own operations.
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New Guide Offers a Roadmap for Independent Practices
The first installment spans 71 pages and covers critical operational areas including contract language, EMR configuration, care team design, and risk stratification. It also tackles physician incentives and documentation. About 25 deeper-dive companion documents are set to follow. Ten Ten Ten takes its name from an ambitious goal: achieving top 10 health outcomes at 10 percent of GDP within 10 years.
This release arrives as independent practices continue to shrink across the country. Fewer than half of physicians, roughly 47.4 percent, worked in practices of 10 or fewer doctors in 2024. That figure is down from about 80 percent in the early 1980s. The American Medical Association’s president has described this trend as an “unraveling” driven by low payment rates and rising administrative burdens.
Contract Terms Can Wipe Out Savings
The playbook starts with a stark warning: a practice can perform clinically well yet earn nothing due to poor contract terms. Block identified three common traps. Quality thresholds set as gates can wipe out savings even when costs are controlled. Flat per capita benchmarks hurt practices with sicker patients. Rebasing penalties punish success year over year.
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Block said attribution leakage—patients assigned to a practice who get care elsewhere—is the quietest trap but the one she hears about most. Her first test for any payer is to ask for the benchmark methodology and the historical data behind it. “If they won’t share that, I would be very cautious about entering into a contract with them,” she said.
Block emphasized that documentation alone is insufficient. “You cannot code your way to success. It’s not possible,” she said. “Practices that treat value-based care as a documentation project plateau in year two.” Bhargav Raman, MD, MBA, pointed out that medical costs represent 75 to 80 percent of payments. If those costs aren’t controlled, the system becomes unsustainable.
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Since fewer than 10 percent of patients drive 70 percent of the total cost.
The recommended operational engine is simple. A named owner reviews the rising-risk list every Monday, and the team assigns owners for the top 15 to 20 patients during a weekly huddle.
Her advice for the next 90 days involves establishing a baseline. Practices should pull quality performance data from EMRs and payer portals. They must verify the attributed patient panel against the active panel and conduct a documentation audit of 20 to 30 complex charts. A financial analysis covering admissions, readmissions, and risk adjustment factors is also essential. Ten Ten Ten’s practice readiness assessment is currently free for practices.
