Primary care practices operating in value-based care are often measured by performance metrics. But at Munson Family Practice in Traverse City, within the Munson Healthcare network, success starts somewhere else: understanding the realities of the patients they serve — and building care around those realities.
For Dr. Joseph (Bill) Rawlin, Medical Director, and Practice Manager Mistie Atkins leading this residency-based clinic, value-based care is not about optimizing for the easiest patients or achieving benchmarks on paper. It’s about consistently showing up for a complex population — and doing the work required to improve outcomes over time.
“We have a complex, difficult patient panel. The only way to take care of those folks is we have to be highly engaged.”
Designing care around the community
The practice serves a patient population with significant complexity:
- A high proportion of Medicaid and Medicare patients
- Transportation challenges that make access difficult
- Chronic conditions requiring ongoing, coordinated care
For many patients, seeking care is not simple.
“They’ll ride the bus all morning to get to us. Because they want to control their diabetes and do better.”
Rather than expecting patients to navigate a fragmented system, the team has intentionally built a model designed to address the real obstacles their patients face.
Reducing barriers to improve outcomes
A core part of the practice’s approach is minimizing friction wherever possible.
“If a patient has already gone through the effort of riding the bus across town just to be here, asking them to go somewhere else for labs is often too much. That’s where we lose them — and ultimately, we’re not going to get great outcomes.”
To address this, the clinic has expanded what care looks like within its walls:
- In-house point-of-care testing
- Embedded care management, behavioral health, and pharmacy
- Remote patient monitoring to extend care beyond visits
These efforts help ensure that when patients engage, they can access more of what they need in one place.
The culture of caring
While care model design matters, both leaders emphasized that their success is rooted in culture.
The practice benefits from:
- Long-standing team members and low turnover
- Strong leadership continuity
- A deeply collaborative care environment
“We’ve built a team that’s been here a long time… and is really engaged and invested in this community,” added Mistie Atkins.
That environment is intentional. Dr. Rawlin and Atkins both prioritize recognizing their staff and advocating for their team — helping create a culture where people feel valued and supported in taking on the day-to-day challenges of caring for a complex patient population.
With such a strong foundation, the team is able to take on new initiatives, pilot programs, and continuously evolve how care is delivered.
Staying engaged through the challenges
For this team, patient engagement isn’t a tactic — it’s an ongoing commitment.
Reaching patients often requires persistence:
- Multiple outreach attempts
- Different communication approaches (calls, texts, email)
- Continuous follow-up from care managers and staff
“Sometimes it’s just finding a different way to communicate.”
At the center of this effort is relationship-building.
“Our biggest success is the relationships we form with them.”
Dr Rawlin and Atkins expressed a sense of responsibility to the patients they serve. The team doesn’t step away when engagement is difficult or inconsistent. Instead, they continue reaching out, recognizing that many of their patients have faced barriers — or even been dismissed from care elsewhere. For this practice, staying engaged isn’t optional — it’s part of their commitment.
Rethinking what success looks like
In many value-based care programs, success is defined by hitting key performance thresholds. But for Dr. Rawlin, those numbers alone don’t capture the full picture.
“What it’s not is just achieving 75% across the board,” he said. “For us, it’s about taking care of the patients who need us most — even when that makes performance more challenging.”
Instead, the practice defines success more broadly:
- Keeping patients out of the hospital
- Serving complex and underserved populations
- Improving long-term health across the community
“We’re taking care of patients that nobody else will… and that’s really important to our team.”
Even when these patients present additional challenges — or impact performance metrics — the team remains focused on the bigger picture.
“It’s better they’re here than in the hospital.”
A model rooted in real-world care
In practice, value-based care is not a single initiative or program — it’s the accumulation of small, consistent efforts:
- Meeting patients where they are
- Removing barriers to access
- Building trust over time
- Supporting teams to sustain the work
With support from Honest Health, and alignment across the broader system, Munson Family Practice continues to refine its approach — balancing performance expectations with the realities of patient care.
In a healthcare environment often defined by constraints, their model offers a clear example of what value-based care looks like when it is built around people — not just metrics.