Primary Care Physician Models That Work

At mass this past Sunday, our priest talked about constructive and destructive anger. Anger, he noted, can be constructive, especially when it motivates one to speak out against injustice. I feel that “constructive anger” when I write about health and quality of life injustices that occur because we as a country have not invested in primary care, especially as delivered by primary care physicians.

My “constructive anger” becomes even more focused when I see how residents of rural America suffer from healthcare and quality of life neglect because of an inadequate healthcare workforce in their communities, especially represented in the lack of primary care physicians.

I especially experience both “constructive anger” and frustration when I hear healthcare governmental and non-governmental stakeholders, especially payers, accept the demise of primary care physicians as inevitable, and they do not admit their role in this decline and their ability to change this trend.

Seniors, like me, see firsthand how our “healthcare system” has become more fragmented and impersonal. As “the system” continues to compartmentalize physician services into specialties and subspecialties, it becomes even more important that the primary care physician moves to center stage. Patients, now more than ever, need their primary care physician to play an advocacy role as they wander through the maze of healthcare, which we inaccurately define as a system.

As I noted in prior publications that focused on the primary care physician, including my recent publication, “Will The Primary Care Physician Story Have a Happy Ending? ” there are initiatives that can make a difference in both increasing the number of primary care physicians and moving them into center stage.

This blog will focus on the successful models of primary care and specifically why they are successful. I define successful as a win for the primary care physician, a win for the payer, and most importantly a win for the patient and our society. These and other models can be cloned throughout our communities and can inspire more medical students to choose primary care as both their specialty and their passion.

Finally, as I discussed in my blog titled, “Physicians, YOUR Future is in YOUR Hands ,” physicians have options, and they can control their own future.?This is especially true for primary care physicians. So, there is hope. Join me in this “constructive anger” and fight the good fight.

Why is the Primary Care Physician Model Broken?

As noted in my recent blog, “Will the Primary Care Physician Story Have a Happy Ending? ,” the historical reliance on a fee-for-service payment methodology (“the more you do, the more you make”) primarily benefited physician specialists and was the growth engine for hospitals, all to the detriment of primary care physicians.

The primary care physician was further penalized when Medicare developed the Resource-Based Relative Value Scale (RBRVS) in the early 1990s as a basis for calculating reimbursement for physicians.?This coding system does not adequately account for the work performed by primary care physicians in that it rewards procedural work over cognitive work.

Commercial insurance companies also played “follow the leader” in cloning?the Medicare RBRVS fee schedule?as their own base for determining payment levels for physicians and the related services.?This, again was done to the detriment of the primary care physicians.

What Is the Common Similarity Between All the Primary Care Models That Work?

As I have noted in multiple publications, “a healthcare system is shaped by what you pay for and how you pay for it.”? The “how you pay for it” component is especially relevant.

Our challenge today is how to make primary care and family medicine more rewarding and professionally gratifying. As stated above, these issues are driven by the disincentives inherent in fee-for-service medicine.?

Any payment system reform focused on primary care physicians must incent and ensure that all members of the practice are closely aligned to identify and address patients’ issues and allow the physician to play an advocacy role for their patients.

Examples of “how you pay for it” that set the stage for value-based care include:

• Primary care physician practices (especially independent practices) whose primary revenue source is capitated payments. Incentives built into a capitated payment model financially reward primary care physician practices for keeping members healthy and providing optimum cost-effective healthcare services and referrals.
• As noted in a recent blog, teaming “Direct Primary Care (DPC)/Advanced Primary Care (APC) ” with self-insured employers. Since self-insured employers are paying the bill and carrying the risk, there are built-in incentives for employers as a funding source to keep employees healthy (productivity, absenteeism, etc.) and provide optimum cost-effective healthcare services and referrals.
• Non-profit and for-profit organizations and integrated healthcare systems whose business model revolves around the primary care physician and who also enter into capitated risk arrangements with governmental and non-governmental payers. These organizations’ profits/margins are linked to providing cost-effective quality care as well as referrals to value-based specialists and hospitals.

Case Studies of Primary Care Models That Work

1.??? Innovative organizations are collaborating with independent primary care practices as well as multi-specialty practices that have a strong primary care focus to provide administrative infrastructure to both allow the practice to manage capitated risk arrangements effectively as well as provide the necessary financial backing to insulate the practice from high-risk claims.

These innovative organizations provide administrative infrastructure and support services to independent primary care practices transitioning to value-based care models.

In my own state of Ohio, organizations such as Agilon Health have partnered with independent primary care physician groups such as Central Ohio Primary Care , Toledo Clinic , Community Health Care and Pioneer Physicians to allow the practices to embrace risk/value-based payment methodologies such as capitation .

Agilon Health developed a platform that is utilized by their primary care practices partners. They are in thirteen states and one hundred communities. Agilon Health teams up with the existing pool of primary care physicians and gives them the data analytic tools and incentives to truly focus on high-value medical care.

Agilon provides the capital, data, payor relationships (with Medicare Advantage Plans), executive experience, and contract support that allow physician groups to take on the risk of total care for their most vulnerable patients.

I recently visited with the President of Pioneer Physicians, Dr. Victoria DiGennaro and their Administrator, Kathleen Kostelnick,EMBA, FACMPE . I thought I was in primary care physician heaven. Pioneer’s primary care physicians (approximately 60 in number) were indeed on center stage. Their main revenue source is global capitated arrangements with Medicare Advantage Plans. They not only provided quality, team-based services to their patients, they also played an advocacy role for their patients by directing them to value-based specialists and hospitals. They also required any of the referred hospitals to allow nurses and primary care physicians access when their patients were in the inpatient setting.

2.??? Teaming DPC/APC with self-insured employers

Advanced Primary Care (APC) is a practice that shifts the focus of primary care toward quality. Instead of focusing on numbers, APC ensures?patients are provided with high-quality care. APC allows providers to be free of traditional time constraints due to the need of seeing a high volume of patients. In turn, this allows clinicians to spend more time and provide more comprehensive care to their patients. In addition, if a patient needs to be referred to a specialist for more additional services, APC practices can maintain that relationship and ensure that the patient’s care is thoroughly coordinated throughout the treatment process. The improved effectiveness of primary care at the population level leads to substantial decreases in costs for the patients.?

Enlightened consultants and brokers are partnering with self-insured employers and third-party administrators in developing value-based benefit designs as well as incorporating Direct Primary Care/Advance Primary Care practices into that benefit design to further the search for value.?The combination of a self-insured employer and DPC/APC also sends a message to traditional insurance companies who do not value the role of the primary care physician in the value equation.

Bryce Heinbaugh is Managing Partner for IEN Risk Management Consultants , an employee benefits firm located in Northeast Ohio, and he is associated with Health Rosetta . Bryce is a former student of mine, and he is a national advocate for teaming DPC/APC with self-insured employers, especially in rural America.

His APC model includes primary care physicians, nurse navigators, community pharmacists, etc. The self-insured employer’s benefit design has zero copays if employees and their dependents utilize the APC physicians. Incentives are also built into the benefit design to encourage employees/dependents to follow recommended referrals to value-based specialists, hospitals, and centers of excellence.

Specialists, hospitals, and centers of excellence referrals focus on quality; price is secondary. Bryce’s team (including nurse navigators) utilizes data from creditable third-party data sources to identify quality clinicians and hospitals.

Bryce also partners with community pharmacists and transparent Pharmacy Benefit Managers (PBMs) to provide both the best costs and services to their self-insured employer partners.

3.??? Non-profit and for-profit organizations and integrated healthcare systems whose business model revolves around the primary care physician and who enter into capitated risk arrangements with governmental and non-governmental payers.

ChenMed:

Recently, I had the opportunity to interview Daniel McCarter, MD FAAFP , MD, National Director of Primary Care Advancement at ChenMed.

ChenMed is one of the largest networks of practices in the United States, providing high-quality care for seniors. ChenMed is a physician-led, integrated care medical center that delivers high-quality health care for seniors who are Medicare Advantage beneficiaries.

ChenMed partners with insurers to ensure that high-quality care and adequate resources are available to attend to the social determinants of health impacting patients’ healthcare needs. Through innovative payment arrangements with Medicare Advantage plans, ChenMed takes on 100 percent of the financial risk through value-based contracts. The payment is adjusted based on each patient’s health status. ChenMed believes capitation provides the freedom and focus needed to care for patients effectively. The goal at ChenMed is to provide patients with more healthy days at home. Doctors are paid on a straight salary, working five days a week and 3-4 weeks of call per year.

ChenMed has grown to include more than seventy primary care offices in ten states east of the Mississippi. ChenMed offers concierge level medical services for low- and medium-income seniors. Older folks with complex chronic medical conditions are their focus. ChenMed primary care practices are placed in underserved areas and patients are exclusively covered by Medicare Advantage.

Care teams are constantly changing and adapting in response to data about patient needs. Specialists recruited to the ChenMed primary care package include cardiologists, endocrinologists, infectious disease specialists, and nephrologists.

If a patient requires hospitalization, ChenMed’s care team, including a case manager or contracted independent hospitalist practice, visits and stays in close contact with that patient while in the hospital. The care manager acts as a personal in-hospital advocate, like a lawyer representing a client.

ChenMed also employs community case managers to help patients who do not necessarily need to visit the office to see a physician.

Since 2011, ChenMed has doubled its size every 2.5-3 years. Currently, they are ramping up to add another twenty offices in two additional states. In five years, Dr. McCarter projects that ChenMed will have five hundred offices and about two thousand physicians.

Kaiser Permanente Primary Care Model:

Kaiser Permanente is one of America’s leading healthcare providers and nonprofit health plans. Their health plan finances the care delivered by the more than 24,605 physicians of the Permanente Medical Groups, 73,618 nurses, and 75,000 allied health professionals in their forty hospitals and 618 medical facilities. They serve 12.5 million people in California, Colorado, the District of Columbia, Georgia, Hawaii, Maryland, Oregon, Virginia, and Washington.

They serve their members using a unique business model that combines health coverage and care delivery into one coordinated experience.

Under their financial model, they receive a prepayment for each member and then are responsible for their health care. This incentivizes their members to improve and maintain their health — supporting a focus on prevention, health promotion, health maintenance, and effective management of both acute and chronic conditions.

The Kaiser Foundation Health Plan collects member premiums in advance and then pays delivery system partners for members’ care throughout the year. This creates flexibility within and across the health plan, the hospitals, and the medical groups to deploy those resources to best meet their members’ needs and encourages wise use of resources.

Physicians are salaried. As a result, they can focus on providing the highest quality care rather than spending time on billing and identifying ways to meet revenue targets. Physicians do not have fee-for-service incentives to provide unnecessary care. They also do not benefit from withholding needed care that supports member health, a result of guardrails and accountabilities that measure and ensure high-quality care.

The medical groups invest in primary care (as the captain of the ship) and ensure the right number of specialists and subspecialists.

Their primary care services include everything from basic health checkups to disease-management programs. Those programs include appropriate specialist consultations when needed, but primary care physicians remain in charge of patients’ overall care. Even if patients need to be hospitalized, care delivery is seamless because all physicians and other health professionals have access to KP HealthConnect, their electronic medical records database.

Their internal and family medicine physicians use a variety of technologies within primary care to support the entire care journey of their patients.

Health education is a core part of Kaiser Permanente’s integrated care delivery model and one that augments their primary care. Through health coaching, online and in-person classes, health education works with clients across demographics to provide culturally competent education and skills to support total health.?

Recently, Kaiser Permanente acquired Geisinger .

As noted in this article, Kaiser Permanente and Geisinger?have a long, shared history of innovating to improve health outcomes and population health through an integrated care model built on value-based care.

As also noted in the article, “The two health care giants formed a new, nonprofit organization known as Risant Health, and that presents an exciting opportunity to build out value-based care in a “next-generation” type of way.”?

Conclusion

It would be short-sighted of payers (both governmental and non-governmental) to attempt to minimize capitated type payment levels to primary care physician practices. As I have noted repeatedly in my publications, you cannot pay too much for primary care physicians to provide value-based care.

Also, as more successful primary care physician models appear in our communities, both federal and state regulators need to require the elimination of non-compete language in employment contracts. Non-competes stifle opportunities for physicians and penalize the patients and our communities.

As discussed in a prior blog titled, “Being Cared For By Strangers – Why We Cannot Cut Out the Primary Care Physician From Inpatient Hospital Care ,” I discuss the importance of the primary care physician staying connected to their patients when they are in the inpatient setting of the hospital.? As you will note from this blog, all the successful models made sure that the primary physician was “involved” when their patients were in the hospital’s inpatient setting.

Finally, as primary care physicians move to center stage in a risk/value-based world, it is critical that their training in medical school and residency programs prepares them for this task.? As noted in this blog, healthcare has become increasingly fragmented, with specialists and sub-specialists focusing on narrower areas within their own specialties. The primary care physician will need to have enhanced problem-solving and critical thinking skills and a broad enough clinical understanding to piece together our fragmented healthcare system as it relates to their patients’ health.

I welcome discussion on this blog from all readers, especially physicians and payers.

Tom Campanella is the Healthcare Executive in Residence at Baldwin Wallace University. Backed by more than 35 years of experience in the industry—particularly the health insurance, physician and hospital sectors—he’s focused on strategic advising and community outreach. Follow Tom’s articles on LinkedIn for his latest weekly coverage of the healthcare industry.

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