Patient-centered medical home philosophy boosts patient, physician satisfaction

UCLA-USC intervention could encourage more new docs to enter primary care

By Enrique Rivero October 08, 2013

The common refrain about health care is that it's a broken system. A new joint program between UCLA and USC demonstrates a way to mend the system with a new patient-centered program that is getting rave reviews from patients and from the residents and nurses who provide their care.

 

The program, Galaxy Health, debuted at Los Angeles County+USC Medical Center in 2012 with the goal of substantially improving an on-site clinic for residents and demonstrating to county officials that intuitive and inexpensive interventions can dramatically improve patient care and physician and staff morale.

 

A new UCLA–USC study published online in the JAMA Internal Medicine, a peer-reviewed journal of the American Medical Association, outlines how the Galaxy model works in a public setting, with a favorable effect on both patients and medical residents.

 

"We all know that fewer and fewer young physicians are choosing careers in primary care because of the difficult work schedules, lack of support and lower salaries," said lead study author Dr. Michael Hochman, who conducted the research as a Robert Wood Johnson Clinical Scholar in the division of general internal medicine and health services research at the David Geffen School of Medicine at UCLA. "What we did here was to move in the direction of a team-based approach, and it resulted in improved satisfaction for physicians-in-training with their primary care experiences."

 

Dr. David Goldstein, an associate professor of clinical medicine at USC's Keck School of Medicine and chief of the division of geriatric, hospital, palliative and general internal medicine at LAC+USC Medical Center, was the study's senior author. He conceived the Galaxy Health program.

 

"My hope was that Galaxy would reveal that a minimal investment and reorientation in delivery focused on the patient and enhanced access to care could improve the satisfaction of patients, staff and physicians, even in an underfunded public environment," he said. "I think it worked out well. It's not rocket science."

 

The Galaxy model established round-the-clock, seven-day-a-week access to physicians, made urgent clinic appointments available within hours and coordinated care in the ambulatory environment. It was based in part on increasing interest in a concept known as the patient-centered "medical home," which provides a team-based, coordinated approach to care that aims to make the primary care team central to the patient’s health needs. While the concept may not sound that different from the traditional vision of high-quality primary care, Galaxy's innovation is making this vision a reality in a complex, disconnected health care system.

 

"Galaxy Health has proven its value and effectiveness, as measured by patient satisfaction, access to care and provider satisfaction, in an incredibly challenging clinical environment," said Christina Ghaly, interim CEO of LAC+USC Medical Center. "Its remarkable success is to the benefit of our patients at LAC+USC Medical Center and can be a model for other safety-net, resident-run clinics struggling with implementing patient-centered medical homes."

 

The project was funded primarily by a three-year, $750,000 grant from UniHealth Foundation.

 

The study findings also support further investment in primary care, particularly in teaching settings, where the next generation of primary care leaders will be developed, said Hochman, now medical director for innovation at AltaMed Health Services, a large federally qualified health center in Southern California. There is currently a shortage of primary care physicians, and the situation is expected to become more acute as baby boomers continue to reach retirement age.

 

The researchers conducted their study at three primary-care internal medicine clinics at LAC+USC, an urban academic medical center serving a safety-net population. They focused on expanded access to care, enhanced care coordination and team-based care. Galaxy Health included the creation of a call center staffed by two care coordinators, telephone renewal of prescriptions and the availability of up to five urgent care appointments each day.

 

Input from patients and staff during prior focus groups was incorporated into the study. The researchers surveyed patients and residents before the intervention and again one year later. They also analyzed emergency room and hospital visit rates.

 

Though the clinics did not satisfy all the elements needed to qualify as a patient-centered medical home, overall their score jumped from a previous 35 to 53 out of 100 possible points. The satisfaction rating from patients increased from 48 percent to 65 percent in the intervention clinic, compared with a jump from 50 percent to 59 percent in the controls. Patients were particularly pleased with access. Satisfaction with urgent appointment scheduling increased from 12 percent to 53 percent in the intervention clinic, compared with an increase from 14 percent to 18 percent in the control clinic. 

 

The composite satisfaction score for residents went up from 39 percent to 51 percent in the intervention clinic but fell in the control clinic from 46 percent to 42 percent.

 

The study noted that emergency room and hospital visits were not reduced.

 

"This was an anticipated finding, because we expanded access to care to an underserved patient population, and frequently when this happens, there's a spike in emergency and hospital room utilization," said study co-author Dr. Arek Jibilian, assistant professor of clinical medicine in the Keck School's division of geriatric, hospital, palliative and general internal medicine. "However, we believe that a sustained commitment to primary care will ultimately reduce emergency and hospital utilization, and this is something we hope to see as the program continues."

 

Study co-authors are Steven Asch, Arek Jibilian, Bharat Chaudry, Ron Ben-Ari, Eric Hsieh, Margaret Berumen, Shahrod Mokhtari, Mohamad Raad, Elisabeth Hicks, Crystal Sanford, Norma Aguirre, Chi-hong Tseng, Sitaram Vangala and Carol M. Mangione. Additional contributors include Becky O'Neal and Roman Corral.

 

The demonstration was primarily funded by the UniHealth Foundation in Los Angeles. In addition, the study was funded by grants from the Robert Wood Johnson Clinical Scholars Program; the U.S. Department of Veterans Affairs (grant 67799 to UCLA); the UCLA Resource Centers for Minority Aging Research Center for Health Improvement of Minority Elderly (RCMAR/CHIME) under NIH/NIA Grant P30-AG021684; and the NIH/NCATS UCLA CTSI (grant UL1TR000124).

 

The Keck School of Medicine of USC , founded in 1885, is among the nation's leaders in innovative patient care, scientific discovery, education and community service. It is part of Keck Medicine of USC, the university's medical enterprise, one of two USC-owned academic medical centers in the Los Angeles area. This includes the Keck Medical Center of USC, composed of the Keck Hospital of USC and the USC Norris Cancer Hospital. The two world-class, USC-owned hospitals are staffed by more than 500 physicians who are faculty at the Keck School. The school today has more than 1,500 full-time faculty members and voluntary faculty of more than 2,400 physicians. These faculty direct the education of approximately 700 medical students and 1,000 students pursuing graduate and postgraduate degrees. The school trains more than 900 resident physicians in more than 50 specialty or sub-specialty programs and is the largest educator of physicians practicing in Southern California. Together, the school's faculty and residents serve more than 1.5 million patients each year at Keck Hospital of USC and USC Norris Cancer Hospital, as well as the USC-affiliated Children's Hospital Los Angeles and Los Angeles County+USC Medical Center. Keck School faculty also conduct research and teach at several research centers and institutes, including the USC Norris Comprehensive Cancer Center, the Zilkha Neurogenetic Institute, the Eli and Edythe Broad Center for Stem Cell Research and Regenerative Medicine at USC, the USC Cardiovascular Thoracic Institute, the USC Eye Institute and the USC Institute of Urology.

 

General Internal Medicine and Health Services Research is a division within the department of medicine at the David Geffen School of Medicine at UCLA. It provides a unique interactive environment for collaborative efforts between health services researchers and clinical experts with experience in evidence-based work. The division's 100-plus clinicians and researchers are engaged in a wide variety of projects that examine issues related to access to care, quality of care, health measurement, physician education, clinical ethics and doctor–patient communication. The division's researchers have close working relationships with economists, statisticians, social scientists and other specialists throughout UCLA and frequently collaborate with their counterparts at the RAND Corp. and Charles Drew University.

 

The Robert Wood Johnson Foundation Clinical Scholars program has fostered the development of physicians who are leading the transformation of health care in the United States through positions in academic medicine, public health and other leadership roles. Through the program, future leaders learn to conduct innovative research and work with communities, organizations, practitioners and policymakers on issues important to the health and well-being of all Americans. This program is supported in part through a collaboration with the U.S. Department of Veterans Affairs.

http://newsroom.ucla.edu/portal/ucla/patient-centered-medical-home-248773.aspx

Dallas heart surgeon uses medicine as ministry

By MARC RAMIREZ

DALLAS (AP) — At 83, Carl Smith found himself facing quadruple-bypass surgery and the real possibility that he might not survive.

Within hours on this spring morning, Dr. Mark Pool would temporarily bring Smith's heart to a stop in an attempt to circumvent its blocked passages.

And to help his patient confront the uncertainty, Pool did something unusual in his profession: He prayed with him.

The power of healing: Medicine and religion have both had their day, and they haven't always been able to coexist. But as today's medical treatment becomes more holistic, doctors are increasingly taking spirituality into account.

The Dallas Morning News (http://dallasne.ws/1cbWHgS) reports that studies show a majority of patients want their spirituality recognized, and most med schools now have classes related to the topic. In general, the new thinking asks doctors to note their patients' spiritual leanings and open doors to expression, especially when life is at risk.

Pool, a highly regarded heart and lung surgeon at Texas Health Presbyterian Hospital Dallas, is fervent about his Baptist faith. For about a year, he's routinely asked patients if they'd like him to pray with them pre-surgery — a gesture he says is always appreciated but one that exceeds advocates' suggested bounds.

"A physician should be open to a patient's spirituality but shouldn't push religion on patients," says Nathan Carlin, assistant professor at the University of Texas Health Science Center at Houston. "That's confusing personal and professional roles."

An inherent power differential divides doctors and patients, says Christina Puchalski, director of George Washington University's Institute for Spirituality and Health and co-editor of the recently published Oxford Textbook of Spirituality in Healthcare.

"They're coming to us for something other than prayer," Puchalski says. "If I, as a patient, perceive (a surgeon) as having my life in his hands, and he asks me to pray and I say no, he may not treat me well. And that's putting undue pressure on the patient."

As the saying goes, there are no atheists in foxholes: The idea that your fate is out of your hands offers fertile ground for re-examination.

"The moment somebody tells you that you have cancer," says Methodist Dallas Medical Center's Rohan Jeyarajah, a gastrointestinal surgeon who prays with patients, "you're going to believe in something."

But the situation, he says, requires caution: "We have to be careful about being in a position of perceived authority and not overstepping that bound. This is like a teacher-student relationship. There's a chance you could be inappropriate."

Pool pushes forward, eager to share the belief that drives him without making people feel awkward or flouting that power imbalance.

"I don't want to exploit their situation," he says. "At the same time, I want to give them the opportunity to explore the faith that I know."

You could say Pool comes from a religious background. His father, his grandfather, his father-in-law, his brother-in-law: all ministers. The family joke was that he started going to church nine months before he was born.

By age 6, he was well versed in Bible basics, but then something odd happened. One day at a prayer meeting, Pool says, he was touched by — well, not quite a vision, but an awareness.

"I had already understood that Jesus came to save the world," he says. "That was nice. But then I understood: Jesus came to save me. And that changed everything."

He's pursued a path of faith ever since. Medicine seemed like a good way to help people. Even so, as a med student, Pool pondered ditching the whole thing to go to seminary instead.

As a member of First Baptist Church of Dallas, he and wife Jessica lead relationship classes on Sundays for dozens of young married couples. Even in his crisp, black-patterned suit, Pool is impossibly youthful — lean and rosy-cheeked, posture straight as a fence post.

And as a cardiothoracic surgeon, another realization has set in: "I have a ministry. I don't need to be standing in a pulpit. I have found a ministry I did not expect. I am able to minister to people in times of need."

Since Texas Health is a faith-based hospital system, he felt at ease taking that step.

"The vast majority of people believe in God," he says, "and yet when people come to the hospital, that's completely ignored by doctors. If anything, they call the chaplain. It's unfortunate that more doctors don't try to engage that part of a patient's life."

That's starting to change. Two decades ago, barely a few med schools offered classes on spirituality. Now, three-fourths of them do.

"Medicine has figured out that we ignore the more human sides of health care at our own peril," says Craig Borchardt, interim chair of humanities and medicine at Texas A&M University.

Studies show 60 to 80 percent of patients want their beliefs noted, he says — not as affirmation but as a sign that the doctor actually cares. But fewer than 20 percent of doctors bring it up.

The push has met with some backlash — from busy doctors reluctant to take time away from other concerns or others who don't like talking about it.

"Some staff are more comfortable with it than others," says Mark Grace, vice president of mission and ministry for Baylor Health Care System.

He doesn't reject the idea of doctors offering to pray, but "if you don't listen to the answer, that's where you get into problems. . The doctor needs to be prepared if the patient says no."

George Washington University's Puchalski says the bottom line is doing what's best for the patient.

"Physicians are generally not trained to lead prayer," she says.

To illustrate the power differential she says exists, she recalls a patient who was also a fellow parishioner. One day, she noticed the woman hadn't been to church for a while, then realized the woman hadn't come into her office either.

When the patient finally resurfaced, Puchalski pressed the matter: "She told me, 'I thought you'd be upset that I switched churches.' That gives you an idea of the power we have over patients. So I would really caution against (taking advantage of) that."

Pool gleans his patients' spiritual beliefs at their initial meeting. Then, on the morning of surgery, he says: "This is a time when a lot of people turn to faith. Would you mind if I prayed with you?"

No one, he says, has ever declined, not even those who believe differently or not at all.

It's 6 a.m., and Pool, shiny black boots poking from beneath blue scrubs, briefs Smith on his surgery. At 83, Smith is fit, mowing the yard occasionally, an active driver.

But coronary artery disease caught up with the retired Farmers Branch pharmacist, slowing his blood flow and causing chest pain. Over time, it could lead to a heart attack.

Madge Smith, his wife of 63 years, and Leah Wilson, his youngest daughter, are near. Scott Smith, his son, would join later.

Pool explains his plan: He'll make an incision down Smith's breastbone, then take arteries from his left and right side, and a vein from his leg, to form new channels for blood to flow through his heart.

"So," he tells Smith, "you told me you're a Sunday school leader. . Would you mind if I said a prayer for you?"

Smith is touched. Pool places his hand on Smith's shoulder and begins:

"God, thank you for Mr. Smith. We ask that you would guard his life, keep him safe and bring him through this operation. Replace any anxiety that he may have. Give him a great assurance of your love and your power.

"I ask you to watch over our team, that you give us all clarity of thought, that you guide my hands as they move. We pray these things in Christ's name. Amen."

"Amen," Smith says.

Later, as Smith's family awaits the outcome, his wife says: "I have never had a doctor do that. It just meant so much to us. We just thought it was sent from God."

At 6:45 a.m., Pool starts in, using a tiny electric saw to patiently work through Smith's chest and breastbone.

The arteries he wants dangle inside like strings of soaked cooking twine above Smith's quivering lungs. He snips one end of each, then applies small plastic clamps to stop the thin spurt of blood.

"See that?" he says. "That's the blood flow that will be going into the heart."

A shot of potassium literally stops Smith's heart cold, temporarily abdicating its work to a heart and lung machine. To the heart, Pool will divert the snipped arteries, and repurpose a vein taken from Smith's leg, to offset the blockages within.

But first he has to open the heart's protective sac, unveiling the still-beating organ as it heaves inside. Pool eases it to one side, to reach a portion underneath — and in that moment, Smith's heart, the force pumping blood and oxygen throughout his body, rests in Pool's cradling grip.

Out in the family waiting area, Smith's son Scott says: "God has his hand on everything. He's in control. We're not. It's in God's hands."

Pool initially wondered if his praying might give patients pause, whether they'd worry he wasn't confident enough in his own skills to get through the surgery.

"It's been the opposite," he says. "They value the humility."

Last year, Shea Bowen of Kaufman had just delivered a son at Texas Health Presbyterian Hospital Rockwall four weeks early. Suddenly, she became short of breath. Tests revealed a tumor in her heart.

She was rushed to the network's Dallas hospital, where Pool met with her and her husband. She was shaking then, a complete wreck.

"It was terrifying for me," Bowen says. "I had to leave my few-hours-old baby. We knew there was a chance that . Not everyone comes out of surgery.

"Dr. Pool could tell. His words were 'I don't know if you guys believe in God, but I do,' and as soon as he said that, we both burst into tears. He said, 'I can cut and I can sew, but God is going to heal you, and I'm going to do everything in my power to make sure that happens.'

"There's a lot that's a blur, but I remember the comfort of knowing the person who was literally going to stop my heart and cut me open was going to do that for me under God."

Not long ago, Pool contacted a local evangelistic organization. "So I could up my game," he says. He wants to learn how to share his faith without being a "turn or burn" proselytizer.

"I wouldn't want for somebody to make a decision in a moment of crisis that they wouldn't make otherwise," he says. "I don't want to say, 'It's your last chance: Smarten up or else.'

"It doesn't mean I can't share my faith just because it might upset somebody in the world. This nation was founded on Christian ideals."

Pool pauses when asked if he'd pray with followers of Islam, a faith he considers antagonistic and unforgiving.

"I don't think they would get the same meaning" from it, he says. "Not that they would feel offended, but . not comforted."

He tries to avoid a holier-than-thou air and — with patients, anyway — doesn't claim only certain believers get into heaven.

"It's not my job to get somebody to make certain decisions," Pool says. "All I can do is live a life that makes it appealing to somebody and then share it with them. If I share and they say, 'I'm not interested,' I say no problem and move on. But seeds can be sown that you never see the fruit of."

Smith's operation was a success. Six weeks later, Pool meets with him one last time.

"You're doing extremely well," Pool says. "I'm going to fade away now. You don't have to come back and see me."

"I'd be 6 feet under if it wasn't for you," Smith says.

Pool dismisses the thought. "I'd like to say a prayer with you," he says.

Smith bows his head and closes his eyes.

"Lord," Pool begins, "thank you for getting Mr. Smith out of the hospital and getting him home. We ask that you continue that process of healing and give him a spring in his step once again. In Jesus' name we pray."

Smith is upbeat. He believes the gesture will help him get better. And in the end, that might be the most important thing of all.

___

Information from: The Dallas Morning News,

http://www.necn.com/08/04/13/Dallas-heart-surgeon-uses-medicine-as-mi/landing_nation.html?&apID=0f389f14177f4a05b0e9de465c5d3004

Why NHS England is launching 'TripAdvisor' for patients

Unleashing the power of people is going to be fundamental to improving outcomes across health care, says Tim Kelsey, National Director for Patients and Information at NHS England.

Last weekend it emerged that 22 serious incidents are being investigated in connection with the line Photo: PA

By Tim Kelsey, National Director for Patients and Information, NHS England

10:00PM BST 29 Jul 2013

3 Comments

When patients are ignored, they are most at risk: that was the central conclusion of the report by Robert Francis QC into Stafford hospital. It has been at the centre of every NHS scandal - the quality of care is jeopardised if the patient voice is not heard and respected.

I recently met a former nurse whose daughter has severe learning disabilities. She was exhausted by the powerlessness and routine indignity of her experience: often she would turn up at the A&E department and wait for hours to be admitted and then wait again for a hoist to arrive by the bedside so that her daughter could be lifted from her wheelchair onto the bed. 'I wish they would remember us,' she says. She complains but her voice has not been heard; her experience as a customer and patient has not improved.

It's not everyday, everywhere, for every patient - most, by far, receive an exceptional service, but to ensure the NHS delivers high quality care for all, we need transparency of the patient and carer experience. It is the absence of this transparency that often allows poor care to go undetected.

So on Tuesday we are publishing the first results of the Friends and Family test - the first time a health service has reported a single measure of patient satisfaction for every hospital. Patients and carers have been asked to score (on a six point scale) the quality of service on inpatient wards and A&E in English hospital trusts on this basis: ‘How likely are you to recommend our ward or A&E department to friends and family if they needed similar treatment?’. We have encouraged trusts to ask further questions to gather more specific service feedback. From now on, results will be published every month on the NHS Choices website (www.nhs.uk) so that citizens can hold local services accountable for improvement. In most cases, nurses and doctors get the feedback weekly so they are able to target improvements as quickly as possible.

This is the boldest move yet to promote real openness in the NHS and to concentrate our focus on improvement in care. For a year, a pilot has been running in the Midlands and East region of the NHS in which more than a third of a million people have given their feedback. Frontline staff have been quick to embrace this data as a tool to change things for the better. People complain about standards of cleanliness, isolation, lack of communication and poor food. NHS workers have been able to respond: switch the heating up, provide fruit on the ward, take more time to tell patients what is happening to them - or simply have a bit of a chat. Mid-Staffs would not have had such tragic consequences if action had been taken on patient complaints far sooner. This kind of routine feedback enables a different kind of conversation between the patient and clinician.

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We hope that comments will be complimentary. In Chelsea and Westminster hospital A&E one left a comment along these lines 'I was drunk but the staff still treated me with respect' - a reminder of the situations extraordinary NHS staff deal with on a daily basis.

This kind of information - user-generated feedback is the jargon - is now fundamental to the way we make choices as consumers in the rest of our lives. Trip Adviser was launched 13 years ago and has more than 100m hotel customer reviews on its site; customer ratings and comments on retail sites like Amazon have transformed the way in which many people buy things. In New York, more than 90,000 citizens each day feedback on local services and this, according to Mayor Michael Bloomberg, has become one of the most powerful tools the city has to target improvements.

The NHS is not a hotel chain nor a city authority: but there are vital lessons it can learn about the power of transparency and feedback. Unleashing the power of people in this way is going to be fundamental to improving outcomes across health care - and to the effectiveness and sustainability of the NHS.

Transparency is not universally welcome in this public service - being open can be difficult and challenging - but the NHS is putting the patient voice irrevocably into the mainstream of its activities. By October, we will have extended the measure to all maternity services and by the Spring of 2015 to every service which treats NHS patients.

Today we will learn some home truths about the NHS: some Trusts will be surprised by the number of patients who would recommend their services and they will need to take a long hard look at how they quickly transform their customer experience. We will all be watching their progress. We need a transformation in the quality of customer service in health and care: patients must be respected as people. The NHS belongs to us all.

http://www.telegraph.co.uk/health/healthnews/10209799/Why-NHS-England-is-launching-TripAdvisor-for-patients.html

Leading the Charge for Change from the Encounter Level

By Kameron Gifford, CPC / 7.13.2013  / kgifford@ermconsultinginc.com

You can’t manage healthcare today, with yesterday’s models, and be in business tomorrow...

In the context of education, is it culture or strategy that drives our desire for something better? In terms of change, is it more power or responsibility that one is seeking? And what has enabled some leaders to drive mass change across large organizations while others fail? Perhaps the single greatest predictor is the power of influence, the human factor that encourages and sustains the necessary energy to get to that point of “something better.”

The process of identifying and eliminating waste and ultimately defects was made famous by Toyota and has since infiltrated every other industry on some level. But can process improvements alone be enough to tackle the bureaucracy of America’s healthcare system? Can regulatory reform inspire those farthest from Congressional hill, those who return to the front lines day after day to care for our aging population of seniors or will it take something more?

The path of progress must not be paved in external motivation alone but incite the flames of internal desires to be effective. If the agent of change is not truly embodied in the cause themselves, then can the message accurately be broadcast from payer to provider to consumer or is it lost in translation?

As a consultant, an educator, or a trainer, it is that single moment of transition from external to internal, that aha moment, if you will, that keeps us coming back again and again. Empirical Risk Management was founded on the belief that change, must be initiated at the initial point of contact to be effective, and in managed care that means the process must begin when the patient walks in the door.

Over the last week, my husband and I were once again taken aback at the power of an individual to influence and inspire those around them. In Buffalo, New York just a few shorts steps from the Mission of Mercy Hospital, we witnessed progress first hand. Discreetly set against a row of similar houses turned businesses that line just another typical lazy road in upstate New York. But this is not your typical practice, inside you will find a leader, whose charge for change begins with strength and whose passion resonates within all four walls. The epitome of a healer, a champion of champions.

Our call to action was prompted by a desire to improve the “team” and to create a shared vision for the future. Our mission was not defined by reaction, but instead action, originating from that desire for something better. We were not there to “fix” a specific problem, but instead to observe, assess, and to improve if at all possible. These projects, coined RPI or rapid practice innovation, are not for the faint of heart, and in fact the obscurity of the task often leads most to shy away. However, it is that exact uncertainity that elicits my passion. For isn’t it the shared success of the sum that is greater than the individual triumphs?

The value that is derived from a receptionist who understands the clinical significance of a 1% improvement in a Hgb A1c will far exceed the value of your investment. A nurse who understands the 10 guiding principles that influenced the creation of the CMS-HCC model will inherently improve the experience for both the provider and the health plan. A coder who understands the potential financial impact of rejected encounters on the Medicare Advantage plan will provide incredible value to your revenue cycle. It is this proactive team approach at the initial point of contact that ultimately improves outcomes and minimizes opportunities for errors.

And at the end of the day, it is this shared vision, that unites once starkly contrasting goals into one uniformed march towards innovation.

Health Plan Rorschach Test: Direct Primary Care

Despite its inclusion in Obamacare, Direct Primary Care (DPC, aka Concierge Medicine for the Masses), it’s surprising how few health insurance executives know about DPC. DPC  is a model of paying for primary care outside of insurance. The individual or organization paying for healthcare pays a monthly fee (like a gym membership) for all primary care needs. Generally, DPC providers say they can address 80 or more of the top 100 most common diagnoses.

Once I explain DPC to insurance executives, I have found it’s an excellent Rorschach test reflecting whether that executive’s organization is playing to win or is back on their heels regarding the wrenching changes that are reshaping healthcare from the DIY Health Reform movement as well as the effects of Obamacare. For example, rapid growth of self-insuring by corporations is a trend pre-dating Obamacare but many expect it to accelerate as self-insuring gives companies down to 20 employees more flexibility than Obamacare rules allow.

Forward-looking health plans view DPC as part of a broader strategy to reinvent themselves. For example, the parent company of a large Blue Shield recently invested in the pioneer of DPC, Qliance. Conversely, health plans that are back on their heels simply look at it as a way they will get disintermediated. This DPC Rorschach test will presage how that health plan will fare in the coming years. For example, some will discount it as only applicable for a certain segment of the population such as the “worried well” yet I’ve found the exact opposite. For example, the Grameen Foundation (famous for its Nobel Prize-winning founder known for microfinance) has brought it to low-income populations in New York that the Financial Times reported on. In Washington state, DPC is now being used with Medicaid populations.

Over the years, the California Health Care Foundation (CHCF) has commissioned many excellent reports outlining trends affecting healthcare. Just as they wrote about retail clinics several years ago as they began to emerge, they wanted a similar analysis done for DPC. The CHCF asked me as I’ve studied DPC perhaps more than anyone other than those operating DPC businesses. Many ask why I have OCD on DPC. My answer is twofold.

1. There is a lot to learn from  organizations demonstrating the Triple Aim (lower costs, improved outcomes, better consumer experience). I’ve yet to see any model that more consistently delivers on the Triple Aim than DPC.
2. When you found a tech startup, you make a bet on how the future will unfold so that you can get there before your competition. Our bet a few years ago when we began has now become obvious — healthcare will become more patient-centric, accountable and coordinated. In other words, virtually the opposite of the “do more, bill more” model that is bankrupting our country. My belief is DPC is a microcosm of the future healthcare system so I’ve been studying it and working with DPC providers the last few years. Naturally, DPC providers have a fundamentally different set of requirements than traditional players so it is helpful in shaping our decisions. See The Marcus Welby/Steve Jobs Solution to the Medicaid-driven State & County Budget Crisis for what I wrote earlier. 

The CHCF published the DPC report I wrote in April. It is a good summary of what I have learned. CHCF papers have a neutral, objective tone which is appropriate for their role. However, I have formed opinions about DPC so I’m publishing here my raw perspective on DPC starting with an introduction. Please see the introduction and history of DPC below.

[Contact me via LinkedIn if you'd like a copy of the full seminal study on the Direct Primary Care model]

Introduction

This paper provides the landscape of an emerging practice model called Direct Primary Care (DPC) sometimes referred to as “concierge medicine for the masses”. There are over a half million people in DPC practices. With DPC legislation passed in some states and inclusion in the Affordable Care Act (ACA), the implications, successes and obstacles to DPC growth are explored. The field is too young for detailed national studies so some of the early notable players were studied. Over a dozen DPC organizations were studied as well as interviewed payers, purchasers and consumers to gain their perspective on the DPC model. In state regulatory and legislative language these practices are sometimes referred to as “retainer practices, “ and are defined as those that charge a recurring monthly fee in exchange for a set of services.

Direct Primary Care is defined as retainer practices that charge less than $100 per month per patient. Most charge in the $50-80 per month range. Of note, we are not including in this definition practices that continue to bill insurance companies for their services but charge in addition a monthly fee to patients. While these practices are able to provide additional time and resources to their patients, they are still largely driven by the current fee-for-service business model, and subject to its limitations.

History

Just a few decades ago, it was the norm to have a direct paying relationship with one’s physician, whether it was cash or bartering some product or service. As health insurance expanded from primarily catastrophic coverage to payment for all facets of healthcare, the direct relationship between patient and provider deteriorated. One of the founders of the Direct Primary Care movement, Dr. Garrison Bliss, articulated the changes in healthcare payment and their effect as follows:

“To a very real extent, when patients do not pay or control the payment to their physicians, their power and influence in health care declines.  In the current fee-for-service health care insurance environment funded by employers and governments, physicians are paid for diagnosis and treatment codes.  

Bliss goes on to say that the result of these changes has led to a decline in the perceived value of primary care, a massive dependence on medical technology and a focus on higher cost procedures over effective, results-oriented health care.

Brian Klepper, PhD, and David C. Kibbe, MD, MBA outline the roots of valuing specialist care at the expense of primary care in a piece about the playing field being extremely tilted towards specialists in this Kaiser Health News piece. Part of the transition back to patient-driven care began with the first concierge practice, opened in Seattle in 1996 by Howard Maron and Scott Hall. It was called MD2 (“MD squared”) and charged $1,000 per member per month. Shortly thereafter in 1997, also in Seattle, Garrison Bliss and Mitch Karton converted Seattle Medical Associates from a fee-for-service insurance Internal Medicine practice to a maximum $65 per monthly fee Direct Primary Care practice.  This is currently a three- physician practice that remains highly successful and popular.  Dr. Bliss later went on to establish Qliance Medical Group of Washington PC, the first scalable Direct Primary Care practice designed for the mass market.

Bliss and Karton determined that a panel size of 800 for their combined practice would be the break-even point.  1600 would be a full practice. (i.e., 2 MDs with 800 patients each). Bliss and Karton designed their DPC practice with the following design principles that persist to this day:

• Work for our patients directly – know who’s the boss (the patient).
• Give the providers and the patients time to do the job right.  Keep the panel sizes low and expectations high.
• Be open when patients need you to be open (12-hr days, weekends) and/or accessible electronically.
• Don’t charge insurance co-pays or deductibles.
• Don’t pay providers to do anything but the right thing for our patients – no incentives to “do stuff” as the fee-for-service model has encouraged.
• Build an electronic medical record that does medicine, not insurance billing.
• Monthly fees go to care, not an “insurance bureaucracy tax”.
• Frequently ancillaries are either free or at cost such as lab tests and prescriptions.

Within a year of Seattle Medical Associates converting its practice to Direct Primary Care, yet another innovative practice in Seattle – SimpleCare – was created by Vern Cherewatenko, M.D. and David MacDonald, D.O. Dr. Cherewatenko describes what led them to switch their model:

We both had excellent business staff and business-wise ran a very tight ship. Our combined practice billings totaled over $10 million, not a tiny operation by any means. With a combined annual practice billing of $10 million we calculated that we were losing approximately $7 per patient or $80,000 per month.

They realized they couldn’t make it up in volume. With 2 clinics, 55 providers and 75,000 patients, they needed 6 clerks just to deal with copying of records from patients transferring in and out of various managed care plans. They analyzed their average patient charges and they described it as follows:

• Their charge for a 10-minute patient visit was $79.
• The insurance companies typically reimbursed $43
• Costs of collection were anywhere from $5-20 depending on the staff time, billing system, etc. (All doctors know they are discounted, but most doctors overlook what it costs to collect the $43).
• Therefore, the actual fee reimbursement for a $79 charge was $23.
• With a single, all-inclusive exam room overhead at $30 (the national average), they discovered they were losing about $7 on each of the 75,000 patients they were seeing annually.

This analysis caused them to rethink what they had taken for granted.

“We knew we could not cut our overhead any further– we had been doing that for the past 2 years (cheaper copy paper, less fancy patient info, less nurses, less receptionists, no more “pantry stocking,” and so on). We were running as lean as we could, practically on bare bones.”

Extent of Direct Primary Care

Although DPC practices are currently evolving primarily as a grassroots movement and most of these practices make little effort to obtain national recognition, they have been identified in at least 24 states and are burgeoning in several regions including California, Florida, Washington State and Texas.  With the advent of scalable versions of DPC practices with national aspirations like Iora Health, MedLion, Paladina Health, Qliance, and White Glove Health, it is this author’s opinion that the DPC movement will grow rapidly in the coming decade, particularly if the US health care system fails to find other solutions to the problems of declining primary care, high cost, accessibility and poor performance.

Note that some of the DPC providers profiled in this paper also offer additional primary care options such as near-site and on-site clinics. The care delivery model is essentially the same, however they offer their services only to a limited number of employers.

Cottage DPC Industry Emerges

After the first DPC practices formed in Seattle, an array of entrepreneurs followed the model pioneered by Dr. Garrison Bliss or simply came up with a model on their own, unaware that others had begun to develop similar practices. Some of the notable pioneers include Drs. Vic Wood of Primary Care One in West Virginia, Brian Forrest of Access Healthcare in North Carolina, and Samir Qamar of MedLion in California. In addition, venture-backed White Glove Health in Texas developed a model with Nurse Practitioners making house calls.

By sheer numbers, White Glove Health is the most successful DPC organization, with over 500,000 members. The others all have fewer than 5,000 patients thus far. Not all DPC practices have had quick success. For instance, Symbeo based out of New Jersey raised and then burned through capital before it became economically sustainable.

The entrance of the highly successful dialysis company, DaVita, is one of the biggest recent developments in DPC. They bought a DPC/onsite clinic company ModernMed, a healthcare service firm providing direct primary care in 12 states through employer-based, on-site clinics and private physician practices. Later, they bought Healthcare Partners, the country’s largest operator of medical groups and physician networks, for over $4B. The DPC/onsite company is the foundation of DaVita’s new division, Paladina Health. Some of the Healthcare Partners practices could transition to a DPC model. DaVita has jumpstarted Paladina by enrolling DaVita’s largest concentration of employees in Tacoma, Washington with over 1,000 employees and their dependents.

Even more recently, Qliance has received a major infusion of capital from Cambia Health (parent company of a regional Blue Shield). This is one of the best signs that health plans are beginning to wake up to the DPC opportunity. Qliance’s previous investors have been founders of some of the most successful technology companies of the last 20 years – Amazon, aQuantive, Dell and Expedia.

Five Largest DPC Providers:

	Key Accounts	# of Patients	Fee structure	Unique attributes
Iora Health	Dartmouth, Culinary Health Fund, Freelancers Insurance Company	2,400+	Per member, per month (PMPM) based on risk adjusted acuity, currently averaging approx $80 PMPM	Primarily near site clinics for union-based organizations, insurers, and self insured employers
MedLion	Primarily individuals	2,000+	$59/mth + $10 copay	Transitioning fee-for-service practices to DPC – supports hybrid insurance/direct practices; operates in CA, NV, WA
Paladina Health	DaVita employees + 15 undisclosed employers	8,000+	$85-$125 PMPM	Acquired ModernMed;Concierge-level physician access; Transparency solution;Puts fees at risk based on achieving cost savings, patient satisfaction, and clinical outcome targets
Qliance	United Food & Commercial Workers, Expedia	5,000+	Average $65 PMPM	Most comprehensive list of services covered in monthly fee
White Glove Health	Highgate Hotels, Beryl Companies, Ivie & Assoc	40,000 via self-insured employers; 450,000 via health plans	Up to $35 PMPM + $35 per visit fee	House/office calls & remote delivered by nurse practitioners overseen by doctors

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PHARMA & HEALTHCARE

 7/06/2013 @ 9:00AM

This article is available online at:
http://www.forbes.com/sites/davechase/2013/07/06/health-plan-rorschach-test-direct-primary-care/

ACOs strike it hot in healthcare

John Andrews, Contributing writer

June 28, 2013

The hottest letters in healthcare right now are A, C and O. And while together they stand for accountable care organization, industry analysts say providers need to look beyond the acronym in their efforts to build a new business model.

Nick Sears, MD, chief medical officer for Atlanta-based MedAssets, understands that there is some confusion and trepidation among provider groups about how to start an ACO. As a veteran observer of industry trends over the past quarter-century, Sears realizes the magnitude of change that is being required of healthcare providers and the daunting task associated with making the necessary modifications.

“At this point, providers shouldn’t worry about what an ACO looks like, but instead focus on the building blocks that go into it,” Sears said. “Although it is part of the Affordable Care Act, which is currently under scrutiny in Congress, the intent of ACOs will continue even if parts of the ACA are stricken. So providers have to identify their risks in the whole value-based purchasing model because if they don’t they are in trouble.”

As the new healthcare model has emerged over the past couple of years, Jeremy Belinski, director of operations at MedAssets, has taken to call ACOs by another acronym – CIO, for clinically integrated organization. The description seems more apt for the machinations of putting groups together, he says.

“As we’ve dug into the process, we’ve found it is easy to form a legal entity, yet each group has its own model for doing things,” Belinski said. “But just because they’ve joined together doesn’t mean they can make it work. Making it operational has been a challenge. They have to get good at managing costs and aligning physicians, which is easier when you’re part of an organization. The challenge is to extend beyond the four walls of the hospital.”

Managing metrics

Ken Perez, director of healthcare policy for Emeryville, Calif.-based MedeAnalytics, has been studying the metrics associated with ACO configuration in both the Medicare and commercial insurance domains, developing a comprehensive report and a series of informative videos on the subject. His research found that ACO metrics can be divided into six categories: pediatric, ambulatory, prevention, acute care, outcomes, and utilization of services.

“As more ACOs become multi-payer, it is increasingly important to understand — for the sake of leverage and organizational alignment — the general themes and commonly used metrics used in ACO agreements,” Perez said. “This strategic understanding will help shape emerging best practices for successful ACOs.”

In discerning between commercial and Medicare ACOs, Perez found that commercial organizations place greater emphasis on areas of integration, pronounced cost reduction and resource utilization while Medicare ACOs are focused more on quality outcomes.

“There is a lot of variability between commercial and Medicare ACOs because of different programs and models and you have to choose what game you’re going to play,” he said. “The end game for the provider has got to be multi-payer, so whether you start with Medicare or commercial, you will have multiple payers, you must leverage costs across the board and implement a standardized level of care.”

The 9 C’s

“Medical Home” is another moniker associated with the ACO concept and while some see them as interchangeable, Tom Doerr, MD, does not. A general internal medicine practitioner who focuses on geriatric patients, Doerr also serves as director of innovation research for St. Louis-based Lumeris.

The difference between the Medical Home blueprint and a true ACO, he says, is that the Medical Home design does not go far enough in determining how care is delivered.

“There are nine key elements to care called the ‘9 C’s’ and the Medical Home only incorporates the first four elements,” Doerr said. “We architect how care is delivered at the physician practice level with workflows, metrics and behavioral strategies to convert to value-based delivery. The first four C’s are part of the primary care model, but they are not new. An accountable primary care model should include all nine elements.”

The 9 C’s as Doerr explains them are as follows: Contact with the healthcare system; Comprehensive care; Continuous care that is longitudinally focused; Care coordination; Credibility and trust with the physician; Collaborative learning between payers and providers; Cost effective care; Capacity expansion through technology; and Career satisfaction.

“Beyond the 9 C’s they need to have the collaborative payer model,” he said. “The collaborative payer model makes the payer an ally of the provider.”

Doerr appreciates the irony in his advocating alliances between two traditional adversaries, but maintains that a cooperative spirit can occur when each side sees mutual benefit.

“The national movement toward ACOs has legs and is gaining traction,” he said. “It is blending the role of payer and physician; both quality and cost. While some still aren’t comfortable with it, as the movement gains momentum, that resistance will drop.”

http://m.physbiztech.com/news/business/acos-turning-heat-healthcare

PHILIPS : and Georgia Regents Medical Center sign a 15-year alliance to facilitate innovative and affordable care

06/28/2013| 01:13am US/Eastern

• Healthcare industry-defining model to improve patient outcomes and reduce costs through new technologies, operational planning, support and consulting services
• Long term alliance will support multiple GRMC sites, including its combined 632-bed medical center, cancer center, and children's hospital, with an order value of approximately USD 300 million

Andover, MA and Augusta, GA - Royal Philips (NYSE: PHG, AEX: PHIA) and Georgia Regents Medical Center (GRMC), Georgia's public academic health center renowned for its top-ranked doctors, today announced a 15-year alliance to enable increasingly patient-centered approaches to care and to create an innovative business model that addresses current and future clinical, operational and equipment needs of GRMC's multiple sites.

The alliance is a first-of-its-kind delivery model in the United States. Through the agreement, worth approximately USD 300 million, the largest of its kind for Philips, the company will provide GRMC with a comprehensive range of consulting services, advanced medical technologies, and operational performance, planning and maintenance services with pre-determined monthly operational costs over a 15-year term.

The alliance will broadly support the Georgia Regents Medical Center, Children's Hospital of Georgia, Georgia Regents University Cancer Center and the health system's numerous outpatient clinics, which serve the medical needs of four to six million people, across Georgia and South Carolina. Philips and Georgia Regents will work closely to deliver faster, more effective and cost-efficient care from diagnostics to therapeutics, and inpatient and outpatient clinical services. The alliance will impact all care areas, including radiology, cardiology, neurology, oncology and pediatrics, and enhance medical research and clinical technology R&D initiatives for care delivery innovation.

The agreement encompasses Philips imaging systems, patient monitoring and clinical informatics solutions, as well as lighting and consumer products. Philips will also furnish GRMC rapid access to new equipment as well as educational resources. Philips and GRMC will work together to cost-effectively design and deploy innovative patient care strategies.

"By collaborating with Philips, we're bringing all the stakeholders together at the same table to better assess and plan health care for tomorrow. It's no longer a simple supply-and-demand business model," said David S. Hefner, Chief Executive Officer for Georgia Regents Medical Center. "Our goal is to foster an atmosphere of meaningful innovation that will have a significant and positive impact on the health of our patients."

"We are proud to embark on this transformational alliance with Georgia Regents Medical Center as we share the vision that we can create the future of health care by creatively and cost-effectively meeting the long-term needs of patients," said Deborah DiSanzo, chief executive officer, Philips Healthcare."

With more than 100 years of experience in health care, Philips' aim is to provide innovative solutions that address the complexities of health care delivery by working in close partnership with healthcare providers. The long term alliance with GRMC in the U.S. follows collaborations with hospitals in Europe, Asia, the Middle-east and Africa that have resulted in improved clinical operations and care delivery performance.

http://www.4-traders.com/PHILIPS-6289/news/PHILIPS-and-Georgia-Regents-Medical-Center-sign-a-15-year-alliance-to-facilitate-innovative-and-af-17055188/