For decades, the sore throat -- pharyngitis, in clinical terms -- has been the bread and butter of family practice, a symptom of acute bronchitis, strep throat and any number of winter ailments. So when the number-crunchers at Premier Medical Associates noticed that sore-throat visits had dropped by two-thirds over a one-year period, they knew it was more than an aberration.
"This isn't where our practice is going to be, going forward," said Frank Colangelo, an internist who heads the quality control team at Premier, the biggest multispecialty medical practice in Pittsburgh's eastern suburbs, now fully owned by Highmark.
That was in 2008, just as the recession was taking hold and not long after fast-growing urgent care chain MedExpress put its stakes down in Pittsburgh. Office visits at Premier were down by 1,000, out of 80,000 total, mirroring the trend across the country. Patients were either postponing care altogether because of the recession, or taking their sore-throat business toward urgent clinics, which continue to siphon away more of the "acute" illness cases.
Even after the recession ended, Premier realized many of those patients wouldn't be coming back, said CEO Mark DeRubeis. The options were stark -- be content with a fading business model or remake the business model altogether.
Which is how Premier came to be one of the region's most influential evangelists for the "patient-centered medical home" model of care -- an industry buzz-term meant to convey a more hands-on, comprehensive approach that uses doctors, nurses and other professionals to track chronic issues and coordinate the health of a patient population.
In other words, more about the health of the patient and less about the health of the practice.
"It sounds so intuitive, people would assume, 'Gee, isn't that what I'm getting now?' " Mr. DeRubeis said. "Unfortunately, the answer is no."
Medicine -- not just primary care -- has been long wed to the acute-care model, largely because patients tend to seek care when they get sick. "You wake up. You don't feel well. You call the doctor ... and then pretty much you go away until you decide you don't feel good again," Mr. DeRubeis said.
The patient-centered medical home seeks to move care toward a more preventive model and, when prevention doesn't work, a more active management of chronic issues such as diabetes and pulmonary disease. That management manifests itself in a variety of ways: follow-up phone calls post-hospitalization, rigorous prescription reconciliation, regular benchmarking of patient vitals (such as blood pressure) and, most importantly, hiring more staff.
All of that case management requires more manpower -- more physicians, as well as more nurse practitioners and physician assistants. And Premier soon figured out, "We really don't have enough capacity to manage all the chronic care that we know we need to provide," Mr. DeRubeis said.
Fewer visits, more capacity
So it started hiring. Premier now has more than 80 medical doctors and doctors of osteopathy, and about 100 providers in total. That's up from the 65 providers on staff just two years ago. It also keeps a staff of 18 "hospitalists," who are meant to keep tabs on Premier patients when they end up at Forbes Hospital in Monroeville.
Having sets of eyes and ears in the hospital allows the practice to better coordinate the patient's care, and also frees up the rest of the primary care physicians to focus on their jobs.
The care "is handled better that way," said James Costlow, internist at Premier. "A primary care doctor can't be in two places at one time. ... People in the hospital need 24-hour care. And if I'm seeing my usual daily chronic-disease and acute-cares in the office, I'm not over at the hospital."
With a split staff, hospitalists can give their full attention to inpatient cases, and office physicians can see their full complement of 24 patients a day, every 20 minutes, without being interrupted with trips to the hospital.
At first, Dr. Costlow said, "Our fears were that it would [create] fragmented care."
But that fear proved unfounded, partly because of another game-changer -- electronic medical records. Premier installed its Allscripts electronic health records system two years ago, and now physicians can more easily track and exchange patient records between specialists and between sites.
Forbes hospitalists have access to the registry, too.
The orthopedic specialist can now instantly see what tests the internist has ordered; the hospitalists and even triage nurses in the Forbes emergency room can open up the patient's records to see what drugs have been prescribed recently.
"It's always helpful if somebody can see the whole patient chart," said Joanne Wall, Premier's chief operating officer. Across the country, she said, a significant percentage of hospital readmissions are due to adverse drug events, such as overdoses.
Even among patients who aren't readmitted to hospitals, their discharge papers often omit important prescription information or contain other medication discrepancies.
"It's imperative that med reconciliation is done at every point of transition of care," Ms. Wall said. Before the electronic records system was installed, there was a "dependency on the patient [to] provide all this information about their medications. That's not working."
The electronic records help, but Premier's "care coordinators" play a key role, too, following up with a patient post-discharge to make sure that they understand the doctor's order; that they know what medications they are taking and have filled their prescriptions; that they are able to care for themselves; and so on. Those coordinators usually reach out to a patient by phone within a day of discharge.
"The primary care doc needs to do this. We need to be responsible for all of the care that the patient gets, whether it's in Premier, or externally," Ms. Wall said. That's at the root of the patient-centered medical home concept.
Premier's shift from an acute-care model to a patient-centered one was cemented in 2011, when the practice received a call from Highmark Inc., asking if it wanted to participate in the health insurer's new medical home pilot. UPMC Health Plan also invited Premier to do the same.
Premier (then the largest independent medical practice in the region, though it has since sold a controlling stake to Highmark) would be asked to meet quality care benchmarks and track outcomes. Payments would be tied to the quality of that care, rather than the quantity.
"If you are successful, the rewards come down the road," Mr. DeRubeis said.
Competing with the big boys
The rewards did not come as initially envisioned. The following year, in summer 2012, Highmark abandoned the pilot. "They determined that their ability to socialize [the pilot was limited] across the broad network," Mr. DeRubeis said, because most independent practices don't have the infrastructure in place to make such sweeping operational changes.
Nor do most independent practices have a base of 100,000 patients -- including 45,000 adult primary care lives and 15,000 pediatric patients -- that can be mined for broad, meaningful health data, as Premier does.
So if Premier were to continue with this new model, it would be doing so more or less self-sufficiently.
"We decided to keep on," Mr. DeRubeis said. "It was expensive, it required a tremendous commitment of time, energy and resources," spent on new software and hardware, as well as the hiring of eight new nurses to work as care coordinators.
But "the most important tool in the box [is] the culture," he said. If the physicians and care professionals weren't on board with the makeover, it could not have taken root.
The culture was there, and the financial and clinical results have been satisfying: 73 percent of patients aged 50 to 75 have had colon screenings -- a year ago, the number was below 60 percent (the goal is an 80 percent screening rate).
About 65 percent of Premier patients with diagnosed hypertension have their blood pressure under control (the national rate is 53 percent).
And a recent population survey showed that Premier had lower-than-anticipated rates of depression among patients with poorly controlled chronic diseases, a finding that was surprising because it was expected one condition reinforced the other.
Those clinical results, the physicians said, outpace most other practices in the region, a claim underscored by Premier's head-of-the-class score in Highmark's "Quality Blue" program, which gives bonuses to practices and hospitals that meet certain cost and quality benchmarks. Only a few dozen practices achieved Highmark's highest-quality scores.
"It's hard to do this," Dr. Costlow said. "And I find it hard to believe there's only [a few dozen] good groups out there. Being a good physician or a good group doesn't [always] translate into delivering quality or, more importantly, delivering value."
Which is why it could take decades to fully move to a system that pays doctors and hospitals for quality, performance and cost-effectiveness. At Premier, the per-patient cost of care is 7 percent below the rest of the market, according to Highmark's own payment data.
"That's our competitive advantage -- higher quality care at a lower cost," Mr. DeRubeis. "That's where the market is going."
It's not going fast enough, though. Premier figured that by the time patients and insurers realized the practice's value proposition, it might have lost too much market share to urgent care clinics and hospital-owned practices. That's one reason it agreed to sell the practice to Highmark two years ago.
"Eventually, you cannot compete with the big boys," Mr. DeRubeis said. "You're going to need access to capital, and you're gonna need resources" to make wholesale changes in workflow, technical infrastructure and, ultimately, clinical care.
"What better pairing than an organization whose competitive advantage is to provide more value, pairing up with the organization that benefits from that value?"
US health organisation the Centres for Disease Control and Prevention estimates that nearly 2 million US patients contract HAIs each year, and 90,000 die as a result. HAIs are also estimated to cost the US healthcare system $4.5 billion (£2.8bn) in related medical expenses every year. Hand hygiene is cited as the most effective way to prevent the spread of HAIs, and hospitals are aggressively working to elevate hand washing compliance to 100 percent.
