Successful care coordination, business models will hinge on physician collaboration and community-based medicine
The healthcare landscape is shifting rapidly, and for family physicians, that change is placing increased importance on their role within the system. Family physicians can thrive by embracing high-value, patient-centered care, coordinated among providers with the aid of technology and data exchange.
Reworking family medicine with this future in mind is a challenge that many physicians are taking on.
”I really believe that all of the things that family physicians have been doing over the years are poised to really be valued and to be core part of a true transformation,” says American Academy of Family Physicians (AAFP) President Reid Blackwelder, MD, FAAFP.
That transformation won’t occur without growing pains. Right now, health information technology developments have left many providers with enormous amounts of patient data, but lacking an effective way to share it. And in an era of increased consolidation, private-practice physicians are struggling to stay independent and financially viable.
But through increased collaboration and community involvement, physicians are finding innovative solutions to family medicine’s biggest challenges and leading the way toward its brighter future.
Collaboration and community-based healthcare
Wanda Filer, MD, MBA, an AAFP board member, is a family physician at Family First Health, a federally qualified health center with five locations throughout Pennsylvania. She practices alongside nurse practitioners, physician assistants, pediatricians, dentists and behavioral health specialists.
“When I think about team-based care, what it means is the patient can get the care they need, when they need it, by the right person,” Filer says.
Recently, a patient came into Filer’s practice having been diagnosed with a urinary tract infection (UTI) the night before at a retail clinic. She was first seen by one of the practice’s nurses. But when the urinalysis revealed unusual results, Filer was called in to make the diagnosis of an acute gall bladder, rather than a UTI.
It’s occurrences like these that make physician-led teams critical to the future of patient care. “Primary care has never been more complex,” Filer says. “Between multiple medical conditions and multiple medications, you need that expertise and that level of training to help sort out some of the harder and riskier aspects of care.”
Blackwelder says that for family medicine truly to begin transforming healthcare, the patient-centered medical home model (PCMH) must be fully implemented. Under the PCMH model, family physicians will provide care coordination for their patients in a multidisciplinary healthcare system, with ultimate goal of improving patient outcomes and reducing healthcare costs.
But getting there might not be easy, especially at a time when the industry is facing a shortage of family physicians and the financial incentives have yet to align.
Some payers have created bonus payments for PCMH participants, but family physicians are still largely uncompensated for the time they spend developing and coordinating care plans. A report from the Agency for Healthcare Research and Quality concluded that the current fee-for-service payments are not enough for physicians to pay for the additional resources and activities needed in care coordination.
Blackwelder agrees that over the next 10 years, the industry needs to move away from what he calls bullets-for-billing, “where you check a box on a patient form to support billing as opposed to impacting patient care,” and move toward value-based payment models.
But it also remains unclear if the PCMH model will lead to the healthcare costs reductions that it promised. Established medical homes across the country have touted their success. According to the Patient-Centered Primary Care Collaborative, Capital Health Plan in Tallahassee, Florida, had 40% fewer inpatient stays and 37% fewer emergency department (ED) visits under the model.
Other research has called the cost savings into question, however. A 2014 study published in the Journal of the American Medical Association found that a PCMH pilot in southeastern Pennsylvania was unable to lower costs over the course of three years.
But regardless of the model used, Blackwelder says the industry’s future success will depend largely upon provider collaboration.
“That will be the wave of the future,” Blackwelder says. “Nobody is alone. No one is isolated. No one is siloed. We can’t afford that. We have to get comfortable sharing information, recognizing that many different parts of the patient-centered home can provide care, and how we coordinate those so we don’t duplicate efforts.”
While the PCMH model can provide care coordination within a defined practice setting, for large-scale collaborative care to occur, a significant hurdle remains: electronic health record (EHR) interoperability.
Overcoming interoperability challenges
For many physicians, the implementation of EHRs and other office-based technology has been more hindrance than help. But one city in Indiana has successfully broken the interoperability barrier.
“South Bend has been this quiet, little college town that is at least a decade ahead of everybody else,” says Chris Zaenger, CHBC, president of Z Management Group and a Medical Economics editorial consultant. “The reason they are is largely because there is a spirit of cooperation among the physicians, the three hospitals in town and [one of] the largest laboratories in town.”
What sets this region apart is the ability of family physicians to exchange patient data seamlessly and coordinate care with the other healthcare providers in their area.
“We have a central community repository, where any provider in the community, regardless of their electronic health record, can see the lab information on the patient, any hospital encounter, and any other encounters that have been shared,” says Tim Roberts, chief executive officer of the Michiana Health Information Network (MHIN), South Bend’s health information exchange (HIE) network.
Since its founding in 1999, MHIN has served more than 1,500 providers in the northern Indiana and southern Michigan region. Recently, MHIN introduced a new feature to its network that enables a family physician to receive real-time alerts when a patient visits the ED or is discharged from the hospital. This allows the provider to contact the patient and schedule a follow-up appointment.
Although the majority of the providers in their network use Cerner for their EHR system, Roberts says the program’s initial challenge wasn’t implementing new technology. Instead, it was persuading healthcare providers to breakdown their silos.
“When it comes to [HIE], the technology, while it’s difficult, it’s probably the easier thing to do,” says Roberts. “The difficult thing is getting a group of providers to come together and share a vision of how they want to improve patient care in a community and not compete on data. It took this community about five years to get everyone to buy-in to that vision, but once you get over that hurdle, everything else moves quickly.”
But for family physicians still grappling to communicate with other providers in their area, interoperability can’t come soon enough. “The lack of interoperability is probably more frustrating than having a paper chart,” Filer says. “We know what it could be, and we’ve been sold this story. There’s a lot of frustration and anger in my colleagues across the country. They have invested important, scarce dollar resources in practices, and they’re not getting what they paid for.”
In June, the Office of the National Coordinator for Health Information Technology (ONC) released its plan to achieve interoperability nationwide by 2024. Filer, who is on her fourth EHR system, says vendors will need to collaborate in order to drive progress.
Some states, such as Massachusetts, are pushing for state-based HIE networks, but Zaenger says he believes South Bend’s model is best replicated on a smaller scale.
“We could do this kind of stuff on a small community level, if we could get everybody on the same page and then move forward,” he says. “I can tell you that my discussions with doctors today about EMR [electronic medical records] are not about whether you like the product or not. It’s about, can you send a message to your specialist? Can you receive one? Can you communicate and download data from a hospital?” Ten years from now, more family physicians likely will look toward practice models that free them from the administrative headaches tied to traditional fee-for-service payments.
Emerging practice models
After completing residency in 2011, Ryan Neuhofel DO, MPH, opened NeuCare Family Medicine, in Lawrence, Kansas. His practice operates under a direct-pay model, where for a membership fee, Neuhofel provides his patients with same-day visits, point-of-care testing, house calls, video consultations, and other primary care services.
While practices that operate under fee-for-service models may cram their appointment schedule to boost their bottom line, Neuhofel sees an average of six to eight patients per day, and his appointments last much longer than the typical visit. His appointments usually last 30 to 45 minutes, but they can go up to an hour for new patients or those with chronic illnesses.
Neuhofel says he knew even in medical school that an insurance-based model wasn’t for him.
“I came into the healthcare system very naïve,” Neuhofel says. “I realized very early on that the system was broken and that doctors and patients were both very dissatisfied with the ways things were done.”
“I had invested a lot of time and money in becoming a doctor, and I still wanted to be one, but I just did not see myself being happy long-term in any of those traditional options that were available.”
By avoiding the challenges associate with insurance, Neuhofel says he’s able to lower his overhead costs by about half when compared to a traditional family practice.
As the industry heads toward increased regulation and hospital consolidation, the direct-pay model may provide an alterative for family physicians to maintain independent practice.
“[Physicians] don’t want to be employed. They want to maintain their autonomy,” says Neuhofel. “But because of the administrative and regulatory burden, I fear that’s not going to be possible and feasible long term to have a solo or small practice in an insurance-based world.
“The hospitals can absorb some of that administrative burden,” he adds. “But small physician practices are really struggling. I think there’s going to be a division. I think the people who are going to remain independent are going to do it in a direct model.”
While this model offers an exciting and disruptive approach, practice management consultant Owen Dahl, MBA, FACHE, cautions that it’s not a good fit for every market. If an area has a large number of primary care providers, it may be a challenge to get patients who are willing to pay the membership fee, in addition to their insurance premiums.
“If anyone is seriously considering it, they need to take a deep look at their current practice pattern and see what’s going on,” Dahl says. He recommends family physicians make small operational changes in their practice to increase efficiency. For example, direct contracts with local employers to perform annual employee wellness visits for could help primary care physicians regain some of the market frequently lost to retail clinics. As a family physician caring for patients from newborns to the elderly, Filer jokes that she will never be without a job. For practicing physicians, it’s a time of great change, but Filer says the future looks bright.
Looking to the future
“If we can work through the attribution issues, payment and IT, we will have a system that’s far more patient focused,” she says.
Although the path to get there may be fraught with challenges, Blackwelder says he’s confident that the value of the family physician as a thorough and comprehensive care provider will not go unnoticed.
“By the time we look at the future there will be a strong recognition of the family physician and their role,” Blackwelder says.
From Medical Economics by Alison Ritchie, September 24, 2014