N.Y. Doctors, Insurer Try To Change How Medicine Is Practiced

Sept. 10--Independent Health and 140 primary care doctors rolled out a new program last week that they hope offers a vision for changing the way basic medical care is provided to 72,000 patients in the region.

Primary care doctors, the first contact for many patients when they get sick, are considered the backbone of the health care system. But the field faces major concerns, including larger workloads, greater complexity of care and a pay gap with specialists that discourages new physicians from choosing primary care.

This alliance of Independent Health and the 140 physicians, called the Primary Connection, reflects one of many examples here and nationwide of the health care system attempting to reform itself even before major elements of the Affordable Care Act, the federal health reform law, take effect.

The initiative emphasizes care coordination, teamwork, greater use of data to track quality and costs, and payment arrangements that reward quality of care and not just the amount of care.

"Part of what we're trying to do with the Primary Connection is figure out how to take care of more patients more efficiently," said Dr. Irene S. Snow, medical director of the Buffalo Medical Group, a large multi-specialty group.

Doctors involved with the Primary Connection see it as a way to revitalize the primary care professions and improve care by promoting health in addition to treating illnesses.

They and the insurer have agreed to a compact that demands the physicians meet certain expectations. Among other things, they intend to improve communication with specialists and hospitals; use nurses to help coordinate services; share nutritionists, social workers and other personnel; measure the cost and outcomes of care; base some pay on meeting quality targets; and reimburse primary care doctors for work that often goes uncompensated, such as responding to calls and emails.

Independent Health plans to sell a health insurance plan next year linked to the new group, which could grow in size if more doctors take an interest and meet its eligibility criteria.

"We believe there will be savings in which a portion can go back to the doctors and a portion can go toward reducing the insurance premium," said Dr. Michael W. Cropp, president and chief executive officer of Independent Health.

The initiative builds on efforts among physicians here and elsewhere nationwide to adopt a concept known as the patient-centered medical home. The phrase, which was introduced in 1967 by the American Academy of Pediatrics, describes an approach to reorganizing medical practices so that every patient has a primary care physician who acts as the head of a team that stresses greater communication and access to care, and that tracks treatments and outcomes with an electronic medical record.

Primary care physicians include family physicians, internists, pediatricians and geriatricians. They usually are the first doctor patients turn to and take care of a range of issues from regular checkups of healthy patients to those with uncomplicated illnesses or others with more complex issues, especially the elderly, many of whom have multiple chronic conditions, such as diabetes and heart disease.

In 2010, of the 624,434 physicians in the United States who spent the majority of their time in direct patient care, 209,000 practiced primary care, according to the Agency for Healthcare Research and Quality.

Workload is a key issue. Primary care doctors get paid for office visits, and they voice frustration over the increase in uncompensated tasks, including arranging referrals, completing forms, communicating with patients and offering emotional support. Crammed appointment schedules can lead to rushed visits and limited access to patients looking for a new physician.

Primary health care must shift to focus on using a team approach to provide the right care in the right setting, including by using nurse practitioners and physician assistants, according to Snow of Buffalo Medical Group. It also must ensure that patients transition back to their primary care physicians after they see specialists or visit an urgent care center or hospital, she said.

The primary care doctor should serve as the "quarterback" in a patient's treatment, added Dr. David Pawlowski, a member of Highgate Medical Group, a family practice with locations in Amherst.

"This [initiative] puts us in the driver's seat. We control things, as far as guiding treatment," he said.

Primary care doctors say poor communication with specialists and hospitals results in duplication of tests and preventable hospitalizations, including costly readmissions. They complain that the poor transitions between doctors and facilities confuses patients and their families, leading to conflicting medical recommendations and lack of clarity over who is managing the care.

All of which fuels dissatisfaction with the health care system.

"The Primary Connection grew out of our frustration that we still couldn't get good care for our patients," said Dr. Donald W. Robinson, a family physician in Hamburg.

"It's the patient of mine who has to wait six months to see a dermatologist or the one who is seen by a nurse practitioner instead of a cardiologist when the expectation was that it would be the cardiologist," he said. "It's the difficulty of attracting new people to primary care. It also is about doing something about the constant rise in the cost of health care. It's unsustainable."

Doctors in the new initiative must be certified as a medical home by the National Committee for Quality Assurance, have an electronic medical record system and agree to a set of expectations about how they will practice. Cropp said it's hoped more primary care doctors in Western New York - there are about 950 - will join the group in the future, but the program is unlikely to appeal to all of them.

It's also hoped specialists will want to align with the new group to gain referrals.

"We need like-minded specialists and institutions. But everyone involved in this has to understand that there is a burden of responsibility on both sides, including the primary doctors," Snow said.

For example, just as primary care doctors want updates from a specialist about a patient they referred, a specialist wants primary doctors to avoid referring patients with trivial problems and to send along the appropriate medical records when they refer patients with challenging health issues, she said.

The Primary Connection initiative mirrors other efforts arising across the nation as doctors and others seek to reorganize primary care and improve the experience for patients, said Ann O'Malley, a senior fellow with the <org>Center for Studying Health System Change.

"It sounds promising," she said. "Much of this comes down to how doctors are paid. Care coordination is not reimbursed under the fee-for-service payment system, and there's no systematic process to encourage coordination."

If doctors, insurers and hospitals find new models that work, the implications could be significant.

"It could mean less unnecessary care, improved access to doctors and more satisfied patients," she said.

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