Embrace the evolving primary care system and improve your health

Oct. 19--David Sanfilippo quit smoking four years ago and lost weight, too. He had lots of help from his wife, Dawn, as well as other family members and friends -- but he credits his primary care doctor for providing the key evidence to change his ways.

It came in the form of blood pressure, cholesterol and blood sugar tests ordered by Dr. Fuad Sheriff.

"He yelled at me enough during annual physicals that I dropped 40 pounds," cracked Sanfilippo, 35, of Williamsville. "I don't drink pop anymore. No fast food. It's about maintaining the good stuff."

Sanfilippo squares with an Independent Health survey of Western New Yorkers released this week that shows patients have deep faith in primary care providers.

The vast majority of those who participated in the survey said they see those providers as gatekeepers for their health care. They value providers who are honest, who listen and are easy to reach, including during off-hours. Most -- particularly younger patients -- also are fine with making life easier for providers by using online platforms to streamline care.

This is good news for Sheriff and his fellow family doctors -- but comes after a national survey of nearly 9,000 physicians found that three of four doctors experience burnout, more than half consider their morale as somewhat or very negative, and only 10 percent believe they can significantly impact the health care system.

"Healthy primary care is a strong foundation for the whole health care system," Sheriff said. "The problem is the system. The system needs to change."

A new evolution

Sheriff grew up in Tanzania, went to medical school in Pakistan, and worked as a doctor in his homeland until he came to the United States in 1993. He moved to Buffalo a few months later with his wife and children to do a primary care residency in two city hospitals, then joined what was to become Amherst Medical Associates.

The independent primary care practice, two miles west of the University at Buffalo North Campus, today includes six doctors and a family nurse practitioner on a staff of 25. Sheriff's son, Adnaan, is among them. The osteopathic doctor grew up in East Amherst and joined the practice last year.

Another son, Nabel, is in his third year at the UB Jacobs School of Medicine and Biomedical Sciences.

"Buffalo has been very good to us," the elder Sheriff said.

Meanwhile, medicine has changed during the last quarter-century in his adopted nation and region.

Sheriff started his American career working in a patient-centered Health Maintenance Organization (HMO). He watched his field morph into a fee-for-service model that saw the number of medical tests and procedures grow and higher-paid specialists become the major stars. He has stuck around long enough to see the pendulum begin to swing back toward a value-based system that looks to reward doctors for doing a better job preventing illness and keeping their patients from cycling in and out of hospitals.

The transformation began several years ago, as obesity and diabetes rates spiked, chronic illness became a norm -- particularly among older patients -- and a national primary care physician shortage took hold.

Within a dozen years, the Association of American Medical Colleges estimates, there will be 15,000 to 50,000 fewer primary care doctors than needed.

This crunch comes at a time when doctors need to learn -- and pay for -- electronic medical record technology and spend a large chunk of time on administrative work, a dynamic Dr. Adnaan Sheriff said helps explain physician burnout. Large student loan debt for many new doctors also adds to the burden, he said.

"We've been diagnosing other people's problems and not taking care of ourselves," said his father. "Now, any conference we go to, one of the subjects is how to prevent or overcome burnout."

Despite the challenges, Independent Health brass was pleasantly surprised by the survey findings.

"With something like health care that's a bit more complicated, you want to have a trusted source that you can go to," said Dr. Michael W. Cropp, company president and CEO.

The health insurer has been working with Amherst Medical Associates and other primary care practices to give them more time to spend with the sickest of patients while streamlining care for those with minor, fleeting illnesses and who generally have chronic conditions under control.

"The system hasn't enabled the right people to have the conversations" at the right time, Cropp said, and that is one of the things the current health care transition seeks to change.

Keeping up

The Sheriffs and fellow providers in their practice spend weekdays, and half of each Saturday, seeing patients with sinus infections, bronchitis, musculoskeletal woes, headaches, and, in some cases, much more serious conditions.

"My patients have grown older with me," said Fuad Sheriff, 63, and many of those patients have more than one chronic condition. He sees patients with cancer, heart failure and other cardiac conditions, and cardiopulmonary disease. "Every third patient I see has diabetes," he said.

Practice leaders also were surprised to learn recently that nearly one in three patients also struggles with depression, anxiety or another behavioral health conditions. It's a range many other family practices in the region also have reported.

Staff has learned to embrace these challenges.

"The beauty of primary care is we're on the front end," Adnaan Sheriff said. "We are the people who diagnose most of the cases, 90 percent. Then we send patients to specialists. We also provide the back end, continuum of care. These are two ends which are very important...

"We get to see our patients for multiple visits over many years. You get to see their family members and really understand their dynamic. That was what really attracted me the most to primary care, building those relationships with my patients."

The evolving primary care system is designed to play to those strengths.

Amherst Medical Associates opens at 7:30 a.m. to better serve the needs of its patients, many of whom need to be on the UB campus by 8:30 or 9 a.m., the Sheriffs said. The practice also saves slots daily for last-minute appointments. Both are features the vast majority of Independent Health survey participants said they desire.

Office care coordinators know a patient's medical history, including prescription drug use, and work with doctors both inside and outside the office to touch base more often with patients, safeguard treatment and minimize the risk of potentially dangerous drug interactions.

A psychologist is on-site for patients once a week, with plans to add another day or two.

"There's always a doctor on call, even after hours, with access to our charts," Adnaan Sheriff said.

The practice was ahead of the curve when it came to compiling patient electronic records, he said, and during the past year rolled out e-visits and automated patient appointment and care reminders available by phone and online.

More than 40 percent of patients use the practice's online portal, including many Baby Boomers, bucking the trend of Independent Health survey findings. Fuad Sheriff's first e-visit involved a "simple rash" that a patient photographed and relayed online. "I took care of it in 2 minutes and the patient was really happy about it," the doctor said.

The practice uses PatientPoint, a software program that can show health-related videos and photos, and pull up patient records, during office visits. Staff also has developed a strategic partner list of specialists willing to work in combination with them, providing specific care and stabilizing patients, and letting primary care doctors "who know the whole picture" handle overall care, Fuad Sheriff said.

"This is technology, coordinated, comprehensive care," he said. "It's good for the patient. It's good for maintaining the quality of care. It is also good to cut down the cost of care," including lower copays for patients who might otherwise see a specialist or unnecessarily go to an emergency setting.

Remaining challenges

According to the Independent Health survey, when scheduling appointments and facilitating access to services, 65.9 percent of all those responding said they would like to utilize an online portal, including 79 percent of Millennials, compared to only 28 percent of Baby Boomers.

"We like it on our end," Adnaan Sheriff said. "We're on the computer all day long. We're not playing phone tag. We can respond to messages on our own schedule and we're not being distracted from our other tasks. And patients appreciate it because they're speaking right to the doctor and have a record of their care."

He expects telemedicine in the coming years to further streamline the care process, allowing primary doctors, physician assistants and nurse practitioners to focus on the sickest of patients during what can become longer office visits.

The biggest challenge at this point? So-called "global payments" by health insurers that fall far short of the reimbursement physicians would like for their role in the process.

Communication within the health system also continues to be uneven, Adnaan Sheriff said, though he expressed hope that a new Population Health Tool that allows primary care doctors to see patient insurance claims will help improve care. He gave the example of an eye doctor who may have forgotten to notify the primary care office about a diabetes-related eye exam.

Fuad Sheriff said working within the different parameters of health insurance companies also needs to be simplified. There are 125 quality metrics being evaluated, he said, and it would help if the insurance payers became more consistent and prioritized the most important of those metrics.

Nationally, Fuad Sheriff said, "We need to redefine the system. We are targeting disease management. We are not thinking about, talking about, prevention of disease. We are not thinking about health as a whole. That includes the physical, mental, spiritual health of a person. Often, policymakers don't even talk about health."

Changes Amherst Medical Associates already has made look to reflect that philosophy, the Sheriffs said.

"The American perception of health care delivery also needs to change from the consumer standpoint," Adnaan Sheriff said. "It should be more of a consumer-driven society. Where you have increased access, you lower the cost for the patient as well. But some of the responsibility needs to be put on the patient. We have some patients where we're doing all the right things, we're prescribing the right medicines, but they're still continuing to commit to bad habits: smoking, excess alcohol consumption, eating inappropriately. The provider gets dinged if that patient's diabetes isn't controlled. The patient gets off scot-free. Their insurance is still covered."

Insurers, physicians and public health specialists continue to work on that dynamic, Cropp said. Meanwhile, he said, this much is already clear: "Communities that have a more robust primary care capacity in general do a better job of delivering high-quality care, better patient experience and more affordable care."

See a white paper about the Independent Health survey by clicking here.

email: [email protected]

Twitter: @BNrefresh, @ScottBScanlon

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