by Fred Goldstein and Gregg Masters
In July we focused on Primary Care and Population Health and we had quite the line up. From some extremely well known experts to hard working physicians in the trenches ‘walking the talk’ of innovation via transformative primary care leadership for over a decade.
We started with Roy Hinman, MD of Island Doctors in St. Augustine Florida. Island Doctors has been serving global risk Humana Medicare Advantage since 1998 and now manages approximately 18,000 patients! Roy focused on keeping it simple, building out a network of like minded partners, leveraging mid level practitioners at the ‘top of their license’ in the care team, aligning financial incentives, grasping and developing core competencies in clinical risk management and a hospital agnostic approach to prudent utilization of institutional healthcare resources.
We then moved to direct practice pioneer with the CEO and Founder of iorahealth (@iorahealth), Rushika Fernandopulle, MD (@rushika1). Rushika decided to ‘rebuild primary care from the ground up’ and created a care team model in some respects similar to Roy’s that ‘dis-engages’ from a volume based, fee-for-service compensation plan. Iorahealth has been experiencing strong growth in the traditional m
embership or retainer model direct practice milieu where there is no intermediary between the patient and the medical practice. Yet, continuing to innovate in non-traditional direct practice terms iora health as also engaged in the direct employer space via global contracts with Humana. Rushika believes that establishing a dis-intermediated and thus ‘direct relationship’ with the patient via a coordinated care team is their ‘secret sauce’ and key market differentiator.
Week three’s guest was Jay Lee, MD (@FamilyDocWonk)of MemorialCare Medical Group (@MemoricalCareMG), a historically proactive physician organization based 
in Long Beach, California with a service area reaching into south Orange County established to provide advanced comprehensive, effective and efficient healthcare. Jay’s primary role is as the Associate Medical Director of Practice Transformation at MemorialCare Medical Group and Director of Health Policy at the Long Beach Memorial Family Medicine Residency Program. He also serves as the President of the California Academy of Family Physicians (@cafp_familydocs). Jay brought some unique insights into physician acceptance of population 
health and training of residents, stating that changing the culture and aligning both docs and payment incentives were mission critical to success in the transition from one-off episodic care to a population level world view.
The fourth week featured the “Grandfather” of the Patient Centered Medical Home, Paul Grundy, MD, MPH (@Paul_PCPCC & @IBMhealthcare), Global Director of Healthcare Transformation IBM, President PCPCC, Ambassador for Healthcare Denmark. Paul discussed the history of the PCMH and stated that the original concept was based not on being the ‘primary care home’ for the patient per se, but the home for the data about the patient which would allow for better management of the patients condition. In fact the original PCMH was the transplant surgeons who needed to be sure that they had all the data and could coordinate all of the patient’s healthcare needs.
So what did we learn?
Fee-for-service payments and its inescapable production oriented ‘do more, to earn more’ incentive basis is a hindrance to implementing population health, and perhaps contrary to emerging ‘conventional wisdom’ that tipping point may not be so close (the best intentions of Secretary Burwell et al at CMS).
Many experts say we are near a tipping point in the approach to medicine and population health, that as soon as we implement just a bit more value based payment methods, we will reach it. Unfortunately and given the weight of historical inertia, they may be wrong (again?).
In our discussions, there was real and evidence based concern that to do population health requires getting completely away from FFS payments. Rushika takes none, and Roy claimed to only have a handful of patients on this burning platform. They both stated that FFS payments were a problem and hindered behavior change, as well as not allowing for the justification of many population health approaches. Interestingly at MemorialCare Medical Group , Jay stated they still measure physician productivity using RVU’s; so any work that does not have a billing code (think pop health related activities) has ‘no measure or worth’ (my words). The point that stuck out most for me is that if MemorialCare Medical Group has 60 to 70% capitated business, yet they still measure using FFS related codes, making it hard to justify population health services, when do we reach the tipping point?
Paul on the other hand felt that we would incrementally reach the inevitable pivot and felt that the recent CMS announcements regarding the more rapid shift to value based payments would be the impetus. Although he felt there were examples of successful capitated contracts he did bring up the fact that this type of payment can lead to an underutilization of appropriate services, while clearly FFS can lead to an over-utilization.
Bringing Joy into Practice
Both Rushika and Jay independently discussed the need to bring “joy” back into the physician experience, a common theme first posited by senior leadership at ACO management company Lumeris as ‘the triple aim, plus 1’ , where the plus 1 is ‘physician satisfaction’. They talked of the drudgery of having to practice in the current system driven by fee-for-service payments, and the well know productivity formula of 30+ patients a day with an average per patient visit in the 7- 8 minute range. Both felt that practices that introduced a patient centered model, focused on relationships and had global payments allowed doctors to practice in a manner that aligned better with why they had called them to medicine in the first place.
Keeping it Simple
Rushika and Roy discussed how they have very simple systems to manage patients, in fact Rushika felt that EMR’s which had been built upon the FFS model and the need to create a bill, were a hindrance and he did not use one. iora health had instead developed their system from scratch. Roy too discussed how his practice focused on the ‘low hanging fruit’ and that by having no copays for office visits, seeing all walk-ins that day, managing cholesterol, weight and other simple things, they were able to drastically reduce hospitalizations and ER visits. As Roy said and I’m paraphrasing, you don’t need 15 consultants and a big IT system to do this.
Paul stated that IBM had also gone to a no co-pay model for primary care visits for their employees and wanted to be sure their employees had a relationship with their PCP.
Utilizing your staff based upon their expertise
All of the guests had created systems or discussed having specific roles for each team member in particular to maximize the physician by having them focus on
The Role of Technology
While not all of the guests discussed technology, it was clear from Paul and his work both with providers and one of the strongest IT companies in the world that technology and in particular advanced data analytics combined with mobile will lead to a sea change in health and health care. Moving us to the realm of personalized medicine, providing specific services to a specific person to maintain and or improve their health.
What a fantastic month of guests!
Next month, we’re dedicating our series on ACOs, and diving into one of each entity type: 1) physician led, 2) hospital sponsored and 3) health plan enabled to contrast and compare structural characteristics and the relative market success (or failures) reported to date.
Join us!