The new old way of doctoring

When your car starts making a funky noise or needs an oil change, what do you do? You take it to the mechanic. The mechanic fixes it, you pay for the service, and once the transaction is complete, the mechanic spends not another second thinking about your car. 

For years, primary care doctors have worked under a similar fee-for-service model. They treat the people who show up in their offices, but the system forces doctors to squeeze as many patients as they possibly can onto the schedule and doesn’t give them time to consider the people who don’t show up. 

As it turns out, people are infinitely more complex than cars. And treating people only when they get sick enough to show up is an expensive way to do health care. Spurred by health care reform, Medicare and private insurance companies are changing their payment structures to encourage primary care doctors to return to a model where they truly care for the whole patient. 

“It is a fundamental change in the way we view health care. It’s really fundamentally about value, not volume,” said William Moran, M.D., director of the Division of General Internal Medicine at MUSC. 

But most busy doctors in community practice don’t have time to think about how to transform their practices. That’s where MUSC and a $1.9 million grant from the Health Resources and Services Administration (HRSA) come in. With the “Primary Care Training and Enhancement: Training Primary Care Champions” grant, MUSC faculty will work with 25 primary care doctors from across the state over the next five years to help them transition their practices to the new model and become champions for this transformation.

Moran; William Basco, M.D., director of the Division of General Pediatrics; and Vanessa Diaz, M.D., medical director for care coordination for primary care, are co-investigators on the grant. They will form an advisory board chaired by Sabra Slaughter, Ph.D., to select applicants from geographically diverse rural and underserved areas, and MUSC faculty will mentor them. MUSC’s general pediatrics, family medicine and internal medicine combined forces to work on this grant. 

MUSC will work with five doctors or physician assistants each year. The grant provides funding so the trainers can “buy” the doctors’ time, freeing them from practice for a half day each week to concentrate on this transformation without losing money. 

For the first six months, the doctors will learn Lean Six Sigma, a quality-improvement methodology, and will implement a pilot project within the practice. In the second six months, the doctors will initiate a major quality improvement project. To cap off the year, the doctors will present their findings to their state professional societies and attend a national meeting in Washington, D.C. 

The overall goal of this primary care transformation: working toward the "triple aim" of improving the patient experience, improving health and reducing costs. 

For Moran, the MUSC group’s recent site visit to a federally qualified health center brought back memories of his early career, when he practiced in such a center as part of the National Health Service Corps. Traditionally, there has been little collaboration between federally qualified health centers and MUSC, he said, and this grant will be good for both entities. 

“We can bring academic resources to them, and they can help us understand the challenges they’re facing, which are dramatically different from what we face,” he said. 

There are a number of alternative pay mechanisms that have been introduced in recent years or are being introduced. MUSC is already a Medicare Accountable Care Organization (ACO). Under this model, an ACO provides coordinated care with the aim of improving care and reducing costs. 

ACOs that meet quality and patient satisfaction targets along with cost savings get to share in the savings with Medicare. The Centers for Medicare & Medicaid Services pays for transitional care management, and insurance companies are beginning to follow suit. That lets practices coordinate their patients’ transitions to home from inpatient facilities, call them to ensure they’re clinically stable and have their medications and schedule follow-up appointments within two weeks, rather than waiting for the patient to reach out if something feels wrong. 

Blue Cross Blue Shield is also beginning to pay for care coordination, he said. Under these various payment mechanisms, the practice takes responsibility for the quality of patient care, patients’ health care experiences and cost and utilization, Moran said. 

“You’re in charge of their care whether they’re in your office or at home or in New Jersey. They’re still your patients, and you’ve got to outreach to them, and make sure they’re doing OK,” he said. 

Moran said some areas of focus for practice transformation could be asthma or diabetes management. Remote monitoring of vital signs like blood pressure and blood sugar can help the practice stay on top of a patient’s health while also reducing the patient’s burden to find transportation and come into the office frequently. This is especially important in rural areas and for low-income patients. 

“You don’t need to see the patient all the time to manage his or her illness. And you can use your team to do it,” he said. 

Practices also have to figure out how to take a more team-based approach, especially in areas without enough doctors. For example, MUSC’s primary care practice has PharmDs who help manage aspects of particular conditions. These highly-trained pharmacists oversee anticoagulation management for patients taking blood thinners, for example. “Ten years ago, and in many of these clinics still, there were no PharmDs who could help people manage high-risk medications,” Moran said. But, he added, they’re really good at it, and it frees the physicians for other tasks: It’s transformative. 

Moran noted that this national effort at primary care transformation is, at minimum, a 10-year project. The grant will help empower South Carolina doctors in the vanguard of change. 

“It’s expected by the end of the year, they will be champions in their practices for practice transformation,” he said. 

Physicians or physician assistants interested in the program can contact Carole Berini for more information.