The standard 15-minute doctor’s appointment doesn’t exactly encourage patients to ask a lot of questions and talk freely about their health with their physician.
If the single, brief time slot isn’t the best deal for patients, try multiplying it by 30 to get a sense of how big the challenges are for doctors. That’s about how many patients a primary care physician typically sees in a day.
But it doesn’t have to be this way. A new model for primary care is emerging. It’s called advanced primary care, and Neil Patel, MD, can attest to how much better it is for both patient and doctor.
“What could be more important to healing than the relationship we create with our patients?” he asks.
Patel posed that question in a previous job as a primary care physician, when he was tasked with squeezing as many visits as possible into his work day. But those days ended when Patel joined Iora Primary Care, a primary care doctor’s office for adults on Medicare. Now, Patel, Iora’s senior vice president and regional medical director, and his team spend whatever time they need to help their patients improve their health. This unlimited time applies not only to office visits, but also to communication with patients before and after their appointments.
Advanced Primary Care Comes to North Carolina
Advanced primary care is in its infancy in North Carolina. It’s a big part of the shift in health care away from paying by the procedure (known as fee-for-service) to paying for high-quality, cost-effective care (known as value-based care).
Iora Primary Care opened its first North Carolina practice in Winston-Salem in late September. The Boston-based company is one of three advanced primary care providers to open here as part of a recruitment effort that Blue Cross and Blue Shield of North Carolina (Blue Cross NC) launched earlier this year. Iora will serve adults on Medicare in its five North Carolina practices.
Cityblock Health also has launched its North Carolina locations, opening practices in Charlotte and Greensboro this week. The company will care for individuals who are covered by Medicare or Medicaid, bringing together care for physical and behavioral health needs with social care. Additional Cityblock practices will open in Winston-Salem and High Point in November, and Fayetteville in early 2020.
Rahul Rajkumar, MD, chief medical officer at Blue Cross NC, says advanced primary care marks another milestone toward better collaboration between insurers, doctors and hospitals. He also cites the company’s new Blue Premier agreements with large health systems, announced in January, as proof points that North Carolina is helping lead the transformation of health care.
“If you change the payment system, it sends a different signal to providers,” he says. “When you pay for a different experience of care, for quality, and for the things that actually matter, it will transform the patient experience.”
Focus on Quality and Cost
The concept works financially because advanced primary care practices are paid for how well they help their patients improve or maintain their health.
Instead of paying these practices for delivering a high volume of services to a high number of patients, insurers pay them a flat fee for taking care of patients in a health plan such as Medicare Advantage. The practices also have a portion of their payments tied to both the quality and total cost of care. Each practice then must treat patients in a way that improves care, manages costs and enables to it to earn a profit.
The model works, says Sachin Jain, MD, president of CareMore, another advanced primary care provider with plans to open in North Carolina.
"Over the years, we have invested consistently in programs and services not covered by traditional fee-for-service," he says. "Really common-sense things like home-based primary care and exercise, nutrition, and disease management programs for patients who need them and that yield significant improved health outcomes."
Aligning the way care is paid for and the way it’s delivered typically brings improvements in cost and quality. For Iora, that has meant a 40 percent reduction in hospitalizations and 20 percent reduction in emergency department visits, when compared to patient experiences under traditional fee-for-service payments.
Iora’s Patel explains advanced primary care in terms of the differences patients see compared to their typical experiences with primary care.
One obvious one is the amount of time and access patients get with the doctor. Another is access to health coaches, licensed clinical social workers, nurses and operations specialists who can coordinate care across the health care system. Health coaches take notes during appointments, review next steps with the patient, and follow up to coordinate lab results, prescription refills and other needs.
“Patients may be surprised when they get here and there aren’t ten other people in the waiting room,” he says. “Or when they call us, they can get all their questions answered. Everything is just easier and simpler.”
Neil Patel, MD, senior vice president and regional medical director at Iora Primary Care
At Cityblock, care extends from community hubs that serve as a home base for members and their care teams. These flexible care teams – which may include a primary care provider, behavioral health specialist, nurse care manager, community health partner and others – also meet members in their homes in the community, or by phone or video. They spend time getting to know members’ priorities and goals for their health and daily life, and ensure that members have the right care and support toward better health.
“Health starts in the communities where we live,” says Toyin Ajayi, the company’s co-founder and chief health officer. “We have to address what’s going on in our members’ daily lives and in their community to meaningfully improve their health.”
CareMore, originally founded as a medical practice in Southern California in 1993, has two decades’ experience serving Medicare patients using a care model that wraps a variety of resources around primary care networks.
CareMore's Medicare model has shown favorable outcomes, both in helping patients with chronic diseases better manage their conditions and in preventing unnecessary hospital admissions. The company's latest outcomes for Medicare patients show 23 percent fewer admissions and 7 percent fewer acute hospital readmissions compared to the Medicare average.
In 2015, CareMore expanded into Medicaid primary care, leveraging its experience in Medicare Advantage, and began studying how well its advanced primary care model was working.
Results published a year ago in Harvard Business Review tell a promising story about the effectiveness of the model for Medicaid, based on the two states evaluated. In Tennessee, Medicaid patients experienced up to 17 percent fewer days in the hospital and up to 22 percent fewer emergency department visits than the state’s Medicaid managed care patients as a whole. Results were similar in Iowa.
Applying the Model Broadly
Advanced primary care might be new in North Carolina. But it’s not the first effort to help physicians manage rapid change in health care while staying true to what called them to medicine in the first place – helping patients.
As part of Blue Cross NC’s efforts to transform health care by paying for value, the company is working with other primary care practices – especially the independent practices not owned by health systems. The goal is to help them develop processes and use data and analytics to improve quality and care coordination and to reduce costs. This includes sending practice transformation experts, quality consultants, physician leaders and data and analytics experts into the practices to assist doctors and their staff.
Blue Cross NC also is collaborating with Aledade to support independent primary care practices as they form accountable care organizations. Blue Cross NC and Aledade are providing physicians with technology and analytics tools to help them improve the patient experience.
Leslie McKinney, MD, Blue Cross NC’s lead medical director for primary care, says many practices want to adopt value-based care but struggle to find the resources needed to get there.
“Primary care drives the majority of decisions and spending on care,” McKinney says. “We want to bring in the important resources and tools to help independent primary care practices thrive in these value-based models. It’s all about meeting them where they are in this evolution.”
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