Medical home 2.0

By Jonathan Nelson

What happens when a patient-centered primary care medical home becomes the heart of a medical village? Welcome to the next generation of family medicine.

While primary care organizations grapple with educating policy makers as well as their physician members about the patient-centered medical home concept, a group of family physicians in suburban Plano have taken the model to the next level. Legacy Medical Village offers patients a one-stop shopping experience for a wide variety of commonly needed outpatient medical services, all available in one convenient location.

The 100,000-square-foot facility houses a host of clinics specializing in gastroenterology, general surgery, urology, plastic surgery and optometry, plus a full-service imaging clinic and a musculoskeletal team consisting of several physical medicine and rehabilitation doctors, an orthopedic surgeon and a pain management specialist. There’s a sleep clinic complete with furnished bedrooms for observation and a wellness clinic dedicated to the full spectrum of weight loss treatments, and plans for 2009 include adding more specialties and a pharmacy.

The family physicians behind the venture make up Village Health Partners, an award-winning group recognized as one of the best-run practices in the country. They’re led by Christopher Crow, M.D., M.B.A., who calls Village Health Partners the “anchor tenant” of the village, and in many ways, that’s exactly what they are.

“Medical malls” are springing up in metropolitan areas across the country, but Legacy Medical Village is different in that the whole operation is based on a primary care foundation. Crow and his colleagues select the specialists they invite to the village based on a shared philosophy of continuous, coordinated care and evidence-based medicine. The specialists agree to communicate quickly and completely with the primary care physicians, use interoperable health information technology throughout the village and implement open access scheduling so patients can get in to see them conveniently.

“We’re trying to create the ultimate patient experience,” Crow says, and in doing so, they’ve built an innovative model of the patient-centered medical home.

Changing the paradigm

As Crow sees it, the way we build health care delivery systems in America is backward and leads to the fragmented, poor-quality care we get. “The health care system in any major metropolitan area is built around hospitals,” he says. “Even though that’s where a small percentage of an individual’s health care over their lifetime takes place, it’s where the high-margin procedures are. So that’s where they put all their investment.” Next, the hospitals add specialists needed to perform those procedures and finally, they add primary care doctors “in a ring around their hospital to feed their hospital system. In my mind, this is exactly the opposite of the way things should be.”

Crow describes the optimal health care delivery system as a pyramid, where primary care physicians are the foundation. Next come the services that are most commonly generated by primary care: lab work, imaging, therapy and other outpatient treatments. At the tip of the pyramid is the hospital.

He and his colleagues built Legacy Medical Village on this pyramid model, keeping access to care, quality and patient convenience at the core of every decision. They recruited a group of like-minded family physicians from their community and formed Village Health Partners. Once the eight physicians and two mid-level providers came together, they had a large enough group of patients to attract their selected subspecialists to move to the village. They started selling the space in January 2007 and Crow says it filled quickly.

“They have the expertise and the program; we have the volume and the need. This is an absolute community solution to providing better care.”

To demonstrate the kind of comprehensive care patients receive in the medical village, Crow uses an example of a typical, complex patient for most primary care practices: a 50-year-old woman who smokes and who needs a check-up, a chest X-ray, labs, a Pap smear, a mammogram, a bone density measurement and a colon screening. “At Legacy Medical Village, you come in and see your doctor, get your check-up, your Pap smear and your blood work, then you run downstairs and get your mammogram, your bone density and your chest X-ray, then you go across the hall and get your colon screen scheduled. You’re back at work before noon. What was the time savings to that individual person or the company that employs them? What were the financial implications of that time? That happens over and over again with every single doctor several times a day.”

In an acute situation like abdominal pain, Crow simply calls the general surgeon over to examine the patient. If the surgeon thinks the patient may need to be admitted to the hospital, they can go downstairs for a limited CT scan to confirm the diagnosis and then it’s off to the hospital.

“Something like that takes an hour and a half of the patient’s time. They go from my office into the hospital and they’ve seen two doctors and they have their studies done.” In a traditional setting, such a scenario may take more than a day and involve several hours in the emergency room, not to mention the cost difference. “My way costs less than $1,000,” Crow says. The latter would probably cost between $5,000 and $10,000.

“What we’ve seen is the compliance with referrals for important things like mammograms and colonoscopies goes way, way up, because as soon as they leave our office, they can go right across the hall or right downstairs and get those done. We make sure those services are open-access too, so they’re not having to come back two weeks later for that appointment, which again would lead to noncompliance. Therefore we have some of the highest rates in the country when it comes to those preventive measures.”

Business as [un]usual

The concepts that make Legacy Medical Village thrive are the same ones that lie at the heart of successful businesses in every sector—every sector except medicine, that is. “Primary care physicians have been stuck in the Marcus Welby days for way, way too long,” Crow says. While physicians are trained to provide excellent care to patients, they’re not trained to think like the executive in charge of a $10 million business. “Some of those business functions that are crucial for that $10 million company are the same business functions that are almost always absent from primary care practices.”

Not long after Crow and his partner, Sander Gothard, M.D., went into private practice together in 2001, they realized they would need to eliminate waste and streamline their workflows if they were going to have a financially viable practice. So they went to work and in 2006, they were named Practice of the Year by Physicians Practice magazine.

How did they do it? Look around Village Health Partners today and it’s all right there. For starters, they have a robust electronic medical record system that they exploit to the max. In fact, Village Health Partners won the Davies Award for Excellence by the Healthcare Information and Management Systems Society in 2008 for demonstrating superior utilization of their EHR.

They bought the system in 2003 and while Crow estimates they spent about $100,000 on it, it paid for itself in 18 months. And get this: it adds about $80,000 a year to each physician’s income. Crow says that’s due to better efficiency, more accurate coding and an increase in the services they provide patients. Clinical decision support and disease management reminders that pop up during patient visits make it easy for the doctors to provide the right care at the right time. With the click of a mouse, the order is placed in the record, coded and billed automatically. Providing better care pays off in more ways than one.

“Leveraging technology” to automate processes, as Crow likes to say, reduces errors and cost, and it makes work easier, which gives the doctors and their staff more time to focus on making their patients happy. “There is so much technology to automate systems and practices right now,” Crow says. “We do 10,000 refills a month electronically. If we had to do that with the old paper ways of Marcus Welby, we’d have to hire two or three people for that.” They also automate orders for almost 200 patients a day and process around 100 labs each day electronically. The lab results go into the patient record automatically and an alert goes to the physician’s desktop. The doctor can record the results for the patient on a secure voicemail line, send them through secure e-mail, or post them on a secure Web site the patient can check at will.

Automation and efficiency means they need less staff than most practices. According to the Medical Group Management Association, the average family practice employs 4.73 support staff for each full-time physician. Village Health Partners operates at a ratio of less than 3-to-1. Also, automated services are available 24 hours a day and they don’t call in sick.

With the data collected by the EHR, the physicians can generate reports showing their performance on a long list of quality indicators and through their participation in the Medical Quality Improvement Consortium, they can compare their results to benchmarks and national averages. They’ve noticed a dramatic difference in their quality rankings since they started using the EHR. For instance, a few years ago, Crow was disappointed to see that only around 30 percent of the practice’s diabetic patients were getting their recommended eye examinations while the National Committee for Quality Assurance had established a goal of 60 percent. By focusing on that indicator, they were able to exceed the NCQA goal in just over a year. Now that the vision clinic has moved into the village, Crow says more than 80 percent of his diabetic patients are up to date on their eye exams.

Village Health Partners consistently meets or exceeds NCQA goals for all sorts of quality indicators, including blood pressure, cholesterol levels, HbA1c levels and foot exams for diabetic patients, and more. The ability to generate these reports sparks some friendly competition among the doctors. The winner gets a little extra in his or her pay check. The physicians know they’re practicing the best medicine they can, and they like it.

To use an EHR to its maximum potential, physicians need to invest in expertise. That’s not easy to do in a small practice but it gets considerably more affordable when you put physicians together. Consolidation is one of Crow’s watchwords and it’s served him well. “You gain leverage when you start to put people together. You get 10 doctors together, all of the sudden certain business functions are now available to you. You can have a six-figure CIO to run your system, you can have a CFO, you can have a PR team, you can have an accountant that’s available to you more often, a lawyer that’s available to you more often.” Consolidation also means payers are more willing to negotiate, “so you can control your destiny a little bit more. That’s good, because if you’re in control, your patients are going to be better off.”

Another of those business traits often absent from physician practices is the standardization of processes, and that’s where a lot of inefficiency begins. “‘Variance equals cost’ is one of my favorite phrases,” Crow says. “In a primary care office with three doctors, those docs may do things three different ways, establishing three different systems—that equals cost.”

Crow and his partners have built a culture of reinvention, examining common processes, streamlining their workflows and establishing standard operating procedures with the twin goals of eliminating waste and improving customer service. Yes, they use the phrase “customer service” and they’re not ashamed of it.

By applying business tactics and strategies to their practice, the doctors benefit from the same reductions in overhead and increased earning capacity other industries exploit and they’re able to wow their patients at the same time. Ramona Cadoret, manager of physician contracting in the north Texas market for United Healthcare, recognizes the difference. She’s done some physician consulting in the past and says many primary care physicians struggle because they don’t understand basic business principles.

“There are groups we work with where it’s just pure chaos,” she says. “The billing side of it, the collection side of it, the [human resources] side of it, the turnover—just chaos.” Not so at Village Health Partners. “We know that our members are taken care of. The village concept that he’s created, that’s perfect.”

Chuck Lyles is one of many happy patients at Village Health Partners. As president of the health care division of Perot Systems, a company that provides technology solutions to businesses around the globe, he knows a few things about health information technology. “I think we all live in this world of going to a PCP and you go to specialist one, two, three, four and it may take you a series of months to get that done, … having to carry around pieces of paper from physician one to physician 10 to keep it all together,” Lyles says. “[Crow] has been able to go in with an end-to-end model that says, ‘no I’m going to actually build a facility that provides these specialty services, integrate all that into an end-to-end delivery model and oh, by the way, technology is going to be a major driver of that and that’s going to actually reinvent what a [primary care physician] does for his community.’ I think it’s a fascinating idea.”

From an employer’s perspective, Lyles likes the open access and convenience of the medical village. “I can go into Dr. Crow’s office at 7:30 on a Monday morning or a Tuesday morning, and I can go get my lab work done and see him and go see other specialists right there and be back at work by 10 o’clock.” Less time out of the office and better management of chronic illnesses means costly emergencies stemming from poor care management don’t increase company health costs, and that makes employers like Lyles very happy.

“I hear horror stories with my colleagues around this company and the community about ‘can’t get in to see my [primary care physician], can’t get access to data, can’t get my prescriptions refilled, they’re never around.’”

As a patient at Village Health Partners, he can logon to the practice Web portal and request a prescription refill then pick it up at his pharmacy of choice the next day. Patients can also make appointments, request referrals, view lab results and access portions of their medical records. Crow believes “open access” means more than just getting patients on the schedule the day they need to be seen. It’s also creating multiple points of access and lines of communication. Aside from the Web portal, patients can receive an e-newsletter and read the practice blog.

Another patient, Jeff Hochberg likes the ability to contact his physician via e-mail. “I guess I’d be considered a patient who is informed and wants to communicate, wants to have a dialogue and so to communicate with another doctor or other doctors a lot of times involves a call. Somebody takes a message, gets the question to the doctor eventually, then has to reply back by interpreting whatever the doctor says and then gets the message back to you.” For patients like Hochberg, direct communication is the only way to go. Patients who want e-mail access to their physicians pay a $50 annual fee or $100 for families to get premium access to the practice Web portal. So far, about 10 percent of patients have purchased the extra access.

Happy patients = Happy doctors

Jamie Albracht, D.O., practiced in the panhandle town of Dumas, Texas after residency for three years as part of a loan repayment program before moving to the Metroplex and eventually joining Village Health Partners. While he loved the community and his patients there, his solo practice with its paper charts had its difficulties. After seeing 30 or 40 patients in a day, he would still have hours of transcription to complete, which kept him away from his young family.

“By practicing in this situation where we have the technology and foresight to take care of patients in the accessible and convenient way that we’re trying to do, it really allows me to spend more time with my family. It allows me to be the husband and the father that I want to be,” he says.

Crow calls it the “happiness quotient” in primary care. He’s disappointed by the negativity he perceives from so many primary care physicians because he knows it’s possible to make the medical home work for patients and for doctors. He says the doctors at Village Health Partners are going home earlier and spending more time with their families than they were in their previous practices. They have remote access to their patients’ charts, so they can manage tasks from wherever they are. They’re proud of the fact that they can offer their patients all these services in one place. “Of course it’s great that they’re all doing better financially. That makes everyone happier, but they will all say that they know they’re taking better care of patients today.”

“It’s a beautiful, beautiful situation,” Albracht says, “when I know that my patients are cared for and I’m doing it to the best of my ability and to the ability of our practice, and the patients are very happy with their care. That happens because of efficiency. That happens because of attention to detail. It happens because of access and convenience for patients.”