Health is Primary Tour Kickoff Highlights Washington State Innovators

Success Cited in Integrated Care, New Payment Options and Expanding Family Medicine Pipeline

March 23, 2015 03:00 pm Chris Crawford Seattle –

In areas of the country with more primary care doctors per capita, death rates from cancer, heart disease and stroke are lower and people are less likely to be hospitalized.

The Health is Primary city tour kicked off in Seattle March 19 with family physicians in private practice and from academia discussing how they are revolutionizing health care in Washington state.

That is why Family Medicine for America's Health,(fmahealth.org) a partnership of eight family medicine organizations, including the AAFP, launched its Health is Primary(www.healthisprimary.org) campaign: to make the case to patients, policymakers and payers that a strong primary care system will let family physicians deliver on the triple aim of better health, better health care delivery and lower health care costs. Some have suggested a "quadruple aim" with physician job satisfaction as the fourth target.

To kick off the Health is Primary city tour in Seattle on March 19, the group brought together family physicians in private practice and from academia to discuss how they are helping revolutionize health care delivery in the state of Washington. The tour is scheduled to visit Raleigh, N.C., on April 16, Chicago on May 19, Denver on Oct. 2 and Detroit on Oct. 21.

"Family Medicine for America's Health has come together with one mission: to improve health in America," said Glen Stream, M.D., board chair for the group. "Our nation is facing a health crisis. We have the most expensive health care system in the world, yet we rank almost last in industrial countries in the health of our people. We believe the solution to many, if not all, of our health care problems can be found in primary care."

Story highlights
  • The Health is Primary city tour kicked off in Seattle March 19 featuring family physicians discussing how they are revolutionizing health care in the state of Washington.
  • The roundtable event asked panelists about their successes with direct primary care, integrated care teams, innovative payment solutions, reaching underserved populations and expanding the family medicine pipeline.
  • Panelist Thomas Norris, M.D., chair of the University of Washington Department of Family Medicine, said there are encouraging signs across the country of efforts to improve primary care recruitment.

The roundtable event was moderated by author, documentary filmmaker and reporter T.R. Reid, who asked panel members to discuss their successes in areas including direct primary care, integrated care teams, innovative payment solutions, reaching underserved populations and expanding the family medicine pipeline.

Patient-centered Care

Panelist Erika Bliss, M.D., president and CEO of Qliance, a health care group that uses the direct primary care model, said her cousin and Qliance founder Garrison Bliss, M.D., had become discouraged by the fee-for-service, insurance-based system that drove him to see more patients with less value placed on the physician-patient relationship. So he started a practice charging a flat monthly fee and stopped billing insurance. He then was able to see a smaller number of patients and more intensively address their needs.

Seven years later, he launched Qliance as a way to spread the model across the country. The goal was to focus on the triple aim, and even the quadruple aim.

Bliss, speaking on the panel, said patients have responded dramatically to that approach. "They say, 'Wow, I can't believe how well my provider listened to me or how much time and attention they spent to help me.'"

Bliss said people don't want to be sick but they don't want health care, either. "They don't want what we have to offer, but they need it," she said. "So we start with, 'If I was going to do something I didn't want to do, wouldn't I want it to be a pleasant, comforting experience?' That is what we have focused on as our primary foundation."

Panelist Erika Bliss, M.D., (right) president and CEO of Qliance, said her cousin Garrison Bliss, M.D., founded the company after becoming discouraged by the fee-for-service, insurance-based system. He started a practice that charged a flat monthly fee and stopped billing insurance.

Since October, panelist Carroll Haymon, M.D., has been the medical director at a clinic for Iora Primary Care that serves a patient population that is age 65 or older and on Medicare.

One reason she moved from a previous job as a residency director was that her residents were taking jobs and then calling her to express frustration in their new positions. They would say, "I can't get a job where I can provide care to the level that I should be offering," she said. She thought she could create a clinic where those new physicians could practice after their residency and find deep satisfaction while providing a high level of patient care.

Patient-centered care at Haymon's practice means promoting a culture of service, she said, which led the staff to read up on service industry best practices to provide "deep, abiding service" to their patients. She called it "restoring humanity to health care."

"Patients are not a list of problems; they are individual human beings who are complicated," Haymon said. "They need time, energy of devotion and love from us."

She said to achieve that level of service, the facility built a health care team including nurses, social workers and "health coaches." And sometimes the physician isn't the best provider of service to patients.

"Patients don't always need medical care," she said. "They might need someone to sit down and help them fill out their Medicare application. That is patient-centered."

Patient-centered integrated care includes behavioral health, said panelist Russell Maier, M.D., director of the Central Washington Family Medicine Residency program, which trains doctors at a federally qualified health center to eventually practice in rural and other underserved areas.

Within the past year, Maier said, the group of four clinics has gone from one part-time behavioral health provider to six full-time positions and also added community health workers.

Following that change in care model, data showed a 10-percent drop in the number of patients the clinics sent to hospitals for in-patient care, he added.

Return on Investment

Iora Primary Care does not use a fee-for-service model. That means payer partners must share the organization's mission to properly fund primary care and let the team do its work, which leads to an overall reduction in health care costs, Haymon said.

"My feeling is if we can show the payers that health care savings can happen for our older adult/Medicare patients who are poorly served by the current system -- now, we're playing ball," she said.

Bliss at Qliance said that working with Medicaid on direct primary care payment finally dispelled the myths about concierge medicine -- "That we were only out for our own best interests and didn't care about the public," she said. "We're now getting calls from other payers saying, 'This sounds interesting' and, 'We are interested in working with you.'"

Panelist Richard Kovar, M.D., (left) medical director for Country Doctor Community Health Centers, said, "I truly believe that health disparities are at the heart of every family physician in this country. It is what we do; it is what we went into this professional for."

Panelist Richard Kovar, M.D., medical director for Country Doctor Community Health Centers and 2012 AAFP Family Physician of the Year, said the Office of Management and Budget reports that a dollar spent in his health care system using the Medicaid program returns $3.

"In that spread of $1 to $3 is the ability to provide fairer reimbursement to my other colleagues who would love to take care of this population," he said.

Providing Care for Everyone

The definition of "health disparities" is loaded -- including differences among racial and ethnic populations, income levels and rural versus urban areas, Kovar said.

"I truly believe that health disparities are at the heart of every family physician in this country," he said. "It is what we do; it is what we went into this professional for."

And community health systems are an important part of addressing those disparities to improve Americans' health, he said.

In Washington state, that safety net includes about 350 providers -- the majority of them family physicians at about 220 sites, Kovar said. They are part of the national safety net of about 9,000 sites and the largest distributed care network of primary care in this country.

"At the end of the day, we serve that expanded population of Medicaid and those from the (Affordable Care Act) Exchange; we are here to take care of the 'left outs,'" he said. "That voice should never be left unspoken because it represents 30 million people here in this country who are left out often for reasons that are beyond their control. The community health system is here to serve them as its core value."

To integrate care for those underserved populations, Kovar said, community health systems collaborate with behavioral health and other specialists.

Expanding the Family Medicine Pipeline

Panelist Thomas Norris, M.D., chair of the University of Washington Department of Family Medicine, said the lack of students picking primary care over other specialties is still a significant problem.

In countries where primary care doctors are the majority of those providing care or are equal to the number of specialists, health care and related statistics are significantly better than in the United States, he said.

"Here, we have a ratio of roughly two specialists to one primary care provider and it's worsening, not improving," Norris said. "At the same time, our health statistics are worsening and not improving. But the more primary care providers you have, the better health you have."

Norris said the lack of incoming primary care physicians is due to several factors, including the perception that primary care is hard work and the unsavory task of dealing with insurance requirements, which can lead to frustration and mentors swaying students to consider a different specialty.

Secondly, primary care doctors are paid less than colleagues in many other specialties. Students coming out of medical school have large debt loads and are looking at careers that can help pay them off more quickly.

Thirdly, Norris said, there has been a perception that primary care carries less prestige than other specialties, like heart or brain surgery.

So what can be done to combat those issues and recruit more primary care physicians?

In Washington state, many primary care physician shortages are in rural areas, Norris said. The University of Washington Department of Family Medicine introduced an initiative called the TRUST (Targeted Rural Underserved Training) program(depts.washington.edu), which admits students who grew up in rural areas using a separate admission process.

"Right after their admission, we assign them to a small town," Norris said. "That small town's physician and patients are the students' learning laboratory for about four years of medical school."

The program teaches students an approach to rural demographics, disease patterns, chronic disease management, and how to work with locals including pharmacists, social workers, nursing home caregivers and football trainers.

Norris said there also are encouraging signs across the country of efforts to improve primary care recruitment.

"We are seeing some of the newer medical schools focus pretty much entirely on primary care," he said. "Existing medical schools are going more in that direction than they have in a long time. There are a lot of positions out there for (students), especially in rural places."

Norris added that primary care still needs much more student interest. "What needs to happen for that to take place is the payment system reform that begins to change the nature of the way we do our work, so we don’t spend a lot of time on coding and insurance paperwork, and we spend a lot more time taking care of our patients," he said. "At that point, a lot of unhappy people become happy people and this becomes in the student's mind the best job in the world."

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