New Jersey FPs Transforming, Transcending 'Distressed Environment'

As the AAFP constituent chapter that coined the phrase "distressed practice environment," the New Jersey AFP (NJAFP) knows a thing or two about what it will take to build and maintain a healthy network of primary care and family medicine practices capable of caring for the state's nearly 9 million residents. According to Raymond Saputelli, M.B.A., C.A.E., executive vice president of the NJAFP, salvation for the Garden State's medical system lies in practice transformation.

A distressed practice environment, he explained, is characterized by

New Jersey has all of these issues in spades, Saputelli said. And it all adds up to a need to fundamentally reinvent how health care in the state is provided and paid for.

"I think that we've all come to the realization that -- for primary care physicians and family physicians, in particular, and for patients and the health care system at large -- we cannot afford to continue to deliver care in the way we have traditionally delivered it," Saputelli told AAFP News Now. "In New Jersey, you have a situation where a great number of small solo practices are trying to survive in a highly (sub)specialist-dominated area, so … the idea behind the patient-centered medical home (PCMH) becomes even more important."

But, Saputelli said, for the PCMH model to succeed in New Jersey, those small practices must be able to access resources they currently don't have.

"These small practices are already struggling, and they don't have the resources to transform that are available to larger practices," said Saputelli. "They may 'transform' by integrating with larger practices or systems, but I think we also have a responsibility to help those practices that want to transform" on their own. "We need to be able to say to them that we can help, and we have a responsibility to their patients to help their doctors transform and deliver care in a way that offers one of the best opportunities to redefine health care."

To meet that responsibility, the chapter "aggressively engaged in the fight to help practices transform" in 2005, said Saputelli. The chapter banged on doors in the New Jersey statehouse and took the issue to the few insurers that operate in the state.

That paucity of payers generates its own complications, according to Richard Corson, M.D., of Hillsborough, a past president of the NJAFP.

"The number of insurance companies in New Jersey is very small," said Corson. "The payers have been bought out over time and, depending on where in New Jersey you are talking about, each area may only have three major payers.

"In my own area, there is one payer with 55 percent of the insured lives, and so they can dictate. They have a monopoly -- even though it may not be officially called a monopoly -- so … they pay us much less; in some areas, it is 55 or 60 percent of Medicare rates."

To bring the largest payer in the state -- Horizon Blue Cross Blue Shield of New Jersey -- to the table, the NJAFP showed the insurer data supporting the PCMH model's ability to more efficiently and effectively deliver care.

Eventually, according to Cari Miller, the NJAFP's director of private sector advocacy and project administration, the NJAFP convinced Horizon to join it in a pilot project that would accelerate the pace of New Jersey primary care practices receiving PCMH designation from the National Committee for Quality Assurance (NCQA).

"We worked with Horizon in 2009 to do the first PCMH recognition project in New Jersey," Miller said. "And it was very successful."

With the NJAFP overseeing recruitment, monitoring participation and providing the curriculum to selected practices and Horizon funding the project and sharing the cost savings gleaned with the 167 primary care physicians who participated, 32 practices received NCQA recognition.

Corson, whose own small practice gained NCQA Level 3 status in January 2012, said it looks as though many of the payers now are beginning to see the full benefits of the PCMH model, including the increased level of care that physicians are able to provide patients.

"They (payers) are in business, and for them, the PCMH saves money because it decreases hospitalizations," Corson said. "For family physicians, it keeps our patients out of the hospital and keeps them healthy, and I think that's what most family docs care about."

Moreover, he added, "Now, some of the payers are starting to realize that, in order for us to provide that increased level of care, they need to pay us, because we can't hire care managers or the support staff that we need in our offices without some of the savings flowing to us.

"So I think PCMH is going to help because the believers -- like Medicare through the Comprehensive Primary Care (CPC) initiative and the associated commercial payers -- are getting on board," he said. "And I think we're going to see more money to help us improve our practices, improve the care we provide patients and help us be able to afford to do the things we want to continue to do."

In fact, said Miller, 71 New Jersey-based practices now are enrolled in the four-year, multipayer CPC initiative, and the NJAFP is working with CMS, the Center for Medicare and Medicaid Innovation, TransforMED and other stakeholders to make sure everything goes as planned.

"(The) CPC (initative) will launch in New Jersey in January," said Miller. "And the NJAFP has been identified as the lead stakeholder in the state. Currently, the NJAFP is assisting in the ramp-up activities and is in the process of hammering out our specific roles and responsibilities."

According to the CPC initiative, which is designed to test practice redesign models and a supportive multipayer payment model, CMS pays selected primary care practices a set care management fee -- initially, an average of $20 per beneficiary per month -- to support enhanced, coordinated services for Medicare beneficiaries in addition to fee-for-service payments. At the same time, other participating payers will offer enhanced payment to these practices to support them in their efforts, with shared savings a possibility down the road.

Saputelli said he thinks the CPC initiative may turn the tide of the state's foundering health care system and give New Jersey family physicians the competitive edge they deserve.

"(The) CPC (initiative) is the most import thing to happen to primary care in New Jersey in a long time," he said. "It will not only change the way we deliver care, but also now (offers) the opportunity to redefine how we pay for care, what we pay for and the way we pay for it.

"Instead of paying for care in that traditional, episodic, procedural-based format, we now have an opportunity to put our money where our mouth is and say, 'We're going to provide physicians who wish to transform with the resources -- both human and financial -- to do so. We're going to redefine the way that we pay those physicians.'"