Family Physician Efforts Put Rhode Island on Front Line of PCMH Implementation

April 30, 2011 01:30 pm James Arvantes

The Rhode Island AFP has emerged as part of a growing medical home movement in Rhode Island. Family physician practices, public and private payers, and government officials have all come together in an ongoing effort to revamp the delivery and provision of health care services in the state. The result is that Rhode Island now has the highest number of physicians per capita who are practicing in recognized patient-centered medical homes, or PCMHs.

FP David Ashley, M.D., of University Family Medicine in East Greenwich, R.I., right, spends time going over patient Gary Cavanaugh’s electronic health record.

According to state officials, Rhode Island ranks eighth in the country in terms of the number of physicians in practices that have received PCMH recognition from the National Committee for Quality Assurance, or NCQA. In the process, Rhode Island has emerged as a haven for primary care and the PCMH. Even the state's governor has reportedly said that every state resident should have a medical home.

"We want to make Rhode Island a great place to practice primary care," says Christopher Koller, the state's health insurance commissioner. "We want primary care docs to come here because it is a great environment for primary care, and ultimately, we want businesses to locate here because of our primary care infrastructure."

For their part, family physicians have played a major role in pushing the PCMH forward in the state by participating in various collaboratives and committees and by sharing their knowledge and expertise with other primary care practices.

In addition, the Rhode Island AFP has become increasingly active in medical home efforts, thanks to chapter President David Ashley, M.D., of Saunderstown. "When I got up and gave my acceptance speech as the new chapter president last May, I said the medical home was going to be my mission for the next year -- to get us out in front of this whole issue and involved in this cutting-edge stuff," says Ashley, a primary care partner with University Family Medicine in East Greenwich, R.I.

The Rhode Island AFP now has its "finger on the pulse from many directions and sides," says Ashley. In early June, the chapter will devote much of its annual conference to the PCMH, tying it into the future of family medicine in Rhode Island.

"Our role is to make sure people know who is out there and what is available for support," says Ashley, whose practice will apply for Level 3 NCQA medical home recognition in August.

In this way, the Rhode Island AFP has emerged as an informational resource for its members. "We have helped the (medical home) transformation make more sense for people as to what is happening, where it is supposed to be going and what the resources are," says Ashley.

Rhode Island AFP President David Ashley, M.D., has committed to ensuring all patients in his state have a patient-centered medical home.

Most of the forward-thinking family medicine and primary care practices in the state are either recognized medical homes or they are in the process of becoming recognized as medical homes, Ashley says. "It is now time to start thinking about getting everyone else in. Our role is to bring in the rest of the (family physicians)."

Physicians at Family Health and Sports Medicine, a family physician practice in Cranston, R.I., also are enthusiastic about the PCMH model. The practice was one of the first in the state to achieve medical home recognition status from the NCQA, and it repeatedly demonstrates the value of the PCMH model by controlling costs, enhancing access and improving the overall quality of health care.

"Patients are really responding to us because they feel they are getting much more attention and, therefore, better care," says Al Puerini, M.D., one of three physician partners in the practice. "We are able, as primary care physicians, to direct what happens with our patients much more efficiently."

Puerini describes electronic health records, or EHRs, as a key function of a medical home. He now can use the EHR to create patient registries to better identify and work with patients with special needs. For example, "We are able to more easily identify patients with diabetes and spend more time with them," says Puerini.

Nurse Jessica Gremour, left, is a key part of tracking patients’ needs in the patient-centered medical home provided in FP David Ashley’s practice.

Creating the Future

Rhode Island's emergence as a leading proponent of primary care and the PCMH is a result of several converging factors and circumstances. As a small state geographically, Rhode Island is conducive to implementation of pilot projects that test innovative delivery and payment models, such as the PCMH. And as a small state, it is able to spread the lessons of pilot projects across the entire state more readily than a larger state might be able to.

Rhode Island enjoys other advantages, as well. It is the only state with a health insurance commissioner like Koller, who notes he is unwavering in his commitment and support of the PCMH and primary care.

"My statutory responsibilities are to direct health plans toward policies that improve the effectiveness of the health care system," says Koller. "I have not seen an effective health care system that doesn't have strong primary care at its core."

In 2009, Koller ordered the state's commercial insurers to invest more in primary care as a condition of having their rates approved. At the time, commercial insurers were spending about 6 percent of their medical expenses on primary care, far less than the amount spent by large integrated health systems, such as Kaiser and Geisinger.

In addition, Koller was instrumental in developing the Chronic Care Sustainability Initiative(, also known as CSI Rhode Island. This multipayer medical home project now involves 13 practices and 47,000 patients, and includes commercial payers, Medicaid fee-for-service and a Medicaid managed care plan.

As part of CSI Rhode Island, physician practices receive a per-member, per-month fee and are assigned a nurse care manager to work with their chronically ill patients.

"CSI practices are apportioned a nurse case manager, so if you have at least four physicians, you are going to get a full-time one; if you are a solo doctor, you get one for a quarter of the week," says Chris Campanile, M.D., Ph.D., of Cranston, a physician partner at Hillside Avenue Family and Community Medicine in Pawtucket, R.I.

The nurse case managers are the linchpin of the entire program. They provide key support for the CSI practices, says Campanile. They work with patients who need additional time and attention, for example, showing patients with diabetes how to take their insulin. In Campanile's practice, the nurse case manager serves as the main contact between the practice and the hospital, which frees up time for the physicians.

Koller describes CSI as a "pilot project for payment reform."

"It has been the place where health plans and primary care providers experiment in how to pay primary care providers in a different way -- how to get away from fee-for-service and pay on a per-patient basis," he says.

But even beyond that, CSI's self-described mission is to "lead the transformation of primary care in Rhode Island," according to Koller. It has resulted in enhanced care coordination, better patient engagement and higher quality.

Family Physician Leadership

Rhode Island has been able to capitalize on other initiatives to strengthen the PCMH in the state. For example, the state's family medicine residency program at Brown University, under the leadership of Jeffrey Borkan, M.D., has incorporated training on the medical home into its curriculum, creating another base of support for the PCMH.

Rhode Island also can rely on a cadre of family physicians and other primary care physicians who are health care and community leaders, said Koller. Family Health and Sports Medicine and Hillside Avenue Family and Community Medicine were two of the five original practices in CSI when it began in 2008.

Facts About the Rhode Island AFP

Chapter executive: Kim McHale
Number of chapter members: 284
Date chapter was chartered: 1972
Location of chapter headquarters: East Providence, R.I.
2011 annual meeting date/location: June 3-4/Crowne Plaza, Warwick, R.I.

Puerini, Ashley and other family physicians are convinced that Rhode Island represents the future of health care in this country.

"We have been going through a very bad time in health care because of its volume-based nature," Puerini says. "The more tests you do, the more operations you do, the more money you make with absolutely no attention to quality."

The medical home, however, turns that model upside down by basing care and payment on the value of care and not on volume, says Puerini. "As the medical home evolves, it is going to become even more dominant. Little by little, we are going to have more input into what happens with our patients, and (we will) create a health care system that puts the patient at the center and rewards all providers based on the quality of care they give."