Rhode Island’s primary care doctors are not, for the most part, in big medical practices. They work in pairs, at most three or four together, just enough to split some costs. They’re not backed by corporations; any expenses come from their own pockets.
That, experts will tell you, is one of the biggest challenges in getting everyone to adopt electronic health records – or make any dramatic change. Those things take time, effort and money, and small practices just don’t have the resources.
This is what makes this bit of news so significant.
Rhode Island Primary Care Physicians Corp. (RIPCPC), an association that represents 162 doctors in independent practices, has signed a deal with Blue Cross & Blue Shield of Rhode Island to turn virtually all its members into “patient-centered medical homes.”
The deal, which Blue Cross called “a major milestone,” will dramatically expand a pilot program that aims to make the medical-home model – as defined by the National Committee on Quality Assurance – the new norm in Rhode Island’s primary care practices.
To qualify as an NCQA-recognized medical home, a practice must build relationships with patients, offer enhanced access to doctors and information, coordinate care with other providers, and closely monitor quality and outcomes. EHRs are required.
Only a handful of practices in Rhode Island have met the standards for even a Level 1 medical home, and even fewer for the more-advanced Levels 2 and 3.
In January, aiming to supplement the work of the Chronic Care Sustainability Initiative (CSI-RI), a multipayer initiative that has been piloting the medical-home model since 2006, Blue Cross launched its own independent, medical-home project.
Like CSI-RI, the Blue Cross program offers technical support and pays for a nurse to join the practice as a “care manager.” CSI-RI also pays practices an extra $3 per patient, per month; Blue Cross is paying monthly stipends of $10 for starters and then $15, $20 and $30 upon reaching NCQA Level 1, 2 and 3, respectively – but only for patients requiring “complex” care.
Altogether, the doctors in RIPCPC serve more than 300,000 people, including about 120,000 Blue Cross members, but only about 75 to 100 patients per doctor are expected to qualify, said Dr. Gus Manocchia, Blue Cross vice president and chief medical officer.
That’s about 10 to 15 percent of each doctor’s Blue Cross patients, and a fraction of their total panels. But even at $10 apiece, that’s $9,000 to $12,000 in extra revenue for each doctor, plus a paid nurse and free help with EHRs, report-building and data analysis.
In the long run, said Dr. Albert Puerini Jr., president of RIPCPC, the program could boost doctors’ income by 15 to 20 percent. And the best part, he said, is that the extra money will pay for better care and better outcomes, not cramming dozens of visits into each day.
“We’re trying to get away from paying doctors more money for seeing more patients, to get them off this treadmill,” he said. The hope with this project, he added, “is that it’s going to allow us to practice better medicine, get reimbursed appropriately for it, and attract young doctors” who’ll know they can get paid well and “make a real difference in patients’ lives.”
RIPCPC comes to the project with several assets. For starters, as Manocchia noted, it’s “highly coordinated and organized,” with a president, an executive director, and monthly meetings where doctors discuss quality and cost issues, share ideas and learn together.
The group also negotiates a single contract with each insurer to cover all its members, so they’re all on the same page. It has experience with pay-for-performance incentives; they’ve been part of RIPCPC deals with Blue Cross for years, with great success, Manocchia said.
And the group is unusually tech-savvy: It has a side business that created practice-management software and then an EHR, EpiChart, that is used by about 90 of the doctors, Puerini said (plus many more outside RIPCPC).
Some members use other EHRs, but those with EpiChart have the advantage of being able to request upgrades, custom reports and new features and get an immediate response.
“We own it, so we are able, probably quicker than most systems, to go in and tweak the system,” said Puerini. “We don’t have to go to a third-party vendor.”
With this new contract, announced May 12, RIPCPC will for the first time require all its members to have EHRs, Puerini said. Any practice that joins will have six months to have an EHR up and running; the same goes for existing members, except for a handful who are being “grandfathered in” because they are near retirement.
The doctors will work together to meet the NCQA standards, and the smaller practices will share case managers – so perhaps a nurse will work two days in one office, and three in another. They’ll develop reports to gauge how well they’re serving patients (for example, how many diabetics are getting their blood tests on time), and they’ll compare outcomes, to see whether their efforts are making these patients, their sickest, a bit healthier.
Many of the practices have been doing this kind of work for awhile, but the extra resources will help them do more and will focus everyone’s attention, Puerini said. The doctors also hope to bring more services into their offices, such as mental-health counselors and nutritionists, and coordinate care with their colleagues.
Two of the practices, including Puerini’s (Family Health & Sports Medicine in Cranston), are already part of CSI-RI, and though they won’t be joining this new program (they can’t “double-dip”), they are valuable examples for their peers, Puerini said.
“CSI is proving that this works,” he said. “We’re significantly improving clinical outcomes.”
As for the savings that Blue Cross hopes to produce – the “complex” cases account for 54 percent of medical costs, the insurer has said – those may take longer to show up, Puerini said, but he’s confident they will materialize.
“When you start taking weight off people, and getting them to quit smoking, and their blood sugar is down, it’s not a leap of faith to say that down the road, we’re not going to have to spend as much on these people, if they continue doing this,” he said.
Turning all the RIPCPC practices into medical homes will take time, Manocchia said, and Blue Cross is prepared for a “ramp-up process,” with perhaps 50 up and running by year’s end.
One, the largest of the group – Medical Associates of Rhode Island in Bristol with 20 doctors – already started in February, he said, the second to join the program after pilot site Aquidneck Medical Associates of Newport. And along with the RIPCPC members, another 15 to 20 practices are joining in the next few weeks.
Health Insurance Commissioner Christopher F. Koller, who led the creation of CSI-RI, said it’s hard for Blue Cross to make quite as big an economic impact alone as a multipayer initiative can, but it’s still a good program, and targeting the sickest, highest-cost patients makes sense.
“I think any effort to build and expand the primary care infrastructure is important and positive,” he said, “and clearly this is an attempt to do that.” •