Episode 63 - Holding Your Own
The industry’s shift to value-based care, coupled with an emphasis on efficiencies, has made it difficult for smaller practices to succeed alone. As a result, internal medicine and other primary care practices have joined forces in a range of practice models to maintain autonomy. Dr. Eric Harman, a family medicine practitioner at Mountain Region Family Medicine, joins our podcast to discuss his practice’s success as a physician-led accountable care organization (ACO), as well as the challenges and benefits of operating as an independent practice.
Joe: On this episode of "Putting Possibility Into Practice," have you considered selling your practice to a hospital system? Are you watching your own medical practice or have you been in private practice for a long time and still enjoy that private setting?
We are talking about physician independence, is it right for you? Hear from a provider on maintaining your independence and some advice if you may be considering a new practice model. This is "Putting Possibility Into Practice" and it starts right now.
I'm Joe Agostinelli, Social Media Manager at Greenway Health and welcome to this episode of "Putting Possibility Into Practice". If you are a returning listener, thanks for tuning in once again and if you are a new listener, we are glad you found us on your platform of choice and we'll have more information on subscribing on those platforms a little later on in this podcast.
Today we are discussing physician independency. Recent studies show that hospital-owned medical practices dropped to 28% of the market in the third quarter of 2018, that's down from 32.6% in 2016. Are you starting your own practice? Have you been in practice and considering a new practice model? To discuss these topics and more, I welcome, Dr. Eric Harman of Mountain Region Family Medicine to this episode of "Putting Possibility Into Practice." Dr. Harman, thanks for joining me.
Dr. Harman: Well, thanks for having me.
Joe: First off, we'll start off with the easiest question. Just discuss the practice a little bit. Where are you guys located? Some of the specialties and a little history of the practice?
Dr. Harman: Okay. So Mountain Region Family Medicine was formed in the late '90s by some doctors who can kind of were not too happy to be hospital-employed physicians. And they came together to share overhead and administrative duties and they made it easy, they wanted to really practice their own way but share those costs. And since that time, you know, they started out at about 5 to 8 physicians, grew eventually to 15. And we've sort of struggled to maintain that number over the years. We're in Northeast Tennessee, single specialty primary care. We have one internist and the rest of us are family medicine people. So we're dedicated to remaining independent and have enjoyed our practice that way. But things have changed over the last few years, but mostly for the better.
Joe: And staying on top of changes in the healthcare industry, probably a little harder to do when you're independent?
Dr. Harman: It can be. I think it's more challenging for small practices, one or two providers, there are a lot of challenges, that doesn't mean you can't overcome them with the help of other services but it's a little nicer to have more partners and have some more bargaining power with insurers and different entities.
Joe: And what led your partners to form an ACO and what challenges did you encounter in the process?
Dr. Harman: Well, we've been involved in quality medicine for a long time. We had worked with the multi-specialty IPA, physician's organization for many years. Many of our partners have been involved in the board level and planning and working on quality issues. And so when the idea for an ACO, when the ACO program came up, some of the partners in our group and a couple of other primary care groups got together and said, "We think we can do this." Now, we weren't the most sophisticated over those groups but what we did we were just out there doing really good medicine and that showed up.
We finally realized that, hey, we were doing really high-quality, low-cost medicine. We didn't realize it and the other partners are like, "We want you to join us." And so we became a physician. We've started a physician-led ACO in about 2016, I believe that's the day which was called Qualuable ACO. And pulled together these three groups and had around 20,000 and a little more covered lives. And just because we like the concept of doing what we were doing and saving money, trying to reach the triple aim of improved patient experience plus better costs and low and higher quality at the same time. And we thought we could do it and we were successful.
And one of the years we were in the top eight ACOs in the nation. And we saw the value of doing that and it led to changes in our practice working on population health, things that when I went to medical school we didn't study a whole lot, you know, that was in the master's of public health arena. But now it's sort of integral to what we do is looking at your whole patient population, not just the one at a time patient encounters, of course, those are very important, but those, sometimes those aren't the people that you're seeing, you have this whole population of people and trying to lift the population health at the same time.
Joe: You know, on the population health topic, you talk about reaching folks and something I had seen actually [inaudible] website was in 2018, outside of the office, you guys actually you make home visits for patients who may not be able to travel into your office?
Dr. Harman: Right. What's really interesting when you start looking at the costs that you're incurring giving medical care, we started looking at all the costs and of course the cost leaders are hospitalization. But then, you know, near the top of, as a percentage was transportation, ambulance service, taking people to and from the office was a humongous, you know, million dollar costs within our ACO.
And so we started thinking, what could we do to help people along those lines? Some of them just can't come, they don't have transportation, they have to be transported by ambulance or sometimes it's a temporary situation where they're disabled for whatever reason but in a few months, they can come back in.
So we had the idea, actually it was one of our partner groups, said, "We're thinking about doing home visits." I heard that and I was like, "Guys, we need to think about this." And like it has happened a lot of times people in the practice are like, "You're crazy, you know," because there are 15 of us and we sit down and have regular meetings and they're like, "Why, what's the idea behind this?" And we started talking about the costs.And finally, after about six or nine months, we said, we're going to try this and people were like, "Well, I don't think we had that many patients, you know, could we really use it?"
And once we started it, it suddenly filled up. And people found the need, those people who could only come by ambulance, the scenarios I was just discussing. Plus sometimes we have people that became acutely ill and needed someone to see them to keep them from having to go to the emergency room or to go to the urgent care. Really, they would mostly go to the emergency room and we can get our nurse practitioner to go out and see them and maybe save them. And I'm Sure, we've saved several admissions. We actually are expanding the program, we added another nurse practitioner cause she was...the one we were using was so full. So it's been a very successful program.
Joe: Awesome. And what other types of challenges have you guys come across and faced?
Dr. Harman: Well, it's initially just getting our head around the data, you know, trying to look at the whole population of patients, look at our metrics to be able to report efficiently. Those were some of the biggest challenges. Getting people on board with certain programs, you know, discovering our costs and how to work on those costs.
And so we had to start some disease management programs based around those most high-cost patients and in our region really is COPD related illnesses that tend to be the hardest high-cost people. So those were challenges to overcome and getting everybody on board. But mostly people got onboard after some cajoling and just showing them that, hey, you know, we can be successful in this and you will be reimbursed better for what you actually have been doing all these years.
Joe: And how is Greenway not only helping you remain independent but at the same time, how did Greenway help in launching that home visit service in 2018?
Dr. Harman: Well, it will allow our providers or the nurse practitioner program to create in the field a document so that everyone could see what was going on in, the case managers and the primary care physician, we can all share the information. That's the way I think it helps there. Greenway has been a great partner for us, it's been a cost-effective solution to allow us to be able to capture data, share information about patients and also look at our population health issues in the way we had to do to be able to improve population health.
Joe: And how important is the role of interoperability and maintaining your independence?
Dr. Harman: Well, I think it's important we have to know as much as we can about patients and keep their health as good as we can. And it's a challenge, you know, still people aren't on the same playing field all the time, we do in our area have an HIE which has been moderately successful, there are other portals that we use. So I think it is really important to hit the ground running to be efficient and caring for patients.
Joe: Some of the benefits of remaining independent, if there was a provider out there who was thinking, "Am I gonna stay independent? Am I going to sell the practice?" What advice would you have for staying independent?
Dr. Harman: Well, we're dedicatedly independent. And in primary care, I can speak to that probably the best, we see our colleagues unfortunately in other situations and as employed physicians which again a lot of us had been employed physicians and you're just at the whim of whatever the hospital values you.
At many times they will come and say, well, you know, we don't think you're pulling your weight here, we need to know that you're actually doing a great job. You're doing a lot of this work and you're not getting compensated for. And that can lead to being, you know, very disheartened, very disgruntled. We enjoy the work we do, we feel like we have control and ownership of it.
And now with the new payment models, we're actually getting compensated for doing these things that if you're in an employed physician, you're probably not going to get compensated for. Its amazing how extra money that comes into a huge organization never seems to make it down to primary care. But in our group, you know, it's not that way. And I think as a primary care physician in particular, you will have the ability to do better in this new model of payment.
And I think as a specialist, the time is coming that we share savings programs, we will have a lot more partnership and even the specialists will, you know, probably do just as well, perhaps even better with having a different model of care where it's mostly been now procedure-based where they make so much money and now it'll be more selectively.
Unfortunately, there are incentives sometimes to do procedures where maybe they're not needed or maybe if you used a different device, a cheaper but of higher quality device, that would be better and those are the kinds of things we're gonna be looking at. So we're gonna partner with high-quality specialists and they're going to make money from working with us on that. So I think it's, you know, I like being independent, I think most doctors really do. That's what we went to medical school was to deliver care the way we thought it was best delivered to help the patient the best.
Joe: And what advice do you have for providers who may be considering a new practice model such as an ACO or IPA?
Dr. Harman: Well, I think we, in our experience with physician-run ACOs, we feel like that's the best model. Again, with the hospital ACOs, I think there are obviously some very successful ones, but in general, the physician-led ACOs were probably more successful. And so if you, if you're really wanting to be in one of those, you might want to look at the physicians and try to partner in their area, the groups in your area and trying to partner with them, bring on them.
And of course, the more patients you have, the easier it is to be successful. So partnering, something we weren't in the habit of doing before we started doing this, has become a really important issue for us. And we made friends with some of our prior rivals to get together to work on population health, and it's been pretty amazing the change that's occurred in that way.
Joe: So we've talked about the new, you know, home-service launched in 2018 what's now looking ahead at this year, and you know, in the final eight months of the year, hard to believe it's approaching May already, but what's in store for the practice for 2019?
Dr. Harman: Well, there are always challenges and we try to meet them head on best we can. We are trying to expand to be able to have a bigger patient footprint so that we can have more cloud with negotiations and in our region. And there has been a big merger in our health market that's happening all across the country.
So to remain independent, you have to have at least a little size or at least partner with other groups. And we also are entering into CIN, clinically integrated network with another big group that is also high-quality, low-cost. And that will even give us a little bit more cloud. But it's just kind of being able to stay relevant so that you can help your patients.
We're also looking at adding a new program on behavioral health which we think impacts a lot of emergency room visits and then thereby hospitalization. So, you know, we have to meet the metrics of all the shared savings plans we have. And those are sort of requirements. But you know, then we want to look outside the box and say, "Okay, you guys are making us do this, but what's the most clinically relevant things that we can do on our own to improve care and also lower cost?"
Joe: Well, Dr. Harman, thank you for joining me on this episode of "Putting Possibility Into Practice." I appreciate your time.
Dr. Harman: Well, thank you. I appreciate.
Joe: And we wish everybody back at the practice all the best for continued growth as we continue along in 2019 and might be catching up on some of the topics that we had talked about maybe on a future episode.
Dr. Harman: That sounds good.
Joe: Thank you so much.
Dr. Harman: Thanks.
Joe: Once again, that's Dr. Eric Harman, he is with Mountain Region Family Medicine. We thank him for taking this time as we talk about staying independent and whether or not it is right for your practice. For more information on the product solutions that can help with population health and your practice, we invite you to visit our website www.greenwayhealth.com.
And a reminder, as I mentioned earlier, if you have not yet subscribed to our podcast, you can do so on your platform of choice, you'll get notifications each week when new episodes are uploaded. We are on Apple iTunes, Google Play Podcasts, Stitcher FM radio. We are also on Spotify, Libsyn, SoundCloud, TuneIn Radio, and iHeartRadio plus look for more platforms coming soon.
Once again, Dr. Eric Harman talking about physician independence and we thank him for his time today. I'm Joe Agostinelli, the social media manager at greenway health. And this has been another episode of our "Putting Possibility Into Practice." Thanks for listening.