John Farley, MD, has been an internal medicine physician for 23 years and has seen the fee-for-service concept of primary care become akin to running on a treadmill. Over the past several years, he has transformed his practice, Birmingham Internal Medicine Associates (BIMA) into one of patient management instead of focusing on how many patients can be seen in a day.
"My goal is to restore the physician-patient relationship to one of trust and communication. It will be based on managing care 24/7 and moving away from the transactional fee-for-service model," Farley says. "The fee-for-service model rewards physicians for volume, not for quality of patient care. As a result, we fill up our schedules every day to generate revenue which results in shorter visits and difficulty for sick patients to get timely care. They end up seeking care from more expensive providers such as urgent care clinics and emergency rooms."
Innovation is coming, but the change is being led by entrepreneurs instead of doctors. "Well-intentioned laws like the Stark laws and HIPAA are innovation killers," Farley says. "They make it hard for doctors to develop innovative care models without breaking these laws."
Farley has a vision for building a better primary care delivery model and has begun to implement those ideas into his practice. "First, we need to kill the idea of the doctor visit," he says. "Currently, it is how we are paid, but it is the root of all evil. We need to change the model from one of episodic sick care with the occasional physical to a patient management model."
Under such a model, insurance companies would pay physicians a monthly fee to manage patients' care 24/7. The fee would be based on patient age and the degree of his medical problems. The fee would be adjusted for hitting or missing quality and cost parameters.
Physicians would still be incentivized to work hard because the larger the panel of patients, the more revenue would be generated. "In this team-based model led by a physician, nurses and nurse practitioners would see patients with simple illnesses like sinus infections and urinary tract infections. The doctor would review their work and be available to consult on complicated cases. In our practice, RNs and nurse practitioners see most of our patients which allows me to treat the sickest ones," Farley says. "They would be seen the same day which should reduce emergency room visits and hospitalizations."
Over the years, Farley and his staff have worked to bring about transition at BIMA with the goal of improving the care they provide. Their first major change was the adoption of an electronic medical records system over 10 years ago, prior to it being required by the government.
"We also pushed a patient portal long before it was in style. We now have more than 70 percent of our patients using our portal to get test results and to schedule appointments," he says. "This has cut down on our number of incoming and outgoing phone calls. The portal eliminates the middle man as well as any delay and the potential for medical errors."
Electronic appointments and online appointment scheduling are also available, and a virtual office visit program allows patients who have been seen in the office in the past year to go online and be treated, for a small fee, for simple problems without an office visit. "We also started a case management and quality department that allows nurses to follow up on our hospitalized patients and schedule appointments at our clinic within seven days of discharge," Farley says. "Data shows that such follow up has decreased readmissions to the hospital within 30 days of discharge."
BIMA has also opened a daily walk-in clinic every morning from 7:30 to 9:00 a.m. Patients can come to the clinic during that time without calling. "The walk-in clinic has significantly decreased urgent care and emergency room visits as well as middle-of-the-night calls to the physician," Farley says. "Patients don't mind waiting if they know they can be seen the next morning."
These changes at BIMA have been positively received by patients. "Everything we've done is tied to our goal of providing more convenience for patients, increasing quality, and lowering cost. When we come across high-cost providers for testing, we switch to providers who provide services at a lower cost because many patients have high deductibles and increased out-of-pocket expenses," Farley says. "We have attracted tens of thousands of new patients and are adding one to two physicians a year."
BIMA has partnered with St. Vincent's Health System which also is looking at the utilization model. "We have learned a lot from Ascension Health Care, the parent company of St. Vincent's, and I'm excited about what they are doing. I believe the old system is backwards and I can't stay on that treadmill. I want to change from a sick care system to a well care system, really bend the model and solve the primary care shortage. I want to offer better customer service to our patients at the right place, the right time, and at the right cost," Farley says. "Our business plan focuses on quality. If we focus on that, everything else will take care of itself."