By far Baptist employs more primary care physicians (PCP) than any other hospital in the city. They form the largest medical group in Alabama with about 65 PCPs in about 12 locations.
But other hospitals have begun to delve into primary care more readily in the last few years. Brookwood Medical Center bought three primary care practices in the metro area last year and one the year before, each with one or two physicians.
St. Vincent’s took another route and built and staffed four of their own primary care clinics in the area. They’re about to hire their sixth doctor.
This push by hospitals to accrue primary care practices and physicians harkens back to the same trend in the 80’s and 90’s. But this time, both parties are wiser.
“It didn’t work back then,” says Nan Priest, Chief Strategy Officer for St. Vincent’s Health System. “But this time, it is the government doing it and not the private sector, and that makes a difference.”
Sheila McKenna, Chief Development Officer with Brookwood Medical Center, says bias on both sides killed partnerships in the past. “Back then it was very much toward the physicians and untenable for hospitals. I’ve seen the opposite too. And neither one lasts.”
For hospitals, the fixed salaries were the bane of those partnerships. “When they were put on salaries, physicians became less invested and wanted to see fewer patients a day, which they hadn’t done in their own practices,” Fenn says. So hospitals abandoned the relationships.
Now all three health systems hire primary care physicians under a productivity contract. “Your revenue minus your expenses equals what you take home. That way the doctor is incentivized to see as many patients as they want to see,” Fenn says.
“Contracts need to be as much like an independent practice as possible but still put up guardrails for both sides,” Brookwood’s McKenna says. “We give them the tools and let them move forward. We don’t tell them how to treat patients at all.”
The hospitals’ motivation to seek more PCPs stems from the Affordable Care Act changes, many of which have yet to be defined. But all agree that having primary care physicians as part of their services both prepares them for possible future changes toward bundling services and medical homes and also serves their patients and bottom lines.
“Primary care physicians are where all the activity goes on with patient relations and a tremendous amount of referral to specialists and hospitals,” Fenn says.
For St. Vincent’s, starting their own clinics was about filling in the service gaps. “We realized that there were a few geographical locations in our area where our patients didn’t have ease of access for primary care,” Priest says, adding that about 30 percent of their ED patients don’t have PCPs. “We recognize that people expect certain services closer to home. We respect that. So we help fill in those gaps.”
“We’re looking at this as an opportunity to fill a need for the community and continue to expand our footprint,” McKenna says.
The hospitals also recognize how difficult it is for small practices to recruit additional physicians with the looming healthcare uncertainties and to keep up with technology, such as electronic medical records. “Those are two of the major things we’ve seen that hospitals can provide in these partnerships,” McKenna says.
All three hospitals have stepped up their recruitment of PCPs in the last few years. “It’s more competitive,” Fenn says. “You can’t wait around anymore, because even though St. Vincent’s and Brookwood are just getting into employment of primary care physicians, Atlanta and Mississippi and Florida have been working hard at it.”
But as hospitals prove they can efficiently take over inventory management, billing, government-required standards reporting, and endless coding and electronic records changes, physicians may see the advantages of tighter partnerships and releasing operations management.
“Doctors in our state really feel strongly about autonomy so they feel like it’s important to maintain their own livelihood,” Fenn says. “They do partner with hospitals, but don’t go to the next level in employment and allow hospitals to manage the practice for them.”
But becoming part of a larger health system has its benefits, they all say. “In addition to the financial advantage is the shared knowledge,” Priest says.
For instance, St. Vincent’s participated in an Institute for Healthcare Improvement (IHI) study on ventilator-dependent pneumonia patients. “IHI came out with seven things you can do in order to prevent patients from developing pneumonia that had significant, immediate results. We shared that with everybody in our system,” Priest says. “Doctors love to work with organizations that focus on clinical outcomes.”
“The future is going to be how you reduce the cost of care, and that’s largely built on internal medicine that deals with chronic conditions,” Fenn says. “Primary care physicians are the hub of where patient care begins and, after any acute episode, comes back again.”