Northwest primary care medicine: Curing what ails us
At the center of fixing the Northwest's medical mess, primary care becomes the patient
ABOUT 25 MINUTES into his appointment with Dr. Harry Shriver at Group Health's Factoria clinic, Grover Williams, who has diabetes, casually mentions the tingling in his feet — an ominous symptom.
In the typical 10-minute doctor visit these days, Williams likely would have been out the door before getting around to his tingling feet, and a serious warning sign would have gone undetected.
Williams, 72, was lucky. Although he didn't know it at the time, he was the beneficiary of one of a handful of local projects aimed at radically reforming how front-line doctors care for patients.
These are the brave new experiments, the out-on-a-limb efforts to provide a model to reinvent and — their proponents hope — resuscitate primary care, the care most patients need most often.
Ideally, family doctors and other primary-care providers keep patients healthier — and save money — by managing patients' chronic diseases such as diabetes or high blood pressure and coordinating care by specialists who divvy up each patient into single body parts.
But most primary-care doctors, paid only for office visits and procedures, don't have time. Many talk about their daily life as though they're hamsters: "running faster," "never caught up."
"You're always feeling like you have your finger in the dike," says Dr. Suzanne Spencer, the recently retired chief of Group Health's Factoria clinic. "You feel you're overwhelmed, fearful you're going to overlook something."
Dr. Michael Tuggy, director of the family medicine residency program at Swedish Medical Center/First Hill, says: "Every primary-care doctor knows we have to omit and skip incredibly important parts of patient care, primarily around prevention and education."
Like patients everywhere, you know what it's come to: Long waits to be seen, shrinking appointments, and good luck on evenings and weekends. Most important, you sense that nobody is really paying attention.
"It was always like (the doctor) was on a stopwatch or something," says Jeff Poppe, 58, who started seeing Group Health doctors in 1998. "It was like he was, 'OK, why are you here? Answer my questions.' "
Report after report warns that a primary-care shortage looms — here and everywhere. A bazillion baby boomers with complex chronic diseases are lumbering into geezerhood, burned-out primary-care docs are making fast tracks toward retirement, and increasing numbers of debt-laden medical-school graduates are shunning primary care for the better-paid, more likable lifestyles of specialty practices.
If nothing is done, says Dr. Roger Rosenblatt of the University of Washington Department of Family Medicine, the primary-care system will collapse, and with it, the whole health-care industry — maybe the whole economy.
That creative ideas for fixing this mess would sprout in the Pacific Northwest isn't surprising.
The UW School of Medicine's primary-care training has been rated best in the nation for nearly two decades, and its renowned program sends primary-care medical students and residents to train and work in rural clinics around a five-state area. Group Health Cooperative wrote the book for consumer-governed health-maintenance organizations and the focus on prevention. And Seattle spawned the first "concierge" retainer-fee primary-care practices in the nation.
These are not the only experiments going on around the country, or even in the Northwest, as much political attention shifts to remaking health care.
But each of these potential models is uniquely powerful. Each aims to restructure primary-care delivery and financing, emphasizing a team approach to preventing disease, coordinating care, giving patients access and improving quality — not volume. Significantly downplayed or eliminated is the traditional fee-for-service model.
President-elect Barack Obama has the lingo: "medical home," "patient-centered care." Now he's taking over the wheel. But which way to turn?
Advice: Take a look out West.
GROUP HEALTH'S "Medical Home Model" pilot project, which began in early 2007, was what allowed — even encouraged — Williams' doctor to spend so much time with him.
To some, the project may seem too obvious, too subtle, too incremental to have earned the excitement it's generated among those involved. After all, these doctors haven't invented the cure for cancer. All they've done is treat whole patients — coordinate their care, deal with issues before they become emergencies, and focus on prevention and healthful lifestyles to stave off illness.
But here's the big deal: They spent more time with patients, but they didn't spend more money — a feat that convinced Group Health to begin rolling out the new system to all its clinics, and to submit the pilot's results to a major medical journal for publication.
Before the pilot began, Spencer often saw two dozen patients a day, many with complex problems. Appointments were double-booked, and doctors were always behind. "All day long it would be frenetic, all out of control; then afterward, you'd chart on everybody and do phone calls," Spencer recalls.
One night, "I was sitting in my office at about 8 p.m., thinking: 'I'm not sure I can do this anymore.' "
For a clinic, losing a doctor is expensive. Group Health figures it costs about $287,000 to recruit and select a new one.
Drive-through visits were also costing the insurer money when patients with uncontrolled health issues ended up in the hospital.
Taking a leap of faith, Group Health funded a two-year pilot at Factoria. There, each patient was matched with a team that included a doctor, a medical assistant, a physician assistant, a nurse and a pharmacist. Their job was to deal with immediate health issues but also zero in on "lifestyle" issues like weight and smoking, and, if necessary, guide the patient through specialty care. Team members relied on electronic medical records, and used phone and e-mail to communicate with patients when it made more sense.
For Grover Williams, the new model meant Shriver had time to talk to him about getting better control of his blood sugar, a back-and-forth conversation over months.
Group Health realized early on that the experiment would require hiring more doctors, but they bet on saving money as emergency visits and hospitalization declined.
That's exactly what happened, along with a significant improvement in staff satisfaction.
Spencer put off retirement for many months. Now semiretired at 63, she's sold on the model. So is Dr. Eric Seaver, who joined Group Health two years ago after seven years in primary care in California.
"It had lost all its pleasure," says Seaver, 41, who had been thinking about leaving primary care. "I wasn't given the time or the opportunity to provide the right level of care without a huge sacrifice on my part."
At Factoria, "I get up in the morning looking forward to work. I enjoy seeing my patients . . . and I can actually see myself practicing primary care for a long time in this type of environment."
Poppe, now one of Seaver's patients, compares the old with the new as night and day. "The way he's interacted with me has enhanced my quality of life."
IN A REMODELED office in the Medical Dental Building in downtown Seattle, Qliance Medical Group is betting that its retainer-fee model is what saves primary care.
At $39 to $129 a month, depending on patient age and services, Qliance fees are a fraction of some high-end concierge practices — a term Qliance's leaders don't like. They believe their model will benefit not only individuals with spare cash but small businesses and low-income patients, and hope to expand to satellite clinics. By eliminating insurance, "we save over 40 cents of each dollar spent on primary care," CEO Norm Wu claims. They've also been able to invest in an electronic medical-records system and sophisticated lab equipment.
For the fee, patients get all the primary care the clinic offers, including X-rays and basic lab tests, and quick access, including e-mail, to doctors. The clinic is open weekends and evenings, and each doctor will carry 500 to 800 patients, compared to the typical 2,500 to 3,000.
In 2007, Qliance's founder, Dr. Garrison Bliss, and his cousin, Dr. Erika Bliss, helped put such retainer-fee practices on solid legal ground in Washington by convincing wary lawmakers that lower-cost retainer practices could be an innovative, affordable option, and shouldn't be burdened with cumbersome insurance regulations.
One large investor, Second Avenue Partners' Nick Hanauer, says: "What I think health-care reform in America looks like is the Bliss model."
Matt White, a 31-year-old Amazon employee, followed Dr. Lili Sacks to Qliance from a large Seattle multispecialty practice. To make it work financially, he and his wife switched their full insurance coverage from Amazon to a high-deductible plan and added a health-reimbursement account, a fund he can use tax-free for health expenses.
Financially, he says, it's now a wash. But comparing the care with his earlier experience, he says: "It's a massive quality difference."
Sandria Woods-Pollard, a 61-year-old city worker who is Dr. Susan Casabona's patient at Qliance, remembers when doctors made house calls.
With Qliance and Casabona, she says, "I feel like we're getting back to that."
When she recently had severe back pain on a weekend, she got in quickly. Casabona helps her keep close track of her diabetes, high blood pressure and medications.
"I want somebody to pay attention as I get older," Woods-Pollard says. "For me, this is a godsend."
IN THE AUDITORIUM at Swedish Medical Center, Dr. Jay Fathi is talking with the fervor of the evangelist he is. The doctors in the audience, members of the King County Academy of Family Physicians, have wolfed down boxed sandwiches after long workdays, eager to hear about "innovations in primary care."
Even before all the reimbursement details were pinned down, Swedish began planning to remodel a floor in its Ballard hospital for its Primary Care Pilot Project, betting that insurers will see the clear blue logic in its plan.
Swedish expects to open the clinic later this year with a radically different model: per-patient payments from insurers expected to range between $37 and $83 per month.
In this clinic, doctors would no longer be paid by the visit or by the procedure — the "treadmill" that Fathi believes is pushing doctors out of primary care, patients into emergency rooms and costs of health care skyward.
"As long as volume is the driver, that's not going to lead to good outcomes," says Fathi, Swedish's medical director for Primary Care and Community Health.
The Swedish clinic — the first in the nation to be built from the ground up for this new model, Fathi says — would care for about 2,000 patients, a mix of people with private insurance, Medicaid or Medicare, and some who are uninsured. At this "medical home," providers would emphasize quick access, prevention and coordination of care. Those who don't get that, Fathi says, end up in the ER anyway. He recalls a 28-year-old single dad, diabetic and uninsured, who recently ended up in intensive care because he couldn't get in to see a doctor.
Rich Maturi, a senior vice president for Premera Blue Cross, one of the region's largest insurers, says Premera is on board. "We think that the fee-for-service system is a big part of the problem," he says.
Dumping it would free clinics to hire chronic-disease managers or nutritionists instead of billing clerks and to use electronic records to improve treatment instead of create invoices. If the experiment at Swedish works, it could be a model for melding the retainer-fee primary-care approach with the larger world of insurance.
"It's a small pilot but it's doing all the big things," says Gina Jesberg of IBM's Global Healthcare and Life Sciences division, which is helping Swedish build its systems. "They are a micro example of a best-case scenario."
EVERYTHING IN health care is complicated. Like the children's teaching verse, the patient bone's connected to the insurance bone, and the insurance bone's connected to the employer bone. Then there is the tax bone, the medical-education-payment bone, and the politics bone.
Last year, the Legislature authorized plans for several "medical home" pilots to begin later this year, though the state's budget troubles may prove troublesome.
The three models detailed here have the advantage of a head start, but each has potential shortcomings.
Not everyone can afford a Qliance-type retainer model. It doesn't cover mammograms, MRIs or expensive drugs. Some worry it could encourage patients to drop insurance.
The Group Health pilot reaped financial savings because it's a self-contained system providing both insurance and health care. But in a fragmented system, savings at clinics and hospitals don't necessarily help insurers or employers who pay the premiums.
And although the Swedish model aims to bring the fragments together, key will be whether insurers and employers see financial benefit.
For most of us, it's a no-brainer that we'd be pleased with faster access, a health team that pays attention and, very likely, better health.
Grover Williams drives down from Everett to Factoria to see Shriver, who is now clinic chief, and says: "It's worth it when you have a good doctor." When something serious is going on, Shriver spends a lot of time talking to him, often by phone.
Now, Williams is exercising, has started a diet and is taking insulin. His blood sugar is under much better control, and he feels encouraged.
There's much disagreement among health-care pundits about what would best cure health care's ills. But no one quarrels with the sentiment expressed by Fathi at Swedish: "What we're doing now is not sustainable. It's going to implode."
Carol M. Ostrom is a Pacific Northwest magazine staff writer. Mike Siegel is a Seattle Times staff photographer.
Copyright © 2009 The Seattle Times Company
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