As an organization, Pioneer Physicians Network believes that the center of healthcare should revolve around the patient and their primary care physician trying to quarterback that care. Dr. Victoria DiGennaro, CEO and family physician at Pioneer Physicians Network, said that emphasis has allowed the clinical team to provide excellent patient outcomes.
“It has also allowed us to maintain a better quality of life and lower burnout for our physicians, which is a huge issue in medicine right now, and it has allowed us to remain independent,” she said. “We like to say we’re fiercely independent, which has been nice in the current landscape, especially with some of the major health systems that surround us.”
Currently, the organization has about 60 primary care physicians (PCPs) with an additional 30 nurse practitioners (NPs) serving 22,000 patients within three counties in Ohio. Pioneer’s clinicians do everything for the patient. They are responsible for their total cost of care in terms of pharmacy, hospital spend, ER spend, surgeries, etc.
Pioneer has “countless” patient stories and successes of how they’re providing better care for patients in this model, Dr. DiGennaro said. For instance, recently one patient came in for a routine bloodwork follow up. The patient was distraught and emotional during her visit. She kept talking about her computer. In traditional fee-for-service, the PCP would have 10 to 15 minutes to go through the visit and move on, but because Pioneer is doing comprehensive care, the PCP took a step back and talked to her. The clinician figured out she was having some kind of issue logging into her computer at home, and that was distressing her.
The PCP called the nurse care manager and asked her to go check on the patient at home. The nurse manager went out the same day as the office visit, and helped get the patient back into her computer. The nurse manager called the PCP back to indicate more was going on than a simple computer problem.
“So we brought the patient in, did testing, and it turned out she had early dementia,” Dr. DiGennaro said. “We were able to diagnose her, get her on appropriate treatment, provide resources at home, and prevented a bad outcome. This is a patient who in the fee-for-service world would’ve just been overlooked and literally could have crashed into care down the line because of her mental health issues. So much of the care happens outside of the exam room.”
Another benefit of Pioneer’s approach is that it has access to comprehensive data on specialists and uses it to determine the best place to send a patient. Pioneer uses that data to tier the specialists based on quality and cost.
“That helps our PCPs guide the patient to the right specialist,” Dr. DiGennaro said.
In another example, an elderly patient with several comorbidities came in for neck pain. When the PCP got the X-ray of her neck, it was determined she had broken her dens, which is the bone you break when you hang yourself. “Again, in a fee-for-service world, I would’ve just sent her to the ER, and she probably would’ve had expensive surgery and bad outcomes. But because I had the specialist data, I called up one of the tier one orthopedic spine doctors.” The orthopedic doctor saw her the next day and determined she was not a surgical candidate based on all her other comorbidities. Instead, she received a much less invasive approach to care through a neck brace, pain control medications, and physical therapy. “The woman lived another year very happily and comfortably, and didn’t have to go through a procedure that could have actually caused her passing,” Dr. DiGennaro said.
A team effort
The better Pioneer does clinically, the more they have been able to reinvest in the organization. They’ve experienced almost 40% PCP growth since the start of their partnership with agilon.
The clinical investments have extended beyond the PCPs. Pioneer utilizes nurses in several different ways. There are nurses that work within the central care teams and meet, call and do home visits with patients.
Pioneer also has embedded nurses in local emergency rooms. When a Pioneer patient comes to the emergency room, the nurses help coordinate care with the hospital. For instance, if the ER physician needs to talk to the PCP, the nurse will help with connecting the two clinicians. If a patient gets admitted to the hospital, Pioneer nurses follow that care and will help coordinate discharge services and other elements of care with the hospital team. “The goal is to help get the patient to the right level of care.”
Along with PCPs and nurses, Pioneer employs social workers and has access to pharmacy services. There are palliative care, renal care and heart failure programs within the communities that Pioneer serves. “All these different things combine to provide that total level of care to bring the patient in house to where they need to be.”
Taking a risk
In order to approach primary care differently, though, the Ohio-based primary care provider needed to take a different approach to how its physicians were reimbursed. Since 2018, Pioneer has been responsible for the total quality and cost of their patient population in Medicare and Medicare Advantage arrangements.
Pioneer’s principal partner in the full risk model is agilon, a company that provides technology, people, capital, process and access to a peer network of more than 3,000 PCPs who are delivering care to more than 700,000 patients. agilon’s platform helps independent physicians to improve care for Medicare members and participate in the benefits of improving health outcomes. “As the platform of physicians and members scales up and quality grows, so do the potential cost savings from improving care,” the company states on its website. agilon shares in the outcome with its physician groups in a long-term partnership model.
By partnering with agilon, physician practices make a joint commitment to transform health care delivery by shifting to a value-based Total Care Model for their Medicare patients that improves outcomes and lowers cost. Established in 2016, agilon has expertise in full-risk, value-based care for Medicare Advantage and Fee-for-Service innovation models. Currently, more than 30 physician groups and health systems are in long-term partnerships with agilon and have transitioned to full-risk for their Medicare patients through agilon’s technology-enabled platform.
Pioneer chose agilon for a couple reasons, Dr. DiGennaro said. First, it’s a true partnership model in that Pioneer is able to maintain its independence. Second, Pioneer clinicians were intrigued with the idea of being fully responsible for the care of its patients. “What’s interesting about the healthcare space is there’s so much waste in the system,” she said. “When you break it down, it’s something like 8% of that spend is primary care. Yet, if you invest in primary care, you can decrease the spend, admissions and morbidity/mortality that happen to patients outside down the road.”
Incentives must align
When it comes to primary care in the United States, healthcare stakeholders – including payers, providers, and the government – all seem to agree that there needs to be more access to it and more clinicians providing it.
“Obviously, everybody wants more primary care, but what are they really doing about it?” asks Thomas Campanella, a healthcare consultant and former Healthcare Executive in Residence at Baldwin Wallace University.
Judging by the fact that the number of primary care physicians continues to dwindle, stakeholders aren’t doing nearly enough. Fewer students in medical school are choosing primary care because of a combination of higher educational debt and more potential earnings in specialty roles. “When students look at primary care versus some specialties, the compensation could be two, three, four times higher in those other specialties,” Campanella said.
Linked to the workforce shortage is that the number of independent providers – traditionally made up of family doctors – also continues to shrink. The days of the small, one-to-two-person primary care family medicine practice are fading away. Health systems, retailers, insurers and even private equity organizations have gobbled up most of the market share over the last two decades.
For primary care to work well, clinicians need to spend time with patients, getting to know them, and trying to find ways to keep them healthy, not just going through the motions and handing them off to a specialist.
But the incentives need to align, and in a predominantly fee-for-service world, thus far they haven’t. Campanella said there are gains to be had in more realistic reimbursement models. Payers and providers can try something more risk and valued based, he said. In this approach, there is a little bit of upside and downside as it relates to providing the appropriate value, and/or some form of capitation, which is providing the providers X number of dollars per member/per month to take care of the individual.
“A way those providers then would make money is keeping them healthy; in other words, you’ve got to change the paradigm from payment systems that focus on escalating healthcare costs – the more you do, the more you make – to payment systems where you are actually more financially successful if you can keep people healthy.”
That ideal is not as far off as one may think. Pioneer is a case in point. And in several states, other independent primary care practices are acquiring smaller, independent, primary care practices to compete with larger health systems and private equity organizations. Payers are keen to go into full risk with them via Medicare Advantage Plans because of the prospect of an independent primary care physician overseeing the patient’s care.
“Primary care is calling the shots on the health of the patient,” Campanella said. “They’re looking at the person from a holistic standpoint, and ultimately are in the best position to provide that care.”
Data has shown that independent primary care providers are much more focused on keeping patients healthy and not issuing referrals for specialists or tests that are unnecessary, Campanella said. The independent physicians direct care – when needed – to the best providers, no matter which organization they happen to be at. “That could be independent providers. That could be in different hospital systems. That could be outside the region, because they have that form of independence … It’s a win for the Medicare Advantage Plan, and it’s fuel to keep the independent practices going.”
Investing ahead of the outcome
Dr. DiGennaro said there is a lack of knowledge when it comes to what value-based care can look like. “Traditionally, the fee-for-service world has been happening for so long that – especially for those in primary care – you’re just not aware of what else is out there.”
Regulatory challenges with Medicare in the last several years have added to the problem. Compound that with increased medical utilization, and it’s becoming very challenging to break out of the fee-for-service world.
Along with its partnership with agilon, Pioneer participates in the ACO Realizing Equity, Access, and Community Health (ACO REACH) Model through the Centers for Medicare & Medicaid Services (CMS). This federal program provides novel tools and resources for health care providers to work together in an accountable care organization (ACO) to improve the quality of care for people with Traditional Medicare. REACH ACOs are comprised of different types of providers, including primary and specialty care physicians.
To help advance health equity, the ACO REACH Model requires all participating ACOs to have a robust plan describing how they will meet the needs of people with Traditional Medicare in underserved communities and make measurable changes to address health disparities. Additionally, the model uses an innovative payment approach to better support care delivery and coordination for people in underserved communities.
Patients in a REACH ACO get help navigating the health system and managing their conditions, according to CMS. They may have greater access to enhanced benefits, such as telehealth visits, home care after leaving the hospital, and help with co-pays.
Begun in 2022, the program is set to expire in 2026. Dr. DiGennaro has spent a lot of time advocating in Washington, D.C. and with different groups to promote value-based care. Specifically, she and her organization want to see the ACO REACH model or some form of full-risk model continue beyond 2026.
“We need that stability, because all of these things cost a lot of money and resources,” she said. “We have an entire care management system with nurses, social workers, and care managers. We have to invest ahead of the outcome, and if we don’t have the stability knowing that the government is going to continue those programs, it becomes very challenging for smaller, independent groups to maintain that. We must continue to advocate so that we can continue this trend and get more people into the value-based care world.”
Avoiding burnout
For today’s primary care providers there’s much to do for patients. Often too much, when you consider the sheer volume of tasks and information required to provide and coordinate care – portal messages, telephone calls, reviewing labs, documents and specialist notes.
There aren’t enough hours in the day. Indeed, following national recommendation guidelines for preventive, chronic disease and acute care would take a primary care physician 26.7 hours per day to see an average number of patients, according to a recent study conducted by the University of Chicago, Johns Hopkins University, and Imperial College London. That breaks down to 14.1 hours/day for preventive care, 7.2 hours/day for chronic disease care, 2.2 hours/day for acute care, and 3.2 hours/day for documentation and inbox management, researchers noted. “Obviously the math doesn’t work,” said Dr. DiGennaro.
Patient and administrative task volumes are major contributors to the high burnout rate of physicians. Compound that with the projected 60,000 PCP shortage in the next 20 years, an aging population living longer and with more (complex) health issues, and the momentum is shifting in the wrong direction. “If we don’t do something, we’re on the precipice of major problems in our healthcare system going forward,” Dr. DiGennaro warned.
What to focus on
In a LinkedIn blog post on the topic of primary care models that work, Campanella wrote that “it would be short-sighted of payers (both governmental and non-governmental) to attempt to minimize capitated type payment levels to primary care physician practices… You cannot pay too much for primary care physicians to provide value-based care.”
Also, as more successful primary care physician models appear in communities, both federal and state regulators need to require the elimination of non-compete language in employment contracts, he wrote. “Non-competes stifle opportunities for physicians and penalize the patients and our communities.”
Value-based care could help by better aligning compensation for physicians and providing a path for people to remain in medicine, Dr. DiGennaro said. “I think that’s the kind of thing that we need to focus on, because if you think about a traditional PCP, they were seeing 30-plus patients a day running that hamster wheel to survive using fee for service. Whereas if you’re focused on value-based care, you might see half that, with longer appointments and more resources. So it provides you, as the PCP, with more help to take care of the patient and also provide the patient with better outcomes.”
For the patient, provider and payer, it’s a “win-win-win” all around.
Reasons behind shifting ownership model
According to a recent analysis of physician practice arrangements by the American Medical Association (AMA), between 2012 and 2022 the share of physicians working in private practices fell by 13 percentage points from 60.1% to 46.7%. In contrast, the share of physicians working in hospitals as direct employees or contractors increased from 5.6% to 9.6% between 2012 and 2022. The share of physicians working in practices at least partially owned by a hospital or health system increased from 23.4% to 31.3% between 2012 and 2022. In 2022, 4.5% of physicians worked in a practice owned by a private equity group, similar to the percentage in 2020 when the AMA first added private equity to the analysis.
Four of five physicians indicated the need to better negotiate favorable payment rates with payers was a very important or important reason in the sale of their practice to a hospital or health system, AMA said. Next was the need to improve access to costly resources and the need to better manage payers’ regulatory and administrative requirements. Each was flagged by about 70% of physicians as a very important or important reason.
“The AMA analysis shows that the shift away from independent practices is emblematic of the fiscal uncertainty and economic stress many physicians face due to statutory payment cuts in Medicare, rising practice costs, and intrusive administrative burdens,” said AMA President Jesse M. Ehrenfeld, M.D., M.P.H. “Practice viability requires fiscal stability, and the AMA’s Recovery Plan for America’s Physicians is explicit in calling for reform to our Medicare payment system that has failed to keep up with the costs of running a medical practice.”