Re: Walmart Health: Just had a great dental visit this morning, which was preceded by helpful reminders from Epic, and…
John Jacobsen, MD is CMO of Think Whole Person Healthcare in Omaha.
Tell me about yourself and the organization.
I am a board certified family physician. I was a rural banker for 10-plus years before returning to medical school. Prior to joining Think, I was in private practice in rural Nebraska for 10-plus years providing full scope family practice including obstetrics, C-sections, upper and lower endoscopies, minor surgical procedures, ER, and hospital and nursing home work. We provided care from the womb to the grave.
TWPH is a large primary care center focused on patients 55 or older with two or more chronic diseases, which is the highest cost segment of American healthcare. Our goal is to provide 90-plus percent of a patient’s healthcare under one roof in a patient-centered medical home, eliminating the fragmentation that exists today. At the present time, we have 24 PCPs, a palliative care physician, a hospitalist, four physical therapists, a podiatrist, a dentist, a psychiatric APRN, and an optometrist. We have 12 clinical pharmacists who work directly with the physicians and their patients. On our first floor, we have a convenience care clinic for walk-in appointments. We have two digital X-ray suites, a 64-slice CT scanner, 3-D mammography, ultrasound, and a bone density machine. Ninety-five percent of labs ordered are done in our moderately complex lab. In addition, we have three chronic care nurses who are just starting chronic care management. Lastly, we have a fully robotic pharmacy on site as well as a retail area.
I left private practice to join TWPH as I believe primary care is the only segment of the healthcare industry that can truly attain the Triple Aim of improving patient satisfaction, improving patient outcomes over time, and lowering cost. Today, in American healthcare, there are really three players – the healthcare systems, the payers (CMS and commercial insurance), and independent physicians. If you look at how each of these segments attain the Triple Aim, primary care is the only one positioned to do so. Let me explain.
The payers, CMS or an insurance company, can only affect cost. They are unable to improve patient outcomes over time and they cannot improve the patient experience as they are not directly involved in providing medical care. To lower cost, they will require things like pre-authorizations for high-cost medications or procedures, which is a form of rationing.
The healthcare systems argue they can attain the Triple Aim because they are able to control cost better by having vertical integration; however, recent studies have shown the costs actually rise because you eliminate the small amount of competition that does exist in a community when this happens. All the healthcare systems in Omaha have purchased independent primary care offices. They require their PCPs to refer to their specialty services, use their diagnostic services, and admit to their facilities, which leads to not only higher costs but also increased fragmentation for the patient or their caregiver, as these specialists are scattered throughout the community.
What has been found is that PCPs in healthcare systems are disengaged, primarily for two reasons. First, in our current fee-for-service marketplace, the physician has to see a patient every 10 to 15 minutes in order to make a reasonable living. This does not give them the time to listen intently to what the patient is saying nor ask pertinent questions outside the specific symptoms being presented. Secondly, the physicians providing patient care are not the ones making decisions about how this care is given. Most are not involved in evidence-based pathway development, in the selection of the EHR they have to use day to day, or in the structure or management of the employees within their clinic. Essentially, they are ‘told’ what to do and how to do it. Physician disengagement leads to a poorer patient experience and usually poorer outcomes and in turn leads to the patient disengagement. In addition, the costs of imaging or surgical procedures are three to five times higher in a hospital than in free-standing imaging centers or ambulatory surgical centers.
The TWPH model’s initial focus is on the patient experience. We feel that if the patient, which we would rather call our customer, has a good experience, they are more likely to become engaged in their healthcare. It is important to understand patients with chronic disease provide most of their care themselves or through a family caregiver. For example, if the customer comes to the clinic for their diabetes exam, they can have their lab drawn before the appointment so the results can be discussed with them by their physician during their appointment. If they are on multiple meds, the provider can have them visit with a clinical pharmacist who can make sure there are no drug-drug interactions, side effects keeping the individual from taking their medications, and make sure the person can afford the medications prescribed. The customer can get their immunizations, see the podiatrist for their diabetic foot exam, have their diabetic eye exam done and see the dentist all in the same day. If the customer is a female, they could also have their mammography and bone density scan completed as well. If the person is newly diagnosed, diabetic education classes will be provided on site.
We also have a full teaching kitchen available for them to work with a dietician or nutritionist on how to change their diet and cooking habits. With increased patient engagement, you will naturally see improved disease outcomes leading to fewer procedures, fewer ER visits, and fewer hospitalizations. We also have a robotic pharmacy on site which can dispense meds in vials, but also in what we call “pouch packaging.” The clinical pharmacists work hard to synchronize all medications a person gets to come due on the same day of the month to eliminate the customer going to the pharmacy multiple times a month to get refills. Total cost of care for the customer will come down, without ever denying care.
Where is TWPH with Meaningful Use?
Being a startup, we had physicians join TWPH from independent practices as well as hospital systems. These physicians were at different stages of MU before we opened the doors, some having qualified each year where others had not met any of the MU criteria. We have filed for a hardship for 2016 due to the requirements not being published in time for us to meet them.
What EHR and patient portal vendor do you use?
We use Allscripts Professional as our EHR. Allscripts uses a portal called Follow My Health.
Are you working on any other healthcare IT implementations? If so, what timelines have been established? One of our biggest projects at the current time is electronically connecting to other providers in the Omaha community. We are doing this through NeHII, a HIE; however, many practices and facilities do not subscribe to NeHII. We are therefore trying to link directly to these providers and facilities via the direct messaging capability of the EHR. We are also working with a company called Vatica,that has developed a program to simplify the Medicare annual wellness visit in an effort to improve the care of our Medicare beneficiaries. Being an ACO, we are also looking at data analytics, disease registries, etc.
What coordinated care initiatives are currently underway?
As of January 1, we are a MSSP ACO and are awaiting our CMS claims data, which we will begin to analyze. We also have a Total Cost of Care agreement that went into effect on January 1 with Blue Cross Blue Shield Nebraska. We are analyzing the claims data to identify the high-cost users in addition to the gaps in care these patients are experiencing.
We are piloting, with a limited number of our providers, moving patients into CCM using the required annual wellness visit or extended evaluation and management visit. We feel CMS, with the development of CPT 99490, is providing us the opportunity to offer to our customers a broader base of services we could otherwise not afford to provide without this monthly reimbursement. Our model is the epitome of the PCMH concept.
Aside from EHRs, what types of technologies do TWPH physicians use when they interact with patients? Anything particularly “new” like wearables or telemedicine?
Being a startup, we have not implemented wearables or telemedicine. This is on the horizon for 2017. Most of our physicians use scribes. Depending on the provider, the scribe may be in the room with the provider and the customer, or they may be what we call angel scribes, where they are connected to their provider via an encrypted communication line on another floor in the building. They document the visit in real-time. This allows the physician to focus on the customer instead of focusing on the computer in the room. Each of our exam rooms has a big screen TV. The scribe can display lab results or X-ray images on the TV screen, allowing the physician to review them with the customer during the office visit. We soon will be projecting educational videos on these screens..
Are you looking to expand into other states?
The TWPH model is an experiment. To our knowledge, our clinic is the only one of its size and scale in the US that is trying to change not only the culture as to how medicine should be provided within the clinic walls but also trying to change the patient perspective that primary care can provide the bulk of their care within our four walls. Our initial plans are to open two to three more facilities in Omaha and one in Lincoln. Expansion to other states is also on the horizon.
How receptive have patients been to your progressive brand of primary care?
For the most part, our patients, or more often their caregivers, understand and believe in what we are trying to achieve. It has been interesting as some customers feel seeing three, four or five specialists is an honor instead of realizing that having their health deteriorate to the point of needing to see a specialist is a failure of the current healthcare system. We want to instill the belief, not only in our customers but also in all Think providers/employees, that if a person ends up in the ER or in the hospital, we have failed them as their PCP.
We have had many patients comment to their physician regarding the scribes that, “This is the first time you have listened to me in years,” or “I don’t feel like I am competing with your computer for your attention when I come in to see you.”
Our clinical pharmacist share stories weekly about patients who are confused about their medications and are taking them inappropriately. We have had many customers who were not able to afford their medications until the clinical pharmacist reviewed and found out they were all name brand meds with no generics. Pouch packaging and the synchronization of medications has also been well received.
Do you have any final thoughts?
I truly believe our model of treating the whole person is the only way to change how healthcare is delivered in America. By putting the customer first, always trying to improve their experience will improve their engagement in their own healthcare, which over time will lead to lower costs for all. By providing this care in a large-scale primary care center with multiple medical providers present under one roof you, decrease the fragmentation of the way healthcare is currently provided and is, in my opinion, the future of healthcare in America.