Organizing outpatient care in order to facilitate success in value-based contracts offers both great opportunity and great challenge; no one knows that better than John Farley, M.D. Dr. Farley, an internal medicine physician who has practiced in Birmingham, Alabama, for nearly 30 years, came to the realization that, in his words, “The fee-for-service model of care is like a treadmill” for primary care physicians, who are struggling to produce the constant level of volume to realize strong margins in a time of high expenses and high patient utilization. Farley led a 17-provider practice in Birmingham until five years ago, when he sold the practice to Complete Health, an organization that manages and finances primary care practices, and which has more than 150 providers, and became Complete Health’s chief medical officer. Based in Jacksonville, Florida, Complete Health manages clinics in Dayton Beach, Florida, Richmond, Virginia, and Birmingham.
As the company’s website explains, “As a physician-driven, patient-centric primary care group, Complete Health separates itself from others by offering services designed to make your life easier, including specialized senior programs. Complete Health focuses on personalized healthcare designed just for you. As a value-based care provider, our team provides health care designed to focus on quality care, provider performance, and patient experience. This results in greater care coordination across specialists and hospitals and a patient-centered approach, including your physical, mental, and social needs.”
One element in the operational success of the Complete Health medical practices has been the organization’s partnership with the Atlanta-based patient scheduling company, Relatient. Why is patient scheduling such an important element in this? Relatient CEO Jeff Gartland told Healthcare Innovation recently that “Patient self-scheduling is incredibly important for providers to be able to do it; consumers are demanding it, and yet it is far more complex than anyone can appreciate. In my view, post-pandemic, the need and demand from consumers for more convenient access is increasing exponentially. The patient experience is blurring between clinical outcomes and the consumer experience. You can be the best clinician, but a poor patient experience will impact you. The other half of that is that it’s incredibly hard. People ask, why can’t patients self-schedule the way that restaurant patrons self-schedule using platforms like OpenTable? The analogy we use is, imagine if every time you wanted to book on OpenTable, they asked you a huge slew of questions that you had to answer. If you had to do that every time you booked an OpenTable reservation, that’s the equivalent to what happens in healthcare. The leaders at Complete Health have leveraged the Relatient platform as one tool to improve the patient experience.
Dr. Farley spoke recently with Healthcare Innovation Editor-in-Chief Mark Hagland about the transition from fee-for-service into value-based care delivery and payment, and what that evolution has been like for himself and his fellow physicians in his practice and across Complete Health. Below are excerpts from that interview.
How would you describe your practice and the larger organization?
We’re a primary care medical group. Ninety-eight percent of the physicians in our clinic are in family medicine or internal medicine. We also have a podiatrist and one sleep doctor.
And the corporate entity that organizes your practice and the other practices in Complete Health involves private equity funding, correct?
Yes. Primary care practices can only transition to value-based contracting either through hospital ownership or through infusions of capital. We do have 41,000 patients in risk-based contracts.
Which accountable care and value-based programs are you participating in?
We’re about 60-percent commercial. We’re in an Medicare Advantage HMO; we’re in PPOs. And we have an ACO REACH contract, which began when the program was still called the Direct Contracting program. ACO REACH has been a great product for us. The majority of the patients whom we care for under risk-based contracts, are in Medicare Advantage. And what’s great is that we treat all of our patients in the same way; they all receive essentially a kind of concierge medicine.
The majority of our risk patients are in MA, because we do everything the same, patients all essentially receive concierge medicine.
What percentage of your patients are cared for under risk-based contracts?
Of our 134,000 total patients at Complete Health, over 37,000 are cared for under full-risk contracts—basically, 28 percent. Meanwhile, with regard to specialists, we make careful choices about which providers we put into our preferred network; among other things, they have to meet criteria for referrals from our providers, and we want them to preferably be using lower cost sites of service—for example, ambulatory surgery centers versus hospital outpatient departments, for outpatient procedures—though, ultimately, patients can exercise choice over where they go for procedures.
Transitioning to value-based contracting from fee-for-service payment models is challenging, and involves a great deal of cultural change and change management. Per that, I notice that your clinics are operating in markets that wouldn’t be considered advanced managed care markets. Can you speak to the gradual change management processes involved in working with physicians in less advanced markets?
I like to say that we’re a disruptor; we speak to hospitals and specialists and ask them for certain things. We purchase practices and transform them into value-based practices over the course of a year or more. And some of the health plans have asked us to go into particular markets, in order to move the physician practices forward in those markets. And so operating in those markets has proven to be both an advantage and a disadvantage. There’s a lot of stuff that can be squeezed out; simply putting together a preferred-provider network is a huge move. And changing billing systems. And we go to specialists, and we put standards in place for how quickly patients should be seen.
How have you been able to change the physician culture in those markets?
Because they’re immature markets, we’ve actually been able to pick up some of the highest-performing practices. And we’ve been able to pick up wonderful physician leaders. I’m 60; and there are many physicians like me, who don’t want to quit practice, but who want to get off the treadmill. So you’re getting out of a fee-for-service mentality, stamping out problems, to taking care of patients for life. So we change over the compensation model within a year or two, moving the metrics away from volume to quality outcomes—STAR ratings, etc. And doctors are typically making about 38 percent more salary than in fee-for-service, based on shared savings from keeping people out of the hospital and the ED. We wrap care managers, social workers—in Birmingham alone, we have nine quality specialists, plus member service reps—we wrap those people around the physicians. And then we leverage technology. We have a tool that spotlights care gaps. It leverages claims data. And we use athenahealth as our EMR.
We’ve built a patient-access center, and multiple walk-in clinics. And we check on our patients to try to avert an ED visit. We engage the patients heavily, and we risk-stratify them, using a Hopkins tool. And it’s about 10-15 percent who are the highest-risk patients. And when you’re under these capitated arrangement.
As you know, last month, the Medicare actuaries announced their spending projections, predicting that the current $4.6 trillion in annual U.S. healthcare spending will rise to $7.7 trillion by 2032. That’s mindblowing. Does that coming cost cliff inevitably compel our healthcare system towards value-based payment, in your view?
Yes, it does. And my perspective is formed by the fact that I’m a fourth-generation physician. My family started in medicine in 1896. My grandfather was just playing whack-a-mole in terms of patient issues. And over time, it’s become clear that we have to bend the cost curve; and the reality is that the value-based care model overall just makes sense. It’s clear that as we keep these patients longer, we do better and better with them.
Tell me about your partnership with Relatient?
We just implemented their solution this spring in our patient access center. It’s a tool. You can schedule a hotel room or airplane ticket online. But you still have to call, in healthcare. Now, Relatient applies intelligence to scheduling; that’s phase one, we’ve implemented that, and we’re able to find appointments more quickly. The challenge was that we had to rearrange physicians’ scheduling systems. But the average call time has dropped, our scheduling efficiency has gone way up, and soon, we’ll roll out the patient self-scheduling feature tomorrow.
What’s more, we’re seeing far fewer complaints from patients, as we’re finding slots for them far more quickly. Patient reps are spending far less time with patients, we’re moving from 8 minutes per call down to 3-4 minutes; that will be a huge advance. Younger patients use patient portals, but older patients want to call. But that ability for patients to self-schedule is big; we’re very excited about the potential.
What have the biggest lessons learned so far on your organization’s journey into value?
The hardest part was going into these markets and getting the initial contracts, and structuring the contracts in ways that were advantageous to us. But the biggest single challenge is changing the culture away from the fee-for-service mentality. And don’t send patients to the ER; see them right away. Access is the more important thing, because the earlier you treat the disease process, the better it will be for everyone. You just have to sell it to the providers, because they hear “value-based care,” and they think “cheap”; and I explain to them, no, you don’t have time in the fee-for-service system to truly care for patients and improve outcomes. The culture change is the hardest element in all of it, absolutely.
In addition, data analytics are crucial for success, correct?
Absolutely. We have six medical economics people, and whole IT department. We have basically built our own data warehouse to produce reporting; we don’t have a formal population health management solution. As CMO, I live and die by those reports. I’m the one pushing to make sure we have the data we need; without the data, you can’t be successful in VBC. And a lot of organizations like Oak Street and ChenMed, they’re not taking care of all types of patients; we’re still taking care of all of the patients; that’s been helpful as well.
