By Scott Scanlon – Refresh Editor
Dr. Thomas J. Foels started working part-time at Independent Health in 1994 and has worked full-time for the insurer since 1997, the last four as chief medical officer.
He recently spoke with me about the insurance company’s role in improving primary care across Western New York and gearing up for the latest changes to come under the Affordable Care Act, during an interview that was so wide-ranging and interesting, I wanted to include more excerpts online than what I was able to include in today’s "In the Field" segment in WNY Refresh.
Here’s one of the more important things Foels had to say:
One of the things our CEO, Mike Cropp, often talks about when he talks about the Affordable Care Act on a national scale is that the federal legislation set some basic principles and guidelines, but it doesn’t tell you how communities are actually going to translate that into a solution. Every community is going to have a different take on that, so it’s the responsibility of the community, not the federal government, to make this thing work.
Those communities that step up and do it right, and get it right, are going to succeed because of the health of a community and the health care resources in a community. And the affordability of health care in a community is important for the economy in the community.
Some communities are going to get it right, some are going to try and fall short and some communities aren’t even going to try. But here, I think we’re trying, and early indications are we’re getting it right. I’m optimistic.
Here are several others:
What is the insurer’s role in the team approach to care?
I think we’re an important facilitator. In the early days, we took a strong leadership role in forming that collaborative and maintaining its focus. Since last July, we said, ‘Everybody’s doing such a great job in the physician community, we’re going to step back, organize you to assume the leadership roles and we’re going to be facilitators.’
It sounds like previous efforts by Independent Health evolved into The Primary Connection.
Yes. One of the things that’s an increasing responsibility of primary care physicians is behavioral health issues. Some feel very comfortable with those, some feel less comfortable. Some are a little confused about medications, how to you approach problems. So we identified a team of behavioral health providers who would co-locate in some of the offices and so now the physicians would have a resource down the hall.
We’ve begun to experiment with programs around geriatric care, so for the most frail elders, can we have a dedicated team of geriatricians who would help the primaries?
We’ve created a blur between traditionally what is the health plan role and the provider role. The health plans have a lot of care coordinators that do a lot of telephonic outreach. We have the ability to identify people with very complex problems and we serve as navigator for many of them. We call them up, arrange for transportation, make sure they get to all their specialty visits, help coach them on how to converse with their physicians, help clarify what their benefits are. We we’re housed at the health plan and not at the physician’s office, so we said, ‘Let’s put them at the doctor’s office.’ So a lot of the empty cubicles out here on a Monday are normally filled with care managers (on other days), but today they’re out of the offices. Now, the nursing staff at those offices will identify patients who are falling through the cracks and work with our care managers.
The system's very fragmented. We’ve got to have the whole jigsaw puzzle put together.
How many more nurses, doctors and health care professionals do you have working at Independent Health now than you would have 20 years ago?
The number hasn’t changed, but we’ve gotten more efficient with what we do. We have about 20 staff members who have devoted their full or part-time to The Primary Connection. ... They’re more positioned toward the front line of health care delivery...
How are things going since this new team and data-driven approach to care was launched last summer?
The primaries are telling specialists, ‘This is our model. We’re looking for collaborators.’
We understand, for instance, not every cardiology group in town is going to embrace this, but we don’t need to refer to every cardiology group in town. If there are a couple of groups who are willing to step forward, to align themselves with some things we think are very important principles, that’s what we’re looking at.
For example, our specialty work group would say to the cardiologist, ‘We have a patient that needs to be seen. First of all, we expect to be able to pick up the phone and get one of you cardiologists on the phone immediately, because we’re only calling you because we have something that requires some degree of urgency. And if we have a problematic patient that could be evaluated in your office instead of the emergency room, we expect your office to make itself available for this diagnostic test. Now, we’re not going to send you somebody involved in a massive (heart attack) to your office, but if we’ve got somebody with some unstable angina and rather than send them to a hospital – who knows when someone will see them, when they’ll get a diagnosis or whether I’ll ever be called back – I expect you’ll be available in the next hour, you’ll be available and you will call me and we’ll discuss what happens with the patient from this point on.’
This is already starting to happen.
We’re also saying to the cardiologist, ‘We expect you to be completely transparent about the quality and data and affordability. Share with us your generic rates, share with us how many procedures and tests you're doing, share your quality outcomes. Of the heart failure patients you have, how many wind up being readmitted to the hospital within 30 days? That’s a bad quality indicator if you’ve got a high rate of that happening. If you’re not able to measure that, if the health plan doesn’t have that measurement, we expect you to start measuring.’
So docs have to be willing to sign onto this greater scrutiny and being part of a team.
What changes do you anticipate January 1, when most Americans will be required to have health insurance?
Access is potentially an issue. There will be a lot of individuals who will have medical needs that have gone unaddressed for long periods of time. Now that they’re insured, they’ll be seeking out care to have those needs met.
Primary care is going to be an important component of that, so we’re working very hard to make sure the primary care offices have the capacity to take on new patients. What’s a big concern nationally is that primary care won’t have the capacity nationally and these patients will deflect to emergency rooms and urgent care centers. They do their bit, but they’re not equipped to address chronic conditions. They’re designed to address minor, acute, straightforward, we-can-solve-it-today sort of problems. A lot of people coming into the system will have much more complex problems, so where are they going to go with that?
Based on state figures, there is a shortage of primary care doctors in Western New York.
The answer there is yes, but if you look the through the traditional lens that everything is physician-delivered, you’d say, ‘Too few, we’re in big trouble.’ But if you say, ‘A primary care physician is the leader of a team that includes mid-levels (nurse practitioners) and nurses practicing at the top of their license,’ I’m not going to say we have an abundance of resources ... but I’m thinking the glass is half-full.
We’re looking at the (University at Buffalo) medical school and moving back four years to undergrad schools ... where primary care physicians can have these students in their office to mentor them and to say, ‘Your traditional thoughts of what primary care can be are probably old and outdated. We’re going to show you why this career would excite you and where we think it’s going, and you might want to get on this train now. We’re also reaching out to other para-professional schools for nurse practitioners and nurses, saying these are new roles.
You’ll be on the insurance exchange come January. How will that work?
Individuals and small business will have the opportunity to obtain their insurance through exchanges on January 1 if all goes well. For people with lower incomes, there are income subsidies. So they’ll go onto the web and the web should communicate with all the various government agencies to make sure (an applicant is) a U.S. citizen and their income can be verified by the IRS, and it will pull up what their federal subsidy will be.
And then they’ll go shopping. They’ll have an array of insurance products on four levels – the products with the broadest benefits will tend to have the highest cost compared to those with more modest benefits – and New York State will manage the exchange.
Some small businesses may choose to do what they’ve always done and contract directly with the health plan on all their employees or they’ll say, ‘I’m going to let my employees go out and shop. I’ll subsidize them, but I’ll let them go out and make individual choices.’
This is a big change for the insurance industry, of course, because we’ve tended to have our relationships with employers representing groups of individuals. The exchange is really an individual market.