At the heart of the success of a unique network of 2,500 independent physicians serving one million of New York City's most vulnerable Medicaid patients lies the conviction that medicine is more than a diagnosis, treatment, or cure. Instead, the medical profession is called to integrate a humanistic element that faith, life experience, or drive shapes in every doctor, and that is decisive in how physicians ply this ancient trade of seeking to prevent illness and heal the sick.
Before creating the physician's network, SOMOS Community
Care, SOMOS Chairman and Founder Dr. Ramon Tallaj, an immigrant from the
Dominican Republic, learned that independent doctors were isolated. They
occasionally crossed paths, but in their private practices, they were exposed
to a system that increasingly devoured them in every sphere: pressure from
insurance companies, competition with hospitals, and the demands of government
bureaucracy.
Dr. Tallaj set out to unite doctors, inviting them to join
the Corinthian Medical Group, a precursor of SOMOS. Working together, they were
able to benefit from respective individual experiences and unite as a
collective in negotiating with insurers and providers. Joining CMG proved to be
a significant step toward the progress and stability of doctors' practices.
In August 2014, SOMOS began participating in the application
for the DSRIP or Delivery System Reform Incentive Payment (DSRIP) program, an
initiative launched by former New York Governor Andrew Cuomo to significantly
reduce Medicaid expenses and reform the reigning healthcare model as much as
possible.
DSRIP embraced a noble purpose, seeking to improve medical
care for those most in need. But from its inception, the hospitals tried to set
the tone and prevent a network of independent doctors such as SOMOS – not
affiliated with a hospital system and with many of its doctors living in the
same neighborhoods as their patients – from being included among the 25 medical
service provider systems that would be approved to join the initiative. Hospital
systems were very interested in removing SOMOS from New York City's medical
landscape. Vested interests put up major roadblocks for SOMOS. But in the end,
SOMOS became a Performing Provider System under DSRIP serving African
Americans, Chinese Americans, and Hispanics, including many immigrants.
Still, SOMOS was not deemed reliable. Hence, a hospital was
imposed upon the organization as a trustee, charged with monitoring SOMOS
spending and approving organizational decisions. Happily for SOMOS, Montefiore
Hospital was eventually engaged as a SOMOS trustee, leading to the creation of
a robust and collaborative partnership.
For decades, the US healthcare system has focused on
maintaining the status quo. Even when there were Hispanic leaders at the helm
of hospital systems, health care was always dependent solely on hospitals. The
United States has the best disease service in the world, but not the best
health service that puts a premium on prevention. The underserved, elderly,
immigrants, etc., have had to go to hospital emergency rooms even for a
headache. And then, the astronomical bills come. All this has been known for
years, but no one wanted to do anything. It was better to stay on the side of
the big powerful groups than to risk a political career to benefit the
neediest.
It should be noted that, under DSRIP, SOMOS was paid only
for services rendered. The SOMOS Board closely managed its spending. Nothing is
approved with the mere stroke of a pen, without prior consultations,
discussion, and, above all, verification.
SOMOS booked notable success: by keeping patients out of the
ER and hospital beds, it saved the federal government $48M a year for five
straight years; New York State taxpayers saved more than $300M due to a 25
percent reduction in visits to the ER and hospitalizations; pilot programs
enhanced the quality of the services rendered to patients; and SOMOS earned
Innovator status in New York State, in recognition of its pioneering work
featuring the Value-Based Payment formula, enhancing physicians' fees in accord
with patients' longer-term health outcomes.
Key to SOMOS' success has been the cultivation of strong
doctor-patient relationships. A major factor in this regard is the fact that
many SOMOS doctors live and work in the same neighborhoods as their patients,
with whom, in many cases, they share the same language and cultural background.
Plus, aided by Community Health Workers, doctors get a sense of the social,
family, and emotional circumstances of their patients' lives—the so-called
Social Determinants of Health. For example, poverty may prevent families from
consuming nutritious meals, which may cause obesity, or diabetes, along with
attendant stress.
Unlike hospitals and the countless Urgent Care facilities,
SOMOS doesn't wait for patients to show up at their doctor's door. Since the
beginning of DSRIP, SOMOS has been developing extensive health education
campaigns and distributing healthy eating models and plans. Working with
invited personalities from the Latino world, it developed an app with exercise
plans and nutritional suggestions. Health education is provided in medical
offices, at community gatherings, in churches, and on the street.
SOMOS seeks out, talks to, teaches, and educates people so
that they do not come to their doctor with perfectly preventable diseases.
SOMOS sees the patient holistically, within a 360-degree viewing radius,
considering many factors that other healthcare approaches do not consider. The
highest moral principles inspire SOMOS staff and doctors in their pursuit of
the common good. They are dedicated to the health and well-being of the people
served by SOMOS.
The SOMOS difference between hospitals and the traditional
health system lies in the formula of prevention before treatment. Our doctors are
in the neighborhoods, immersed in the same life dynamic as many of their
patients, whom they also know and have cared for generations. This intimate
familiarity with patients' lives is key to preventive care. It is ironic that
what was once traditional, the family or neighborhood doctor, is now
revolutionary. This has its explanation in the stalemate that large hospital
systems have created as the defining power of health care for years. Hospital
systems, in general, evolved from healthcare facilities to interest groups and
lobbyists that influence and determine health policies at the state and federal
levels. This makes them key factors in a disease-based health system, but not a
healthcare system that has the patient at the center of its vision and mission.
For these large systems established on the idea that the
sicker people are, the better the economic results, it is a nuisance that a
group of 2,000 independent doctors has acquired power and reputation with their
work within the community. They are also concerned that they are losing money
on emergency room visits because SOMOS doctors are treating hundreds of
thousands of people, trying to keep them from getting chronically ill, or
having to go to emergency rooms because they have no one to treat them. In the
SOMOS vision, hospitals attend to only patients with the most urgent and
prioritized needs.
The end of the first DSRIP mandate coincided with the onset
of the COVID-19 pandemic. On this front, too, SOMOS took a course decidedly
different than that of the healthcare establishment, which focused on
hospitalization and the purchase of costly ventilators and other medical
equipment. SOMOS focused on educating the community as to the importance of
isolating people struck by the virus and protecting family members living
together in close quarters. Here, too, the focus was on prevention rather than
treatment of the disease. SOMOS fought hard every day so that our message of
isolation and protection reached all communities. The strategy flew in the face
of large institutions seeking to maintain the status quo of a disease system.
Our doctors took to the streets. SOMOS bought and set up
tents in different neighborhoods to administer COVID-19 tests which SOMOS often
bought with its own funds. SOMOS took to the radio stations, television
stations, and the press with messages that people had to social-distance, and
that they had to isolate the sick, especially from the elderly. Messages were
delivered in English, Spanish, and Chinese. SOMOS educational campaigns were
comprehensive and efficient. Eventually, SOMOS convinced authorities of the
need for people to isolate themselves and of the importance of educational and
outreach campaigns among those most in need.
When, after lengthy delays, SOMOS was mandated to distribute
the COVID-19 vaccine, it did so at distribution points in the community, going
to the people and facilitating access to the vaccine for the neediest. From the
start of the pandemic, SOMOS also delivered food to the neighborhoods, working
in tandem with major charitable organizations. SOMOS is yet to be reimbursed by
the State for all its work and contributions in fighting the pandemic.
Dr. Tallaj, concluding a recent report on the history of
SOMOS, put it thus: "My mission, and as such the mission of the network of
doctors I lead, is to educate our community, our children, and our youth today;
and treat them preventively, if possible, to prevent avoidable chronic diseases
from conditioning their lives in the future."
"This has an economic benefit for the government as a
beneficiary of health programs and for insurance companies. But the greatest
benefit is for the person, the human being, who will be able to live and
function well in our society. If we manage to see the role of the doctor like this,
if we can convince politicians of the fundamental importance of the primary
physician (general practitioner or family doctor) and of the need to allocate
funds to those doctors so that the neighborhoods, regardless of the social
class that resides in them, become conglomerates of healthy people, it will
have been worth facing so many challenges... and to have kept fighting."
