Primary Care Doctors are Becoming Community Leaders

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There is a solution for Medicaid fraud—innovation

In 2020, Medicaid fraud was estimated to be close to $86.5M. It is a staggering figure burdening taxpayer. And clearly, more needs to be done to remedy a situation where fraud is so pervasively present in a program that cares for the most vulnerable patients.

The FBI lists several main types of fraud: double billing, submitting multiple claims for the same service; phantom billing, billing for a service visit or supplies that the patient never received; unbundling, submitting multiple bills for the same service, or charging more for a service that is usually part of a package; upcoding, billing for a more expensive service than the patient actually received; and over-billing, charging the government for medically unnecessary drugs, procedures, or drugs.

Medicaid patients are particularly vulnerable to physicians' fraudulent practices, as they have no easy access to their medical records. For example, a doctor might falsify or exaggerate a diagnosis to facilitate over-billing. The patient may be subject to unnecessary or unsafe medical procedures. 

They are also vulnerable to individuals asking for their insurance identification number and other personal information to bill for non-rendered services. Or their identity may be stolen, and they would find themselves enrolled in a fake benefit plan. 

To battle rampant Medicaid fraud, a new healthcare delivery model holds great promise: Value-Based Care (VBC). The VBC formula stipulates that doctors get compensated according to the longer-term well-being of their patients. The healthier the patients, the greater the compensation for the doctor. In sum, doctors are encouraged and put in a position to do their very best for the people under their care.

The model, as instituted by the New York Department of Health in 2014, was called Delivery System Incentive Payment Program (DSIRP). It provided for an iron-clad protocol that would make fraudulent practices pretty much impossible. Its success is exemplified by the achievements of SOMOS, a network of 2,500 inner-city physicians caring for some 1 million of New York City's most vulnerable Medicaid patients, mostly Hispanics, African Americans, and Asian Americans. 

To make the VBC model work, doctors must carefully maintain patients' Electronic Health Records (EHR), which would periodically be sent to the Department of Health for assessment. That is when it is determined if the patient population is showing signs of enduring health, which in turn governs the doctor's compensation level. Maintaining the EHRs is a job for both doctors and their staff. Fraudulent records would be readily flagged.

Record-keeping also plays a role in Patient-Centered Medical Homes (PCMH). SOMOS staff works with medical practices to turn them into a one-stop portal where a patient's entire care history is recorded, allowing the doctor to keep track of which services a patient receives, be they medical, behavioral, or social. The social refers to doctors keeping track of patients' social issues that may impact their health, such as substandard housing, unemployment, and poverty. Again, a careful electronic portrait of the patient is maintained, with both doctor and staff doing the record-keeping. Fraudulent entries would quickly be spotted.

Now, doctors prone to committing fraud would be ill at ease being part of VBC, even though such physicians would see their income increase, a factor that prompts their criminal behavior. Ideally, VBC would make honest men and women of them. However, it is hard to picture a less-than-ethical doctor in the SOMOS VBC system, which revolves around a close patient-doctor relationship. That bond is created as physicians earn the patients' trust by getting to really know them, their families, and their circumstances. For much of that intimate detail, SOMOS doctors rely on Community Health Workers as their eyes and ears in the community. Given the stature of SOMOS doctors, it is difficult to imagine fraud-prone physicians, with far less than adequate concern for the well-being of their patients, earning such a position of trust.

Above and beyond traditional Medicaid's vulnerability to fraud and waste, there is a relatively poor record of delivering health care to the most vulnerable. Needy patients, people of color among them, often have a difficult time gaining access to the care they need, given the labyrinthine network of doctors to whom, on paper, they have access. A famous Oregon study (conducted in 2009/2010) found that people with Medicaid coverage showed no significant positive effect on major medical conditions—including hypertension, diabetes, and high cholesterol—compared to those without coverage.

SOMOS saved US taxpayers $330M by reducing by 25 percent both unnecessary visits to the emergency room and unnecessary and costly hospitalization. That is the fruit of Value-Based Care. It is high time for traditional Medicaid to be dismantled and for VBC to be rolled out system-wide. Doctors, patients, and taxpayers stand to benefit greatly.

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SOMOS: May we be like the sandalwood tree…

Since its very beginnings, SOMOS Community Care was founded and has developed as an organization with the mission to create and cultivate a collaborative network of primary care physicians and their clinics. Our goal is to implement an innovative and revitalized model of healthcare that prioritizes the needs of our community’s most vulnerable and underprivileged individuals, focusing especially on migrants in New York City.

The highest moral principles inspire us in our pursuit of the common good and we dedicate ourselves to the health and well-being of those we serve. Strong ethical values guide our healthcare organization in the interpersonal relationships we form within the company as well as in how we manage all economic and administrative aspects of our operations.

Our doctors focus on primary and family healthcare with a preventive approach and aim to relieve the strain faced by hospitals. We do this by championing a model where hospital institutions attend to patients with the most urgent and prioritized needs.

Through the years, we can trace the success of our healthcare services, as I have said, to the integration of hundreds of physicians and their clinics, as well as the government funding we have secured through the DSRIP program for state healthcare system reforms. We have been awarded this funding based on our exceptional results and competencies, which allows us to continue developing our mission and vision already detailed above. These results include reductions in the statistics that track stress on hospital emergency systems and reductions in rates of unnecessary hospitalizations.

Our healthcare model emphasizes prevention over treatment, and, as much as possible, healthcare is delivered in the patient’s respective culture, customs, and language by physicians who are immigrants themselves. This model not only enhances the MEDICAID system, but it also reveals, let’s not forget, the difficulties that our organization’s work may face with the traditional hospital system, because, due to a lack of prior, personalized, and preventive care, large numbers of patients who do not need emergency services, or even hospital services at all, attend these facilities.

As the CEO of SOMOS, I can attest to the ethical standards, transparency, and honesty with which we manage our financial resources, the code of ethics that exists at the very heart of our organization, and the desire and spirit that drives us to continually improve our service to the health and well-being of all, particularly the most at-risk members of our city.

 We strive to ensure that all professional services contracted for the development or promotion of SOMOS are executed and compensated accordingly. Likewise, we also strive to guarantee that the healthcare services our network of affiliated physicians provides bear the hallmark of scientific excellence, efficiency, timeliness, and solidarity that the invaluable nature of healthcare demands.

At SOMOS, we are committed to promoting the highest and noblest values of the human spirit both within and outside our organization. We have fostered collaborative, non-denominational partnerships with various religious institutions, including Catholic, Muslim, Jewish, and Protestant denominations.

Our shared pursuit of the common good and the provision of healthcare, as integral values that support individuals, families, and society, has brought us together with these religious organizations. We have supported each other, especially during the pandemic, by utilizing their places of worship to facilitate health campaigns within their communities.

This collaborative work with religious communities has allowed us to personally connect with and draw inspiration from spiritual leaders such as Pope Francis, who continues to inspire us and all of humanity.

The prestige that SOMOS has earned with the passage of time can be traced to the vital healthcare services we have provided to our city, particularly during the COVID-19 pandemic. Also, our humanistic vision and solidarity with those who suffer the most have driven us to extend our services, focused attention, and targeted assistance to communities experiencing catastrophes and emergencies in Haiti, Cuba, the Dominican Republic, Puerto Rico, and beyond.

We aspire to continue to be an increasingly recognized and sought-after healthcare organization. We aim to expand and enhance our services over time, and to achieve this, we hope to continue relying on local, state, and national government support that aligns with our accomplishments, competencies, and workforce contributions.

Neither individuals nor institutions are immune to the challenges of competition, power dynamics, economic fluctuations, and political turbulence that are intrinsic to every society. At SOMOS, we see ourselves as a vital and dynamic component of the social fabric, embracing the risks associated with being an active and productive entity within society. We appeal to the trust of all in our vision and commitment to healthcare as we continue to grow and thrive.

Acknowledging the difficulties that all of us may encounter, individuals and organizations alike, be they due to internal or external causes, we, at SOMOS, strive to be, in the words of Nobel Laureate Rabindranath Tagore, like the sandalwood tree that perfumes the very axe of the woodcutter that lays it low.

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A Medicaid Purge is Under Way

With the pandemic crisis passed, the government has ended special provisions that allowed millions to be covered by Medicaid. Until recently, 93 million people—one in four Americans—were on Medicaid or on the Children’s Health Insurance Program (CHIP). Since pandemic protections ended on April 1, more than 600,000 people have lost their Medicaid coverage. The vast majority lost their coverage because they failed to complete and submit paperwork, as required by state policy.

For example, in Indiana, 53,000 people lost coverage during the first month after the end of pandemic provisions. Almost 90 percent were taken off Medicaid for things like failing to return renewal forms. Many forms were mailed to out-of-date addresses. Activists have urged state officials to give people more than two weeks’ notice before losing coverage. In Florida, 250,000 people lost coverage, 82 percent of them for failing to complete paperwork.

It is clearly unfair to penalize people for failing to fill out and mail in forms. The poor, and especially vulnerable people of color among them, are not adept in dealing with often complicated forms. For those whose first language isn’t English, the process is still more difficult—most forms offer only limited foreign language options. What’s more, many people on Medicaid simply did not know they had to fill out lengthy forms to renew coverage, because during the three years of pandemic provisions renewals weren’t required.

Data from14 states that began cancellations May 1 show that 36 percent lost Medicaid upon review of their eligibility. Most people will get coverage through their jobs, or they will quality for coverage through the affordable care act. Nonetheless, millions of others, including children, will become uninsured, losing access to preventive care and basic prescriptions. The uninsured rate will rise from a historical low of  8.3 percent today to 9.3 percent next year.

Going without access to medical care for many will result in untreated chronic illnesses—diabetes, cardiovascular conditions, hypertension—spiraling out of control. These patients will eventually end up in emergency rooms and costly hospital beds, at the expense of state taxpayers. This is ironic given that states looking to purge Medicaid rolls do so to save money.

There is an alternative. The experience of a unique network of inner-city physicians in New York City—most of them primary care providers—demonstrates that affordable, superior care for Medicaid recipients can produce significant savings. The 2,500 doctors are part of SOMOS Community Care and provide care for some 1 million of New York City’s most vulnerable and needy Medicaid recipients, mostly African Americans, Asian Americans, and Hispanic Americans. 

SOMOS doctors operate under the Value-Based Payment (VBP) system. VBP stipulates that providers are paid according to longer-term health outcomes of their patients. The healthier the patients, the greater the compensation for the doctor. SOMOS has put in place a model of healthcare that enables and encourages physicians to do their best. The key to success is doctors really knowing their patients and responding to their needs—medical, behavioral, and social. This comprehensive understanding of patients cultivates a strong doctor-patient relationship, with the doctor assuming the role of a trusted figure—not unlike the traditional role of the family doctor who was recognized and respected as a community leader.

Community Health Workers play a critical part as the eyes and ears of SOMOS doctors. They visit patients’ homes, reminding patients of doctors’ appointments and assessing their living conditions. The home may have mold issues, or money is scarce due to unemployment, and there is no access to education. These factors are known as Social Determinants of Health, which have a significant impact on medical and behavioral health.

Overall care of patients is carefully coordinated and kept track off. SOMOS transforms doctors’ practices into Patient-Centered Medical Homes, serving as a portal for patients to access the care that they need. The primary doctor can monitor patients’ progress, for example if they must go for treatment to specialists.  The patient is never left to wander alone through a labyrinth of difficult to access care, as is the case with traditional Medicaid. Finally, many SOMOS doctors share the background and culture of their patients, another element that builds trust.

Functioning as a part of an innovative health care initiative launched by the New York State Department of Health called the Delivery System Reform Incentive Payment (DSRIP), SOMOS proved superior care produces significant savings. SOMOS succeeded in reducing by 25 percent both unnecessary visits to the emergency room and costly hospitalizations. This accomplishment saved New York State taxpayers $330M.    

Reforming Medicaid—especially by introducing the Value-Based Payment system—would obviate the purging of Medicaid rolls, and instead make for healthier patients and significant saving.

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Quality Care for the Underserved: The Story of SOMOS

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."

 

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SOMOS Community Care-the role of the corporation

 

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Medicaid’s sorry record cries out for reform, innovation

 

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How to ensure equity in health care.

 

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Health-care reform & the lost art of healing

In 1996, the renown Dr. Bernard Lown—emeritus professor of cardiology at Harvard and founder of the Lown Cardiovascular Group, among other distinctions—published “The Lost Art of Healing.” The book may be more than 20 years-old, but its message is as timely as ever, and arguably more urgent today then in 1996. The New York Times put the spotlight on Dr. Lown’s message when it recently ran an Op-Ed by an intern at Brigham and Women’s hospital in Boston who encountered the venerable physician when Dr. Lown was in that hospital being treated for pneumonia.

In “The Lost Art of Healing,” Dr. Lown charged that “doctors no longer minister to a distinctive person but concern themselves with fragmented, malfunctioning” parts of the body. The doctor-patient relationship, the author lamented then, and still laments today, has become impersonal, mechanical, remote and cold. In “The Lost Art of Healing” he called for the revival of the “3,000-year tradition, which bonded doctor and patient in a special affinity of trust.”

As resident physician Rich Joseph wrote in his column, Dr. Lown has called for “a return to the fundamentals of doctoring—listening to know the patient behind the symptoms; carefully touching the patient during the physical exam to communicate caring; using words that affirm the patient’s vitality; and attending to the stresses and situations of his life circumstances.” 

At 96, Dr. Lown made it clear that he was not pleased with the state of affairs he had warned about all those years ago, and which today he describes as the “industrialization of the medical profession.”

The Times piece is worth quoting at length because it so pointedly and accurately describes the state of contemporary health-care in the US, both in its for-profit and publicly-funded forms. The case is worse for the latter, with traditional Medicaid being particularly prone to impersonal medical care and an emphasis on transactional treatment in the form of tests and perfunctory office visits; a formula that is prone to waste and fraud, and that provides very little if any opportunity for the establishment of a bond between patient and doctor.

Enter the Delivery System Reform Incentive Payment (DSRIP) Program, a pioneering approach to Medicaid ushered in by the New York State Department of Health that has just begun the fourth year of its five-year mandate. Its goal: the reduction by 25 percent of avoidable hospital use at the end of five years, which would amount to a savings of more than $12B for New York State taxpayers. 

These are impressive facts and figures; important as they are for the bottom line, they are secondary. At the heart of DSRIP is superior, holistic care for Medicaid patients who are treated as human persons, not as cost centers or bundles of various medical ailments—care precisely of the kind Dr. Lown insists has gone missing.

SOMOS Community Care is one of 25 so-called Performing Provider Systems (PPS) in New York State, which are funded by DSRIP. To qualify for maximum funding, each PPS is held to strict deadlines, delivering certain levels of care and meeting crucial milestones all, ultimately, leading to those dramatic reductions in hospitalizations. DSRIP is driven by the Value-Based Payment (VBP) or Pay-for-Performance formula. That means that physicians and other providers are not paid according to tests administered or office visits logged, but based on the longer-term health outcomes of their patients. If their patients stay healthy, their doctors earn more. It’s that simple.

VBP, however, is a tool, not an end in itself. Value-based care means that doctors are rewarded, are recognized, for paying closer attention to their patients. Better care, to cite Dr. Lown once again, depends on the development of that “affinity of trust” between doctor and patient. Such an authentic bond requires that doctors make a genuine effort to get to know their patients, which takes time, energy and resources.

Providing truly superior care means that doctors and their staff must go the extra mile not only to comprehensively assess a patient’s physical, as well as mental health; it also means getting to know the patient’s family, the family’s living conditions, and to develop an awareness of the environmental and social factors that affect the home life—the so-called social determinants of health, which Dr. Lown succinctly describes as the “stresses and situations of [the patient’s] life circumstances.” Only in this labor-intensive, patient, persistent and demanding fashion can doctors once again become genuine healers, patients’ confidants, who are trusted and admired leaders of their communities. 

SOMOS Community Care is unique among the 25 PPSs in New York State in that it provides services to the poorest residents of New York City through a network of independent physicians. The other PPSs are hospital-based, mostly massive corporate systems, for which the genuinely and indispensable personal touch is much harder to achieve. SOMOS supports its physicians with a team of Community Health Workers, which train the staff of physician’s practices in digital record-keeping—freeing up the doctor to give his or her full attention to the patient—and which make home visits as needed, making sure medical appointments and regiments are kept, and giving the doctors vital feedback on patients’ home circumstances.

SOMOS, in sum, is making for the contemporary reiteration of the family doctor of old, making him or her again a familiar and relied upon neighborhood figure. In many cases, our doctors live and work in the same communities as their patients, often sharing their ethnic background. Cultural sensitivity and competence, in fact, are a hallmark of the DSRIP VBP formula.

It must be stressed that our more than 2,000 doctors, most of them members of Independent Practice Associations, have gone out on a limb in signing up with DSRIP. The old Medicaid formula stood for a predictable, reliable level of income. The Pay-for-Performance model, by contrast, means that doctors have to work harder, and provide superior health-care, in order to qualify for higher compensation. As independent small business people, our doctors are really taking a chance and deserve a great deal of credit for thus boldly embracing their professional calling in a way that is by no means risk-free.

Value-based care is the new wave of health-care reform; it will deliver superior care, thanks, in part, to a strong emphasis on preventive care. This, in turn, translates into reduced health-care costs by keeping people healthier and out of hospitals, etc. It would make a lot of sense for policy-makers to begin paying closer attention to value-based care—and to consider funding the efforts of Independent Practice Associations. This would enable the independent doctor as entrepreneur to succeed under the VBP regime by providing truly personalized health care, whose quality hinges on that “affinity of trust” between doctor and patient. This would be a much-needed complement to the massive funding of inevitably more impersonal hospital-based systems that currently dominate the publicly-funded health-care arena.

As for SOMOS, we are laying the groundwork for life beyond the DSRIP mandate, which concludes on March 31, 2020. SOMOS Community Care will continue operations as a for-profit entity. Experience to-date has given us confidence in the VBP formula and we are prepared to, literally and figuratively, bank our future on it!

The brave new world of digital health care still needs doctor’s personal touch.

LAST MONTH two major publications devoted significant coverage to the growing, unstoppable trend toward telemedicine and other digital forms of measuring, recording and responding to individuals’ healthcare needs—all for the sake of convenience, accuracy and cost-cutting. The Economist (Feb. 3, 2018) headlined its news analysis with “Doctor You—a digital revolution in health care is coming—welcome it.” The Wall Street Journal (Feb. 25, 2018) published a lengthy feature on “What the Hospitals of the Future Look Like;” the subhead read: “The sprawling institutions we know are radically changing—becoming smaller, more digital, or disappearing completely. The result should be cheaper and better care.”

Optimism abounds. And, yes, there is plenty of reason for it. The Economist notes that the “fundamental problem with today’s system is that patients lack knowledge and control” regarding their medical condition and treatment options; “access to data can bestow both,” the article proclaims.

There has been a veritable explosion of wearable devices that measure blood pressure, for example; others can detect irregularities in heartbeat; other apps are in development that can—with the help of Artificial Intelligence—detect skin cancer and other potentially life-threatening conditions that, early on, do not manifest themselves in obvious, visible or dramatic ways. A digital early-warning system can prompt individuals to seek out medical care for preventive measures.

Care for the elderly is greatly improved by wearable devices that are capable, not only of measuring vital signs, but of detecting falls and sending warning signs to centralized monitoring stations. These, in turn, can dispatch emergency help or alert family members to take mom or dad to a doctor. In a similar fashion, patients of all ages, can have data pertaining to critical medical factors, such as diabetes, automatically sent to their doctors’ computers, prompting corrective instructions or, if needed, a visit to the doctor’s offices. Not surprisingly, Apple has announced plans to petition health-care organizations to allow iPhone users to download their medical records.

These innovations certainly give patients more autonomy in making medical decisions on their own behalf, while also serving as a safeguard to spot potential errors in medical records that could lead to inappropriate or unnecessary treatments. Overall, this digital revolution will save billions of dollars in unnecessary—or, no longer necessary—visits to doctor’s offices and the administration of medical tests.

As to hospitals, the Journal writes, these institutions, too, are developing monitoring systems that can sharply reduce the time patients spend in hospitals or emergency rooms by keeping a remote digital eye on the patients at home; again, the focus is on preventive care—catching conditions before they get out of hand. By some estimates, 30 percent of care traditionally provided in hospitals can be given at home.

More and more, somewhat parallel to the proliferation of no-appointment-necessary medical clinics, large hospital will make room for “microhospitals,” functioning as extended “intensive-care units, where you go for highly specialized, highly technical or serious critical care.” Patients with conditions that can safely be monitored remotely can recover at home. Doctors with various levels of specialization will operate “central hubs” to monitor both acute cases in microhospitals, regular ERs or less severe cases in patients’ homes.

Kenneth L. Davis, president and chief executive of Mount Sinai is quoted as saying: “We need a new model of care that focuses on wellness and prevention and keeps people out of hospitals.” Enormous savings and greater comfort for patients are in the offing.

As The Economist notes, “the benefits of new technologies”—such as wearable devices and downloadable personal health records—“often flow disproportionately to the rich. However, government and insurers have an incentive to provide the technology and self-care, at-home treatment options to poorer populations as well. Alphabet, the parent company of Google, has plans to wade through patient data in poorer parts of cities, where many residents are covered by Medicaid.

Hi-tech innovation at the service of the poor is also the hallmark of New York State’s revolutionary Delivery System Reform Incentive Payment (DSRIP) Program. DSRIP, a five-year program now its third year, provides superior medical care to Medicaid patients at greatly reduced savings ($12B-plus!) to the state’s taxpayers. DSRIP in on track to exceed its target of reducing unnecessary hospitalizations by 25 percent by spring 2020. The program is driven by the Value-Based Payment (VPB) or Pay-for-Performance model: doctors are being paid, not based on the number of hospital visits or tests, but on the longer-term health outcomes of their patients. (It’s promising in this regard that the government has created the Physician-Focused Payment Model Advisory Committee, with the potential of extending VBP models to Medicare.)

Electronic Health Records (EHRs) play a major role in DSRIP architecture; for the New York State Department of Health to track the health of populations, EHR data are integrated with Medicaid claims in order to paint the state of health of large communities. Just as is necessary in the commercial, privately-insured universe touted by The Economist and The Wall Street Journal, EHRs for each patient served under DSRIP must be painstakingly produced, maintained and constantly updated. This process ordinarily demands a great deal of time on the part of physicians, who are glued to their computer screens, rather than being focused on the patient before them.

In sum, the vital personal relationship between physician and patient, between doctor and the patient’s family, has little chance to be established. The personal touch, the human encounter that forms the foundation of an authentic patient-doctor relationship goes missing. That obviously is true for all forms of remote monitoring of patients’ health, no matter how accurate or efficient.

At SOMOS Community Care we have developed a solution; SOMOS is the only so-called Performing Provider System (PPS) mandated by DSRIP that consists of a network of independent physicians; the other 24 PPSs are hospital-based. To free our doctors from the demands of data entry and record keeping, we have dispatched teams of Community Health Workers (CHWs) to our practices, to record patient data themselves or train office staff to do so.

As a result, the doctor—often living and working in the very communities with whom he shares a cultural and ethnic background—is free to pay full attention to patients before him; what’s more the CHWs make home visits, as needed, ensuring that patients keep up with their medical regimen and keeping the doctor abreast of family and housing circumstances that may impact the health of patients and their families.

In this fashion, our doctors assume the role of the family doctors of old—leaders of the community in whom patients can put their trust, in whom they can confide, and by whom they are understood, by whom they are truly known. This new iteration of the family doctor takes full advantage of today’s digital revolution in health care, but without sacrificing what has always been essential for an individual’s overall well-being—quite literally, the personal, healing touch. Such cannot be transmitted in digital fashion, no matter how sophisticated the technology.

Trust between doctor and patient is key to superior healthcare.

This fall, smack in the middle of the ongoing debate about healthcare reform in the U.S., a consummate medical professional published a remarkable book that pinpoints the structural imbalance that ails the country’s $3 trillion healthcare industry. 

In “Back to Balance—the Art, Science and Business ofMedicine” (Disruption Books), Dr. Halee Fischer-Wright, president and CEO of the Medical Group Management Association, writes: “We have lost our focus on strengthening the one thing that we know has always produced healthier patients, happier doctors, and better results: namely, strong relationships between patients and physicians, informed by smart science and enabled by good business practices that create the trust necessary to ensure that patients do what they need to do to achieve” good, long-term health outcomes.

No doubt, something is seriously amiss: among industrialized nations, the U.S. spends the most per capita, but the quality of healthcare and patients’ health outcomes rank lower than those in Germany, the UK, France, and a host of other developed countries. Fischer-Wright knows her stuff: the organization she leads “represents 40,000 practice administrators and executives in 18,000 health-care organizations across all fifty states, where more than 400,000 physicians practice, providing close to 50 percent of the health care in the United States.”

The “art of medicine,” she asserts, “is being crowded out by the science of medicine—and its emphasis on evidence-based procedures, well-meaning protocols, and advances in Big-Health-Data-churning information technology.” There is a relentless “focus on time-consuming but questionable quality metrics, endless billing procedures, and an adherence to process that doesn’t necessarily put patients first.” Case in point: the author cites findings that show that “the average physician now spends nearly two hours on paperwork [digital entries included] for every hour spent with patients, if they’re lucky.”

These factors “keep creating greater distance between patients and their doctors,” writes Fischer-Wright, who insists that “we need to bring the art, science, and business back into balance — with each side playing its part and no more to drive the healthy outcomes that we all desire from health care today.”

The art of medicine, she insists, hinges on trust, the authentic bond between doctor and patient. It is the vital importance of the “human side — the big-hearted, patient-focused, high-touch, active-listening, caring, compassionate, empathetic part of medicine that has been at the heart of the doctor-patient relationship from the very beginning.” 

“A trusting relationship between physicians and patients,” writes Fischer-Wright, “based on compassion, empathy and good communication can have a profound effect on patient health. Trust aids efforts to control diabetes, lower cholesterol, and control pain. Trust improves the mental and physical quality of life of cancer patients. Trust encourages people to get regular preventive care. Trust gives older patients better outcomes and more long-lasting independence. Relationships built on trust have been shown to reduce anxiety, depression, post-traumatic stress disorder, and a patient’s use of end-of-life care. These relationships are linked not only to lower hospital readmission rates for heart failure or pneumonia, but also to more successful treatment regimens, lower health-care costs and much higher patient satisfaction scores.” Trust is everything!

Hence, the book argues, the business and science of medicine must be de-emphasized in favor of more holistic and humane treatment and involvement of the patient, making room, quite literally, for the human touch.

Fischer-Wright proposes a number of intriguing remedies to bring the art, the business and the science of medicine into proper balance. Among them, a suggestion to “design medical care for healthier people instead of strictly for diagnosis and treatment of disease.” The human person is far more complex—emotionally and spiritually—than the sum total of his or her physical condition.

Also, she recommends: “ask the people the right questions, genuinely listen to the answers and then take the right action” for doctors to find out what their patients expect from medical care, without making assumptions. 

Finally, she calls for the creation of “empowered relationships that demand balance in the art, science and business of medicine”—the doctor, the billing person, the office assistant and the patient him or herself working toward a common goal.

Restoring the fundamental trust between doctor and patient is both the foundation and objective of these vital adjustments; it holds the key to putting “the needs of people at the center of the [health-care] industry again.”

As the CEO of a unique health-care network comprised of independent New York City-based physicians, I am most heartened by Fischer-Wright’s insistence on the primacy of the doctor-patient relationship. SOMOS Healthcare (formerly Advocate Community Providers) is a so-called Performing Provider System (PPS) operating under a mandate from the New York State Department of Health as part of its Delivery System Reform Incentive Payment (DSRIP) program. The initiative’s bottom-line objective is to save taxpayers some $12 billion in unnecessary hospitalizations by the end of the program’s five-year term in 2020.

That goal is achieved, quite simply, by providing better care in terms of prevention, diagnosis, treatment, patient follow-up with CHW handholding. This way, medical conditions may be avoided and managed, avoiding emergency room visits and hospitalizations that drive the burdensome cost of the Medicaid system. 

SOMOS Healthcare was formed by community physicians to revitalize the role of the community-based primary care physician. Like the family doctor of old, these physicians often live and work in the same neighborhood as their patients. Often, they speak the same language and share the same cultural background, ensuring sensitivity to the cultural context of patients’ wellbeing. That, we are convinced, is the key to creating an intimate, trusted bond between doctor and patient.

A cadre of specially trained staff and Community Health Workers at SOMOS Healthcare help to reduce the administrative burden of our network physicians by improving workflows, streamlining billing and maintenance of Electronic Health Records, and exchanging data with the Department of Health. SOMOS staffers are also in a position to make home visits and ensure that patients are following their medical regimes. Thus, our approach echoes the author’s recommendation that shifts the balance back to the doctor-patient relationship.

As to the encroachment of the science of medicine, our primary care physicians can readily refer their patients if specialized treatment is in order—but only after a thorough discussion and examination that takes into consideration possible cultural influences or mental health issues. Ours is a sharp departure from the impersonal, transactional, and test-driven practice of Medicaid medicine.

There is one critical area, however, where we part ways with Fischer-Wright. At the core of DSRIP is a shift to a Value-Based Payment (VBP) or Pay-for-Performance formula: increasingly, compensation for doctors is pegged to the longer-term health outcomes of their patients. We respectfully disagree with Fischer-Wright’s rejection of pay-for-performance, even as efforts she has studied over the years may have missed the mark.

For SOMOS Healthcare, pay-for-performance is at the heart of enabling our doctors to be true to their calling of delivering patient-centered health care. For too long, fee-for-service has economically favored large hospital systems. A value-based formula ensures that incentives are appropriately aligned to reward physicians for personal, relationship-based, comprehensive care.

Those with the most to gain are the people — let’s not call them patients, which connotes illness — whose health and well-being are front and center. After all, shouldn’t our health care system focus on health rather than illness?

Over time, that extra effort will include the so-called social determinants of health, such as a patient’s housing and employment situation. It’s not a matter of what Fischer-Wright labels as using “money to force compliance,” but of recognizing and supporting the risk our doctors are taking as small business owners to link their professional success to the genuine well-being of their patients. That, too, is a matter of trust; rewarding virtue is a good investment.

Post-2020, when the DSRIP mandate ends, SOMOS Healthcare is poised to continue supporting our network of community physicians as a for-profit organization, one that likely will begin to address the needs of Medicare recipients as well as our base of Medicaid beneficiaries. As our operations expand and, hopefully, as other organizations in New York State and beyond follow our example, we are confident that Fischer-Wright will discover that pay-for-performance will be a crucial element in balancing the art, science and business of medicine — be it government-sponsored or commercially driven.

How to fix Obamacare

HEALTHCARE advocates for the poor let out a collective sigh of relief when attempts to repeal the Affordable Care Act (ACA) went down in flames. But the story is far from told. Legislators on both sides of the aisle agree that Obamacare, as the ACA is better known, needs significant re-engineering to become economically sustainable.

Criticism, particularly on the part of conservative legislators, is focused on the cost of the plan’s expanded Medicaid provisions. The critics have a point. The established administration of Medicaid-funded healthcare is inefficient. By some estimates, waste and corruption cost U.S. taxpayers close to $140 billion a year, some 12 percent of the program’s total budget.

Lawmakers eager for a solution need look no further than a revolutionary Medicaid reform program in New York State, designed by state Medicaid Director Jason Helgerson and championed by Gov. Andrew Cuomo, who secured $7 billion for the five-year initiative. It’s called the Delivery System Reform Incentive Payment (DSRIP) program. 

This jargon-laden moniker obscures a highly innovate formula for healthcare reform. Gone is the traditional fee-for-service Medicaid model that compensates the health care provider for tests, office visits, and procedures. In sharp contrast, DSRIP shifts to a value-based payment (VBP) model in which the doctor or healthcare system is paid according to the long(er) term health outcome for individual patients.

It makes sense! Health care providers are rewarded for keeping patients healthy. This means the provider—in keeping with the medical calling, it should be added—invests time and energy in comprehensive, holistic, preventive care – ensuring patients follow medical directives, take their medicines, keep their appointments. Suddenly, the patient is at the center of the equation.

At the end of its five-year run, in 2020, DSRIP is on target to reduce unnecessary hospitalizations by 25 percent, which will represent a savings to New York State taxpayers of $12 billion. Reducing avoidable emergency room visits and hospital stays is precisely the fruit of comprehensive, holistic care. Today, it is all too common for Medicaid patients to fall through the cracks and wind up in the ER at great cost to the system not to mention the patient. Let us not forget that we are talking about real people, human beings whose illness and suffering carries its own, often-overlooked cost.

At this writing, the DSRIP program—after 30 months of laying the foundation of a complex infrastructure of clinical care models and performance measuring tools—has entered the second half of its five-year mandate. Since April 1, all 25 so-called Performing Provider Systems (PPSs) are being measured by the state according to performance targets and clinical outcomes. Encouragingly, in the first two years of the program, PPSs earned 95.78% ($2.53 billion of a possible $2.64 billion) of all funds.

It is important to note that NYS Medicaid Director Helgerson’s vision goes beyond the strictly medical and behavioral health factors that determine the well-being of a Medicaid recipient. His goal for healthcare transformation is to also address the social determinants of health. He asserts that successful, long-term reform of the Medicaid system means that, as he put it, the “healthcare sector must embrace a broader role in the communities in which we serve.” 

Research has amply shown that non-medical factors have a significant impact on a person’s health. For the bulk of vulnerable and poor Medicaid recipients living in urban settings, social or environmental conditions have a huge effect on physical and mental health: poor living conditions, pollution, crime, unemployment, lack of access to healthy foods. The list goes on.

The U.S. lags significantly on this front—even though it is very clear that neglecting social determinants of health is costing the country billions of dollars a year. In Helgerson’s vision, the primary care physician, the neighborhood doctor of old, is at the center of a coalition of service providers with expertise to address the gamut of a patient’s needs, medical and otherwise.

One notable stumbling block is the relative shortage of primary care physicians, particularly in lower-income areas. Across the board, less than 30 percent of U.S. physicians provide primary care, compared to well beyond or close to 50 percent in Canada, France, and Germany. Millions of Americans lack access to a primary care doctor, the very person who could play a central, comprehensive role in their health and well-being.

On this score, Advocate Community Providers (ACP) stands out as the only physician-led PPS in New York State. ACP’s vast network of 3,500 providers includes 1,400 Primary Care Physicians and 1,700 specialists who practice in the Bronx, Brooklyn, Manhattan, and Queens. What’s more, many live and work in the same neighborhoods as their patients—patients with whom, in many cases, they share the same ethnic background. Cultural competence is strongly emphasized by the DSRIP protocol and strongly embraced by ACP.

These neighborhood doctors know their patients intimately and understand the social and environmental factors that impact the household. They are committed to the comprehensive well-being of their patients, their families, and the communities at large. This rehabilitation of the role of the family doctor is driven and encouraged by the Value-Based Payment model, as it promotes a holistic approach to healthcare reform.

Such could be the next chapter for America’s healthcare reform, with individual states or the federal government adopting a Value-Based Payment formula to improve the quality of Medicaid care, even as it reduces waste and fraud. Making the considerable investment in a nationwide DSRIP program has the potential of truly enormous savings down the road—savings that in turn could keep Obamacare premiums for non-Medicaid insureds in check. Such radical reform should be able to garner bipartisan support.

Finally, to dream even bigger, why couldn’t the for-profit insurance companies who are part of the Affordable Care Act work with their providers and also introduce—not to say enforce—a Pay-for-Performance formula? Monies spent in the best possible way and savings achieved will benefit all parties—patients, first and foremost, but also providers, insurance companies, and the government. For the business-minded party in charge of the Administration and Congress, truly smart reform of Obamacare at all levels should be a no-brainer.