City MD vs. SOMOS Community Care — A Study in Contrasts

A two full-page advertorial in The New York Times published on November 17, 2023 sang the praises of City MD and the host of differently named urgent care centers as a solution for people confronted with the "glacial pace of getting medical care in New York City and across the country: "It can take weeks to see a primary care doctor, and an emergency room visit can set you back many hours." 

There is no disputing the time it takes to get treatment in an ER. Still, the SOMOS Community Care network of over 2,500 mostly primary providers is highly accessible, caring for some one million of New York City's most vulnerable Medicaid patients. City MD—not particularly present in the city's most needed neighborhoods—is an option for those with Medicare or private insurance but not for those with traditional Medicaid coverage. This reality makes SOMOS, in fact, the "City MD" for the underprivileged. 

SOMOS offers an answer to City MD's claim that "with primary care doctors overburdened, navigating the current health care system can feel overwhelming for patients." SOMOS practices are located in the very communities that are being served, notably neighborhoods that are home to Asian Americans, Hispanics, and African Americans. These community-based practices readily welcome new patients, including those requiring urgent care. 

The advertorial cites an example: "a kid who split his chin open at the gym. He was out of the clinic in 25 minutes. He would have waited five hours in the ER, and his primary care doctor isn't trained for that." City MD acknowledges that "primary care is super important—preventative care is huge." That, indeed, is the focus of SOMOS doctors. They are highly qualified to deal with stitches or other emergencies. If needed, those SOMOS doctors would refer a patient requiring urgent specialized care to a colleague in the community.

There is no disputing the need for primary care doctors. City MD argues that the model of care they provide has changed: "At one point in time, if you had a problem, you would call your primary care doctor. They would interrupt their dinner to take your call and give you advice. That model has become less prevalent." 

This claim touches precisely on SOMOS's unique contribution to the New York State healthcare universe: the restoration of the family doctor of old as a trusted figure and community leader who has a bond with patients and is intimately familiar with patients' medical situations and overall circumstances—someone, indeed, who will take a call at dinnertime.

SOMOS care revolves around the patient-doctor relationship, carefully nurtured and fed with doctors' critical knowledge of their patients' lives. The provider gets vital information about his patient thanks to the work of Community Health Workers, who are doctors' eyes and ears in the community. They visit patients' homes to remind them of medical appointments, assess conditions in the home and the neighborhood, and gather pertinent information about the family as a whole.

Patient intelligence gathered in this fashion includes the so-called social determinants of health: social factors—poverty, subpar housing, and lack of access to healthy foods and other conditions—that can impact both mental and physical health. SOMOS doctors also engage Community-based Organizations to help address patients' social needs. The awareness of a patient's social and environmental circumstances is impossible for City MD doctors, who only get a snapshot of the overall condition of the people they see.

The City MD advertorial cites a finding by the American Medical Association that there is a growing shortage of doctors in the US, which is particularly true when it comes to PCPs. The AMA reports that the causes of the lack of doctors include burnout and "shrinking Medicare reimbursements." The same is true for Medicaid reimbursements, but SOMOS doctors have an edge as they have signed on to the Value-Based Payment model, which stipulates that providers' compensation is tied to the longer-term well-being of their patients. SOMOS doctors are paid extra for going the extra mile. Thus, their earnings are significantly boosted.

Finally, the advertorial states that, besides the shortage of PCPs, doctors "are spending their time doing administrative duties, rather than treating patients." On this score, too, SOMOS has developed a solution:  training doctors' staff to take on the bulk of administrative responsibilities, such as the careful maintenance of Electronic Health Records—thus freeing doctors to focus on their patients.

Of course, City MD meets a need and offers convenient access to medical care. However, there is no substitute for the intimate, comprehensive, and preventative health care at the heart of SOMOS.

Mario J. Paredes is CEO of SOMOS Community Care, a network of over 2,500 independent providers responsible for reaching and delivering care to over one million Medicaid lives across New York City.

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Value-Based Care holds promise to transform healthcare— especially for the underserved

By 2030, the Centers for Medicare and Medicaid Services plans to see all Medicare beneficiaries and most Medicaid beneficiaries enrolled in Value-Based Payment (VBP) or Value-Based Care (VBC) programs. Simply put, VBC links the compensation of healthcare providers to patients’ health outcomes in the longer run. The formula holds doctors more accountable for improving the well-being of the people under their care and provides them with sufficient freedom and incentive to deliver the right care at the right time.

VBC is a remedy for the pitfalls of the traditional fee-for-service system. Fee-for-service means doctors and hospitals are compensated for each service they deliver; they are rewarded for volume—they are paid more if they deliver more services, even if these do not achieve the desired result. VBC changes that dynamic by incentivizing the provision of quality care for the good of the patient—bringing costs down in the process.

VBC also offers a solution for the troubled state of healthcare in the US. The country spends a greater percentage of its GDP on healthcare than other countries. Yet, the US sees the highest incidence of preventable deaths and has the highest infant mortality rate. What’s more, longstanding inequality of access to healthcare leaves people of color and the underserved more vulnerable to illness and disease than the rest of the population. VBC promises to revolutionize healthcare for the most vulnerable.

VBC produced significant savings for taxpayers, as better health keeps people out of ERs and costly hospital beds, and all along, doctors are rewarded for doing a better job. The latter depends to a large degree on the coordination of a patient’s care; that means a primary care physician keeps close track of all the services a patient is getting or needs. This includes medical care as well as behavioral health services. Significantly, doctors are also encouraged and rewarded for being aware of patients’ social needs. Such needs would never be attended to in the fee-for-service model.

Quality of care in the VBC is driven by key dimensions, including efficiency, meaning doctors only use resources that are needed; equity in care stipulates that quality of care does not vary based on race, gender, or income; care is centered on the patient and respects values, preferences, and particular needs; and timeliness means care is given without lengthy delays.

VBC models feature different approaches to doctors’ risks. There is an upside-only risk, with doctors getting more revenue if meet or exceed standards when it comes to quality, cost, or equity. A two-sided risk means doctors also stand to lose revenue if they fail to achieve specific measurements of success. This formula is believed to discourage risk-averse doctors from joining VBC programs.

There are also non-financial rewards for doctors who join VBC programs. The freedom to deliver the right aid at the right time can give providers a sense of purpose and mission. Participation in VBC also enhances a doctor’s reputation.

There is growing interest in VBC models on the part of the commercial healthcare sector. It seems clear the significant growth of the model will require that VBC models become more accessible and offer greater incentives, especially for those providers serving disadvantaged populations. Overall, more research is needed to determine the impact of VBC models on patients, doctors, and the healthcare system at large.

There is a success story in New York City, where SOMOS, a network of 2,500 doctors—most of them primary care providers—is serving some one million of the city’s most needy Medicaid patients. Caring for Hispanics, African Americans, and Asian Americans, the organization has been developing a VBC program since 2014, when it joined New York State’s Delivery System Reform Incentive Payment (DSRIP) program—one of the country’s first such programs.

SOMOS puts its doctors in the optimal position to deliver superior care to their patients. Thanks to the work of Community Health Workers—who visit patients’ homes to remind patients to keep medical appointments—doctors learn of the social circumstances of the patients’ households. These are the Social Determinants of Health. For example, mold in subpar housing may impact physical as well as mental health, while poverty can mean that there are no means to buy fresh and healthy foods.

SOMOS transforms doctors’ practices into Patient-Centered Medical Homes, a gateway to all the care needed for patients, with staff keeping close track of, for example, care given by specialists and its contribution to the patient’s overall health. SOMOS doctors bring another dimension to the job: in many cases, they share a cultural and ethnic background with their patients in whose communities they live and work. Their intimate knowledge of their patients’ health needs and their personal circumstances make doctors into trusted figures and leaders of their communities. This dimension is key to SOMOS’s VBC success. That success translated into savings of $330M through a reduction of 25 percent in the number of ER visits and the number of unnecessary hospitalizations.

There is no doubt that the transformation of US healthcare—especially for the neediest Americans—will require the adoption and embrace of VBC programs. Both doctors and patients are the better for it.

SOMOS Community Care-the role of the corporation

 

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