Better Models for the Business of Medicine

Better Models for the Business of Medicine

A practice that has revived the good old-fashioned house call with a high-tech twist.

A business that lightens the administrative, financial and regulatory loads on health care providers.

Physicians who slipped the chains of accepting health insurance so they can care for their patients on their own terms.

These are alumni who have applied what they consider better models for delivering health care. They’ve reshaped medicine’s business side to get back to practicing its art of providing high-quality, patient-centered care.

Jennifer Hamre

Grad offers toolbox for the doctor’s bag

Carroll Pinner III, M.D., and his son, Ben Pinner, M.D., know how to provide excellent patient care. Carroll’s grandfather, Carroll Sr., opened a clinic in 1915 by the Broad River in rural Peak, SC. Carroll III joined in 1975, and Ben represents the fourth generation of Pinners in the practice. Now, with John Herbert Ferguson, M.D., and a small staff, they serve approximately 6,300 patients.

“It’s a great privilege to be able to do what I do,” Ben says.

The management aspect, however, can be a great headache. “Medicine is evolving to become more outcomes-based, which has created challenges for an independent practice like ours,” he adds. “For us to keep track of our performance, we knew that was beyond the abilities and time of our staff.”

That’s why, when the clinic chose to pursue recognition as a Patient-Centered Medical Home (PCMH) in 2014, they turned to Jennifer Hamre, M.H.A.’09, and her partner, Leslie Britt, M.P.H., CMPE. PCMH standards and recognition are issued by the National Committee for Quality Assurance (NCQA), a private, nonprofit organization focused on improving health care quality by accrediting and certifying clinicians and practices in key areas of performance.

“The goal is to give a patient a medical home that follows through with obtaining any specialty care, getting medications and making sure the patients have no barriers to getting the care they need,” Hamre says. “But it’s complicated for practices to get PCMH recognition on their own.”

Jennifer Hamre says her business works to relieve administrative burdens on physicians and staff so they can focus on providing great patient care.

She and Britt, who had met while working as administrators at a private medical facility, co-founded Solace Solutions in 2015 to help health care providers and organizations achieve the “triple aim” of improving health outcomes and patient satisfaction while reducing the cost of care. Both have broad experience in health care administration, quality and regulatory compliance, technology, staff development and more. Based in Chapin, SC, the company provides a wide range of services onsite and remotely.

Jennifer Hamre, M.H.A.’09
Jennifer Hamre, M.H.A.’09

“As a health care administrator, I found that many health care providers and practices are completely overwhelmed with their overflowing plates relating to things such as electronic health records, quality initiatives, the revenue cycle, clinical and non-clinical operations, financials – the list goes on and on,” Hamre says. “We want to help by taking those burdens off administrators and physicians, which ultimately puts the focus back on providing great patient care.”

Pinner Clinic received recognition as a PCMH Level 3 practice in 2015, and Solace Solutions helped its staff in other ways. Hamre and Britt have implemented and trained clinical staff on quality metrics for electronic medical records, helping close gaps in care; coached nonclinical staff on patient interaction; devised cost-saving strategies and helped improve revenue tracking, billing and coding. Hamre also created a new website for the clinic that’s “much more interactive for patients,” Ben Pinner says.

“They’ve really touched on every aspect of our practice,” he adds. “We’ve prided ourselves on retaining our independence. Jenny and Leslie have been instrumental in our ability to do that.”

Hamre credits DMU classmate and mentor Kevin Kincaid, M.H.A.’09, for encouraging her and giving her a front-line position when he was chief operating officer at the Dallas County Hospital in Perry, IA.

“It was an entry-level job, but she jumped into it with the same energy and passion she would in a C-suite position,” says Kincaid, now chief executive officer of the Knoxville, IA, Hospital and Clinics.

Hamre and Britt gain the most satisfaction from helping their clients – most of which are privately owned – navigate regulatory and financial complexities and regain the joy of providing care. Hamre describes the house calls Pinner Clinic physicians often make to enhance their patients’ well-being.

“These doctors make it easy for me to go to bat for them every day,” she says. “They’re fighting to keep patients seen as people and not just another chart number and, therefore, to keep quality care at the forefront.”

Nilesh and Mehak Nangrani

Using technology to take health care to patients

Nilesh Nangrani, D.O.’11
Nilesh Nangrani, D.O.’11

Imagine you’re the parent of three children and your spouse is out of town. At 2 a.m., one of the kids wakes up with a high fever and abdominal pain. Do you take the chance of waiting it out, or do you bundle up all the kids and go to the local emergency room?

Or let’s say you’re an aspiring corporate executive who is set to make an important presentation in two days that you hope will dazzle the higher-ups. But you’ve got a vicious sore throat that threatens to lock up your voice. Your doctor can’t see you till next week. Do you go to the nearest urgent care clinic, hoping that you 1) won’t have to wait for hours and 2) won’t catch something worse from other patients?

If you live in the Dallas/Fort Worth area, you can opt instead to contact UrgentCare2go and have the care you need come to you. Co-founded in 2016 by husband/wife Nilesh Nangrani, D.O.’11, and Mehak Dhingra Nangrani, D.O.’11, and Nilesh’s cousin, Arti Nangrani, office manager, and joined by Saji Pillai, M.D., FHM, as chief medical officer, the innovative service provides the modern-day house call.

“It’s the bridge between the old-fashioned house call and telemedicine technology,” Nilesh Nangrani says. “We’ve combined these two models.”

Here’s how it works: First, patients register via the company’s website, providing information about themselves and their complaint. A certified medical assistant (CMA) is deployed to each patient’s home, armed with exam equipment and supplies. At home, the patient receives the CMA’s name and profile, a criminal background check and the latest results of a random drug screening. A background check on the patient is also generated for the CMA. The patient then can track the CMA online while he or she is en route.

Upon arrival, the CMA checks the patient’s vital signs and then connects the patient via telemedicine to the UrgentCare2go doctor on call, who uses a digital stethoscope and multiple cameras to conduct a comprehensive physical exam. The CMA can perform basic diagnostic tests, such as for strep throat and influenza, and provide oral and injectable medications the doctor prescribes.

UrgentCare2go is available 24 hours a day, seven days a week, 365 days a year. “We provide convenient, affordable, accessible and high-quality care to people whenever they need it,” Nilesh says. “People actually enjoy house calls. They’re like the on-demand services people want these days.”

The company’s growth reflects that. It started with two CMAs and one mobile unit serving patients in a 10-mile radius. Now, its 12 CMAs and six mobile units deliver care to more than 500 patients a month across the Dallas/Fort Worth metro. The staff also now tracks live traffic conditions to give patients a faster and more precise estimated time of arrival.

Nilesh credits the use of social media for the company’s initial success. With posted reviews such as “Best experience ever!!” and “What an awesome and convenient service!” and positive posts on blogs like “WiseMommies,” word spread like a fast-moving flu bug. Now word-of-mouth referrals and repeat customers are building their client base.

“Our patients don’t have to sit in a waiting room, wait three weeks for an appointment or go to an emergency room or urgent care clinic,” he says.

UrgentCare2go also offers transparency not typical in American health care: The costs of all its services, from the $79 home visit to various tests and medications, are posted on its website.

“We don’t believe in hidden costs. There are no surprise bills,” Nilesh says.

Payment is accepted in cash, by credit card or charged to the patient’s health saving account or flexible spending account. The company doesn’t accept health insurance or Medicare. “This is a completely new health care model – there’s no checkbox for a service like this on insurance applications,” he says. “But we’re often more affordable, especially for people with high deductibles.”

Nilesh continues to work full-time at a local emergency room “to pay the bills,” but he expects UrgentCare2go will generate more than $1 million in revenue in 2017 and then continue to grow nationally.

“If Obamacare is repealed, people won’t be guaranteed or forced to buy into health insurance,” he says. “They’ll be looking for more cash-based services
like this.”

Direct primary care

Alumni give up insurance to give better care

Todd Johnson and Haseeb Ahmed didn’t cross paths as DMU osteopathic medical students, and they practice in different states. But they’re both part of a small but motivated movement in medicine, direct primary care (DPC), that lets them fully focus on taking care of their patients. They each opened the first membership-based, insurance-free practice in their state – Johnson in Lincoln, NE, in 2016 and Ahmed in Overland Park, KS, in 2015.

“I want to build relationships with my patients in more than a seven-minute appointment. That’s an acquaintance, not a relationship,” says Johnson, D.O.’00, FAAFP, who previously worked for a large health system. “Now I have patients for life.”

Ahmed, D.O.’07, M.H.A.’07, previously was the medical director also for a large health system, where he felt patient care was defined too much by the rules and paperwork of insurance. “The health care system has so many stakeholders, and the patient is not front and center,” he says. “I’d do my checkboxes, but driving home I knew some patients would be readmitted. It was sucking the joy out of me.”

Todd Johnson, D.O.’00, FAAFP
Todd Johnson, D.O.’00, FAAFP

Now, the two physicians’ patients pay a monthly membership fee, based on their age, which includes virtually unlimited visits and no co-pays or hidden fees. Both physicians offer discounted lab and imaging services and have pharmacies in their clinics from which they dispense medications and equipment at cost. Patients also have a direct line to their physician in the clinic or via phone or email. 

“I should have access to my patients, and they should have access to me,” Ahmed says in a video on his clinic’s website, Health Suite 110. “They should be able to come through my doors and see me that day or the next day. And when you call, you shouldn’t get a secretary or an annoying voice mail.”

“This is my office phone,” says Johnson, pointing to his cell phone. “I can take the office with me and still take care of patients.”

Literally: He once got a call from a patient with an injured ankle on a ski slope in Breckenridge, CO, worried whether he needed to go to the emergency room. Johnson advised him to first see if the swelling would diminish on its own. It did, sparing the patient the expense of an emergency room visit. Another patient texted him a photo of his red, irritated eye while both men happened to be at a Nebraska football game. Johnson set him up with eye drops that treated the problem.

“Practicing like this is so much more fun, and people are so appreciative,” he says. “And when people pay a membership, they are more engaged in their health. I know they’ve gotten their medications, so compliance goes way up.”

Both physicians recommend their patients have some form of insurance for medical catastrophes, in the same way they have car insurance in case of a collision. “You don’t use your insurance to pay for gas and oil changes,” says Tiffany Johnson, Johnson’s spouse and manager of their practice, Access Family Medicine. “Let’s use health insurance for what it was intended for – the unexpected.”

Educating patients about DPC does take effort. “Literally, we went door to door. I have a new respect for people who do cold calls,” says Ahmed about himself and his clinic co-founder, Kylie Vannaman, M.D. “We’d talk to anyone. They ask, ‘I have insurance; why would I also pay a monthly fee?’ With co-pays and all the other nickel-and-diming that goes on with insurance, people don’t realize how crappy their care is or their lack of care. DPC patients get better care and a better return.”

Now word of mouth is his clinic’s best marketing tool. “Especially from patients who’ve been most neglected,” he notes. “I spend 60 minutes with that person and provide low-cost medications, they’re going to tell the world.”

Haseeb AhmedDirect primary care providers say the model lets them focus on patients, not paperwork. “It’s really about surrounding patients with the resources they need to lead a healthy lifestyle,” says Haseeb Ahmed.

Johnson says that some of his patients save so much with his services, it pays for their membership in his practice. He describes a patient who’d been incorrectly diagnosed with multiple sclerosis and whose severe back pain resulted in hospitalization. Released by the hospital, the patient received osteopathic manual manipulation by Johnson, “popped off the table and walked out without a walker.”

“This is just better care for people – lower costs and higher patient satisfaction,” he says. “Plus all these primary care doctors have a twinkle in their eye. This could solve the physician shortage.”

“All these doctors” are the ones Johnson has met through learning about and practicing DPC. He’d read about the model and then heard about a conference on the topic that he and Tiffany attended. “The guy next to me had to be pushing 65, and he’d just opened his practice,” Johnson says. “He really caught my attention. He was able to go back and do what he loved to do.

“DPC has a wonderful network,” he adds. Johnson got on board and worked with Nebraska Senator Merv Riepe to craft state legislation that defines DPC and promotes it as a way to “improve access to medical care, reduce the use of emergency departments for primary care, and allow emergency departments to treat emergencies more effectively and reduce costs.”

According to the Direct Primary Care Coalition, more than 500 DPC clinic physicians are practicing in almost all 50 states, numbers that are estimated to grow steadily. However, the coalition emphasizes that health care’s constantly evolving landscape and other types of free-market health care delivery models in practice make those estimates somewhat uncertain.

Like Johnson, Ahmed and his partner are DPC champions. They established the Midwest Direct Primary Care Alliance, which meets quarterly to educate and serve clinics in the Kansas City area. He also strives to inspire medical residents from the University of Missouri-Kansas City whom he teaches.

“I really want to get in front of those students and encourage them to think outside of the box,” he says. “As medical students, we get trained to be part of a medical system as employees. We don’t think about autonomy or continuity of care.”

DPC advocates say the model allows physicians to fulfill the reason they went to medical school. Johnson, who knew he wanted to become a doctor since ninth grade, has approximately 600 patients, with a growing base from patient referrals and small business owners who want to provide some type of health coverage for their employees. Ahmed, who in grade school did medical billing for his physician-mother with a typewriter and carbon paper, and his clinic also have approximately 600 patients, including in other states and as far away as London.

“As a physician, you will come to a point in life when you’ll ask, ‘What’s my greater purpose?’” he says. “Being able to provide primary care at its essence is awesome.”

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