Wednesday, August 14, 2013
Hanover — An experimental primary care practice that was launched nearly 11/2 years ago to treat Dartmouth College employees appears to be exceeding expectations in its effectiveness.
The practice at 7 Allen St. known as Dartmouth Health Connect has four times the number of patients it had at its inception in March 2012, now treating 1,200 individuals. Several new staff have been added and the owners are planning to expand the facility by January.
The practice, run by for-profit Massachusetts health care company Iora Health, intends to move into vacant space within the building it currently occupies, formerly home to Omer & Bob’s bike shop. The company could file for its town permit as early as this week, according to Iora CEO Rushika Fernandopulle.
But more than adding space and patients, the early indications about the quality of care and ability to control health costs are “going in the right direction,” said Fernandopulle. Patients seem better able to manage chronic conditions such as high blood pressure and diabetes, and satisfaction remains high, he said.
Many questions remain about Dartmouth Health Connect’s model, which sets up individual patients with a health care “team” and uses a capitated payment system. One question is whether this method of delivering care, which costs twice as much as the traditional primary care model, will lead to less overall health care spending. But Fernandopulle, college officials, the providers and the patients believe it could serve as an example for reforming primary care in the United States.
“It’s going great,” said Melissa Miner, director of health promotion and wellness at Dartmouth. “We think about the initial vision of providing an opportunity for our employees and their covered family members to have access to high quality, innovative care with a care team to support them. I think the employees have really spoken for how the model is working, through enrollment and through the feedback.”
A pioneer in health reform, Fernandopulle’s work has been written about extensively, including in a story that appeared in The New Yorker in 2011. He has opened similar practices in Seattle, Atlantic City, N.J., Las Vegas and Brooklyn, N.Y., and continues to establish new ones.
His model dispenses with the traditional physician-centered type of care and replaces it with a team approach, the linchpin of which is a “health coach.”
The coach — who does not have to have a background in health care — helps the patient manage her condition. The coaches take care of the “blocking and tackling,” Fernandopulle said, of everyday care by meeting with patients during office visits, checking in with them by phone or email to make sure they are staying on top of medication. The coaches also develop a plan for addressing the patient’s health problems and also coordinate with the other providers on the team, which includes a physician and possibly a nurse, behavioral health specialist or others.
Dartmouth contracts with Iora to provide the service, paying a monthly fee for every employee who enrolls. Patients are not billed for office visits and the cost to them is the same as if they were to enroll in Dartmouth’s traditional health insurance plan. The extra cost is borne by the college.
The payment structure is designed to remove the incentives in the fee-for-service model that might otherwise influence decisions about care. Doctors aren’t paid according to the volume of treatments they provide and, in theory, are less likely to call for unnecessary tests.
Organizing payments this way also gets rid of the administrative headaches that bog down so much of the rest of the health care system, said Chris Spelman, a health coach and the practice operations manager.
“I used to spend three quarters of my time on billing and compliance,” said Spelman, who worked in health care for 10 years prior to joining Dartmouth Health Connect. “So much of the work was about overly complicated billing system and not taking care of people.”
The close relationship between patient and coach has been interesting to see, Spelman said. Sometimes, patients will come in and visit with the coach without needing to see the doctor. Not everybody needs weekly check-ins with their health coach. But they have the option.
The practice has also been accessible to patients. About a quarter of the appointments at Dartmouth Health Connect are same-day, said Miner, who is herself a patient.
The model continues to be a work in progress as providers adjust to the needs of the local population, Spelman said. But it has been a place where the providers and patients feel quite comfortable.
“There’s a level of comfort here that would be difficult to replicate,” he said.
Michael Blumenauer, a 46-year-old Plainfield resident, said the notion of a coach for his health care was new to him. He didn’t grow up playing sports and had little experience with coaches, generally. But having someone who could work with him on the daily management of his health has led to significant improvements in his health.
A diabetic, Blumenauer had “quite elevated” blood sugar levels when he enrolled at Dartmouth Health Connect shortly after it opened. Now, his blood sugar is down to normal, he said. He gives much of the credit to his health coach, Tyler Hanna, whom he said was “always encouraging, always practical.”
“(The health coaches) are how do you manage this on a day-to-day basis in a very practical sense,” Blumenauer said. “You have an event coming up, let’s talk about that. ...They really break it down into a day-by-day, practical approach, because that’s what works for me.”
Health coaches have become so popular that Dartmouth has expanded the concept to the rest of its employees. The college has a contract with Iora to offer three “field coaches” to employees who aren’t patients at Dartmouth Health Connect.
The coaches are available around campus to meet with people, answer questions and help them develop a plan for improving their health, Miner said.
Patient satisfaction measured on surveys is high, said Miner. Nine out of every 10 patients said they would recommend the practice to a friend or coworker, she said.
The jury is still out on quality and cost. Iora is working with The Dartmouth Institute for Health Policy and Clinical Practice to study how well Dartmouth Health Connect is doing on those fronts.
There’s not enough data yet to make any firm conclusions, Fernandopulle said, but the early results are promising.
Nearly 90 percent of Dartmouth Health Connect patients with hypertension now have their blood pressure under control, Fernandopulle said. Diabetic patients such as Blumenauer have also shown significant progress managing their blood sugar.
Whether or not the expense of these upfront investments in primary care will be returned in “downstream” savings — via reduced emergency visits and costly specialty care — remains to be seen.
“Unfortunately, it takes a long time to see that,” Fernandopulle said. “But we’re seeing the trend going in the right way.”
Dartmouth officials declined to say how much they were paying Iora to run Dartmouth Health Connect. The college has a five-year contract with the company, which can be terminated by either party after two years.
Neither side said they intended to give up on the partnership.
Health reform advocates have argued for greater investment in primary care with a goal of keeping patients healthy and out of hospital emergency rooms, which contribute to the high cost of care. Currently, the nation spends only about 4 percent of its health care dollars on primary care, Fernandopulle said. Doubling that investment in order to improve overall health should not be too much to ask, he said.
“The whole proposition here is that by spending a little more resources and being smarter about primary care and prevention,” health care becomes less expensive, Fernandopulle said. “That’s the bet that Dartmouth and us are all making. That investing 4 percent in primary care is a stupid investment philosophy.”
“There’s permanency to this practice,” said Tricia Spellman, assistant vice president for finance at Dartmouth, and also a Dartmouth Health Connect patient. “That’s what’s important about the model is the long-term relationship between patient and the clinician. We really want our employees to feel like they can make the change, go there and it’s not going to close tomorrow.
“It’s going to continue.”
Chris Fleisher can be reached at 603-727-3229 or cfleisher@vnews.com.