Nearly five years ago, leaders at Bellin Health in Green Bay, Wis., recognized that their employed primary-care physicians were burning out at least partly due to too many hours spent on recordkeeping and not enough on direct patient care.
In addition, nurses and other staffers besides physicians felt their skills weren’t being fully utilized. Quality scores had plateaued, with significant variation between primary-care sites. And there wasn’t adequate care coordination for patients with chronic conditions to keep them healthy and out of the hospital and emergency room.
So in 2014, Bellin leaders launched a program, for patients of all ages, to transform care delivery by the not-for-profit system’s 120 primary-care teams at its 29 clinics. That rollout, which experienced some financial glitches and revisions along the way, will be completed this month. A key element is adding support staff and increasing their care responsibilities to enable physicians to see more patients more efficiently.
The challenges at Bellin were similar to those facing other primary-care practices across the country. Poorly designed delivery systems have led to widespread job dissatisfaction among physicians. And patients are unhappy that it’s often hard to get in to see the doctor and typical visits are too short.
“There are solutions available, but what frequently gets in the way is an economic mindset based on operational costs rather than opportunity costs,” said Dr. Christine Sinsky, vice president of professional satisfaction at the American Medical Association, who advised Bellin throughout the process.
Bellin leaders began making site visits to primary-care experts in other states, including Sinsky, who had developed innovative team-based, preventive models to improve quality of care and enhance patient and provider satisfaction. In November 2014, Bellin began testing its new model with one family physician, Dr. James Jerzak, and his team of medical assistants and nurses.
Responsibility for pre- and post-visit patient work was handed off from Jerzak to the medical assistant and licensed practice nurse on his team, who were designated care team coordinators.
During the physician’s exam, the care team stayed in the room to enter information in the electronic health record so the doctor could focus on the patient, said Kathy Kerscher, Bellin’s director of primary care. After the doctor left, the care team followed up with the patient on physician orders and scheduling future appointments.
“When I get in the room, I look directly at the patient and engage, which is how medicine was meant to be,” Jerzak said.
Another key element was expanding the role of the care team’s registered nurse in working with patients, often without the patient having to see the physician. This included educating patients and helping them set goals to help manage chronic conditions.
Along the way, Bellin ran into an unanticipated problem. Each team got an additional care team coordinator, with the expectation that they would be able to see at least two or three more patients a day, covering the cost of the extra staffer. But that didn’t happen with all the teams, leading to financial losses.
So Bellin set staffing ratios. Those seeing at least 19 patients a day got two coordinators per provider, those seeing 15-18 patients got 1.5, and those seeing fewer than 15 patients got one. Plus, patient loads grew. Jerzak said his panel size has increased from about 1,800 to 2,000 since the program started.
“I’m in a mode now where I’m feeling somewhat overwhelmed with new patients,” he said. “My time with each patient is probably a little bit less. But patients feel they’re getting more time because I don’t have to do all the computer work in the exam room.”
While some operators of team-based primary-care models say this approach works best financially under value-based payment, Kerscher said Bellin is succeeding even though nearly half of its primary-care visits are reimbursed under traditional fee-for-service. Bellin reports that due to the team-based model, it’s receiving an average of $724 more in payments per patient per year.
One way it’s achieved those results is by maximizing use of Medicare’s billing codes for annual wellness visits, chronic care management and care transitions, which all help cover the costs of the between-visits work by non-physician staffers.