As Costs Rise, Texas Doctors Experiment With Care, Payment Models

PLANO — At Village Health Partners, a comprehensive medical practice in this Dallas suburb, patients receive a year’s worth of wellness exams in a single visit, get their e-mails answered 24 hours a day, seven days a week, and have their mammogram or MRI results logged into their electronic medical record by the time they pull out of the parking lot.

Kelsey-Seybold in Houston is like the Galleria of health clinics: It has storefronts for every imaginable specialty, online, same-day, no-referral-necessary appointment scheduling, an on-site pharmacy, even complimentary valet parking.

As the United States grapples with spiraling health care costs and a system that rewards doctors and hospitals for how sick their patients get, not how healthy they become, Texas health care providers are increasingly experimenting with new payment and care delivery models — joining forces to emphasize efficiency and outcomes.

These new models present a culture shift for the state's physicians, who haven't been as quick to shed a kind of "lone ranger" status as some doctors elsewhere in the nation. But it has provided an intriguing benefit for patients, drawn to the convenience and comfort of a system financially motivated to keep them as well as possible.

“Doctors in Texas traditionally haven’t wanted to share resources, to share financial risk, to share clinical information,” said Tom Banning, chief executive of the Texas Academy of Family Physicians. “But there are pioneering groups here that are putting an emphasis on quality and cost efficiency. They’re innovative nationally, and they’re moving the ball.”

A crisis in health spending

The nation faces an undeniable crisis in health spending; by 2020, the country’s health expenditures are expected to reach $4.6 trillion a year, almost 20 percent of the gross domestic product. Roughly half of this spending comes in government programs, a potentially catastrophic hit to state and federal budgets.

Health care experts say the leading contributor to escalating costs is the dominant fee-for-service payment system, where doctors and hospitals are paid per treatment or procedure, and make more when patients get infections or complications. But they fear returning to the HMO model that limited patient choice and gave physicians a financial incentive to ration care.

The solution, health care providers like Village Health Partners, Kelsey-Seybold and others believe, is clinical integration — where groups of family physicians and specialists share electronic patient information, the costs of case management and care coordination, and the latest research on best practices, all with the symbiotic goal of keeping costs low and patients well.

Texas isn’t blazing a brand new trail; nationally, health systems like the Mayo Clinic in Minnesota, the Geisinger Health System in Pennsylvania and Intermountain Healthcare in Utah have long taken this value over volume approach. Scott & White Healthcare, with its 12 system hospitals and more than 60 clinics, has led the integrated care charge in Central Texas.

But with the rollout of federal health reform, and new Texas legislation aimed at paying for performance, not procedures, more and more Texas providers may join the movement. Last month, the United States Department of Health and Human Services launched a pilot program to pay primary care practices a monthly fee if they provide better chronic care management, give patients 24-hour access to care and health information, and collaborate with specialists to better coordinate care.

The Kelsey-Seybold approach

The Kelsey-Seybold clinic has been a gold standard for the multispecialty group practice almost since its 1949 inception. Today, it employs 373 physicians across 55 specialties in 20 different facilities — all of them with in-house labs and x-rays, and wired for the same electronic medical record. Its flagship clinic, which opened in 1999, looks like a gleaming shopping mall, with storefronts for a multitude of services, from pediatrics to women’s health to day surgery. But its most innovative approach may be KelseyCare, a four-year-old so-called “accountable care” plan offered through Cigna where patients, via their employers, have all their health care for a single year provided at a fixed, customized charge.

Enlarge credit: Michael Stravato

“The real focus ought to be on how much it costs to care for a group of patients over a period of time and achieve desirable outcomes,” said Dr. Spencer R. Berthelsen, Kelsey-Seybold’s chairman of the board and managing director. “There’s way too much attention on unit cost — what is the cost of an office visit or a laboratory test or a day in the hospital.” 

To make KelseyCare work outside the fee-for-service model, the clinic relies heavily on electronic medical records, to ensure there’s no duplication in tests run or treatments provided. They have automated best practice alerts, to make sure patients get regular immunizations or mammograms that could prevent more costly ailments down the line. And they make it convenient for their KelseyCare patients — including three-quarters of those employed by the city of Houston — to get the preventative care they need to stay well, from offering same-day online appointments to housing specialists mere feet from their primary care partners. 

There’s no rationing of care, Kelsey-Seybold executives say — not only would it be unethical, but it would be ruinous to an organization’s reputation. But when a patient comes in with back pain, their doctors don’t rush to perform a costly MRI for a slipped disk; they wait to rule out a far more common muscle strain first.

“It’s designed to elevate the quality of care and take out unnecessary costs, which is a fundamental shift from the prevailing health care system,” Berthelsen said. “There are many things that don’t really help patients, but cost a fair amount of money.”  

Multi-specialty care in North Texas

At Village Health Partners, the anchor tenant for Plano’s 100,000-square-foot Legacy Medical Village, the payment model hasn’t shifted away from fee-for-service yet. The various physician practices at Legacy remain independent, and their doctors self-employed. But founder Dr. Christopher Crow’s idea is similar: Attract patients by making care accessible, convenient and high quality, and reinvest the profits into measuring what works.

As a family medicine physician fresh out of medical school, Crow watched, frustrated, as his patients waited days for lab results, and weeks to get in to see specialists, while their health suffered. “It was like going to McDonald’s and being told to come back in four days,” Crow, now 40, says. “I wanted to build a place where everything was built around access and convenience.”

So he did, opening Legacy Medical Village, a sprawling health complex that, four years later, is now home to 14 primary care physicians and 30 different services and specialty practices that provide comprehensive treatment, from oncology and bariatric surgery to physical therapy.

Legacy Medical Village has a wide range of tenants: a workman’s compensation program, behavioral and weight loss therapy, a sleep study center and a headache department. It runs research trials and has an in-house dentist.

But care is centered around the family medicine linchpin, Village Health Partners, which coordinates the care of its 45,000 patients with electronic records technology, case managers, around the clock email responses and phone pick-up guaranteed within 60 seconds.

The clinic doesn’t accept Medicaid — few residents in Plano’s Legacy community are poor enough to qualify. But it’s a go-to for the region’s corporate headquarters, whose employees can get a litany of preventive and wellness exams in the span of an afternoon, as opposed to taking several days a year off of work. And Crow says the model could be reproduced virtually anywhere — once Texas doctors get past their fierce independent streak.

“Anywhere there’s a population of patients who need health care, these synergies can be stuck together,” Crow said. “The individual models foster zero coordination of care. The physician-led organization is the solution.”