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Monday, November 27, 2023, 2:00 - 3:00 pm ET

ADFM Hot Topic Discussion:

Primary Care Service Line

Presented by members of the ADFM Healthcare Delivery Transformation Committee/ Moderator: Rich Wender, MD, Chair, University of Pennsylvania

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Overview

Introduction: Rich Wender, MD, University of Pennsylvania (5 mins)

Presentations (20 mins total)

5 mins: Anna Flattau, MD, MS, Jefferson University
5 mins: Grant Greenberg, MD, MHSA, MA, Lehigh Valley Health Network
5 mins: Paul James, MD, University of Washington

Open to Q&A (35 mins+)

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Background / Context on this issue

Framing for Rich’s intro

Fundamental questions: Our department are profoundly affected by the relationship between the school, hospital, and the health system. Some of us work in a structure with only a hospital and a system. THis has a big effect on money flow and accountability – and alignment of missions. And how value is perceived. IN a way, gets to the fundamental question of what is the purpose of primary care? The answer needs to remain clear: It’s to improve health of the population – not to be a referral source or a cost control source or a money generating source through value based payment. Those are factors that can sustain primary care.

Most and probably all of us are in a structure that has faculty physicians and non-faculty family docs and other primary care docs. Does the structure pose a threat or serve as a strength? What is the role of the chair in helping this to thrive.

How is primary care organized at your institution and how does it relate to the Department?

Does your system have some –overarching structure to which everyone in primary care belongs? Are there completely separate structures for the academic departments and community based primary care? Who does the hiring? Is the Department involved with hiring the non-faculty primary care docs?

Why does any of this matter? In what way does the structure pose a threat to the department? IN what way does it become a strength of the department?

What is or should be the role of the chair with the primary care docs who aren’t full time with the department?

Does specialty matter? Are the internists and pediatricians hired in a different structure than the family docs?

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Jefferson University

Presented by

Anna Flattau, MD, MS

Framing for Rich’s intro

Fundamental questions: Our department are profoundly affected by the relationship between the school, hospital, and the health system. Some of us work in a structure with only a hospital and a system. THis has a big effect on money flow and accountability – and alignment of missions. And how value is perceived. IN a way, gets to the fundamental question of what is the purpose of primary care? The answer needs to remain clear: It’s to improve health of the population – not to be a referral source or a cost control source or a money generating source through value based payment. Those are factors that can sustain primary care.

Most and probably all of us are in a structure that has faculty physicians and non-faculty family docs and other primary care docs. Does the structure pose a threat or serve as a strength? What is the role of the chair in helping this to thrive.

How is primary care organized at your institution and how does it relate to the Department?

Does your system have some –overarching structure to which everyone in primary care belongs? Are there completely separate structures for the academic departments and community based primary care? Who does the hiring? Is the Department involved with hiring the non-faculty primary care docs?

Why does any of this matter? In what way does the structure pose a threat to the department? IN what way does it become a strength of the department?

What is or should be the role of the chair with the primary care docs who aren’t full time with the department?

Does specialty matter? Are the internists and pediatricians hired in a different structure than the family docs?

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Jefferson University

Overview of Department:

Private non-profit organization
53 university faculty
>400 primary care providers Clinical Non-Faculty Providers
5 (soon to be 6) residency programs; university program has 30 residents
98 Clinical Sites
944,000 visits per year

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Jefferson University

Jefferson Primary Care: ~600,000 empaneled patients
Providers are employed (CIN is separate structure)
Includes FM, IM, and Pediatrics
426,000 in Value Based Contracts, of which 57% commercial, 18% Medicaid, 25% Medicare.

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Jefferson University

Chair and Enterprise Leader is combined role including:

Growth
Transformation to value
Interprofessional care team redesign
Integration with Jefferson Health Plan
Strengthening quality programs including and beyond contract-based metrics
Build-out of social needs program
Community partnerships

What are your biggest pressure points with your service lines?

“New” organization is building foundational structures and processes that do not yet exist (both challenge and opportunity)
Opportunities for alignment of academic activities at enterprise scale
Need to more explicitly integrate health equity perspectives in quality and experience

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Lehigh Valley Health Network

Presented by

Grant Greenberg, MD, MHSA, MA

Framing for Rich’s intro

Fundamental questions: Our department are profoundly affected by the relationship between the school, hospital, and the health system. Some of us work in a structure with only a hospital and a system. THis has a big effect on money flow and accountability – and alignment of missions. And how value is perceived. IN a way, gets to the fundamental question of what is the purpose of primary care? The answer needs to remain clear: It’s to improve health of the population – not to be a referral source or a cost control source or a money generating source through value based payment. Those are factors that can sustain primary care.

Most and probably all of us are in a structure that has faculty physicians and non-faculty family docs and other primary care docs. Does the structure pose a threat or serve as a strength? What is the role of the chair in helping this to thrive.

How is primary care organized at your institution and how does it relate to the Department?

Does your system have some –overarching structure to which everyone in primary care belongs? Are there completely separate structures for the academic departments and community based primary care? Who does the hiring? Is the Department involved with hiring the non-faculty primary care docs?

Why does any of this matter? In what way does the structure pose a threat to the department? IN what way does it become a strength of the department?

What is or should be the role of the chair with the primary care docs who aren’t full time with the department?

Does specialty matter? Are the internists and pediatricians hired in a different structure than the family docs?

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Lehigh Valley Health Network

Overview of Department:

Community-based non-profit Health System with Academics and Research
Number of Clinical Faculty 35 (approx) across 2 residency programs (note 80+ have academic appointments and actively teach medical students)
Number of Clinical Non-Faculty Providers: 160 (approx)
Number of Residents: 32 (will be 36 as of 6/2024)
Number of Clinical Sites: 46
Number of visits per year in the department: 425,945 last FY (13.5% telemed)
List your medical groups: Lehigh Valley Physicians Group, Medical Associates of the Lehigh Valley

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Lehigh Valley Health Network

List your service lines and their size:

Family Medicine: 137 cFTE

General Internal Medicine: 89 cFTE

ExpressCARE: 79 cFTE

763,359 Primary Care visits and 381,602 expressCARE visits FY22

Do you employee all the physicians in your service line? Yes
Who makes up your primary care service lines? see above
List percentages of patients with:

Value Based Contracts 20% (approx)
Fee for service 80% (includes MA)
Payor Mix 40% commercial, 40% medicare, 20% medicaid

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Lehigh Valley Health Network

Are you the leader of your service lines or do you partner with someone else? I am the “Chief Medical Executive of the Primary Care Service Line”

If you are the leader, what are your biggest issues in this role?
Herding Cats, Operational Mandates without concomitant resources or understanding of operational and clinical reality associated with these asks
Balance between the art of medicine, value, patient-centeredness, and finance/volume/visit pressures impacting well-being and morale

What are your biggest pressure points with your service lines?

Cultural development and alignment with Internal Medicine Physicians and their leadership

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University of Washington

Presented by Paul James, MD

Framing for Rich’s intro

Fundamental questions: Our department are profoundly affected by the relationship between the school, hospital, and the health system. Some of us work in a structure with only a hospital and a system. THis has a big effect on money flow and accountability – and alignment of missions. And how value is perceived. IN a way, gets to the fundamental question of what is the purpose of primary care? The answer needs to remain clear: It’s to improve health of the population – not to be a referral source or a cost control source or a money generating source through value based payment. Those are factors that can sustain primary care.

Most and probably all of us are in a structure that has faculty physicians and non-faculty family docs and other primary care docs. Does the structure pose a threat or serve as a strength? What is the role of the chair in helping this to thrive.

How is primary care organized at your institution and how does it relate to the Department?

Does your system have some –overarching structure to which everyone in primary care belongs? Are there completely separate structures for the academic departments and community based primary care? Who does the hiring? Is the Department involved with hiring the non-faculty primary care docs?

Why does any of this matter? In what way does the structure pose a threat to the department? IN what way does it become a strength of the department?

What is or should be the role of the chair with the primary care docs who aren’t full time with the department?

Does specialty matter? Are the internists and pediatricians hired in a different structure than the family docs?

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University of Washington

Overview of Department:

State Institution: University of Washington Medicine
Number of Clinical Faculty: 150
Number of Clinical Non-Faculty Providers: Advanced practice providers at 1 hospital: about 5
Number of Family Medicine Residents: 30 at UW: 730 across WWAMI
Number of Clinical Sites: 15
Number of visits per year in the department: 350,000
List your medical groups: University of Washington Physicians, Department of Family Medicine and UW Medicine Primary Care.

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University of Washington

List your service lines and their size: Primary Care, Hospitalist, Women’s & Children, Palliative Care, Spine and Sports Medicine, Urgent Care and Virtual Care
Do you employee all the physicians in your service line? Yes & No
List percentages of patients with:

Value Based Contracts: Less than 5%.
Fee for service: 95%
Payor Mix: 58% Commercial, 24% Medicare, 13% Medicaid

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University of Washington

Are you the leader of your service lines or do you partner with someone else? Chair and Associate Dean for Primary Care

I partner with the service line medical director who is an internist and we work well together. The major challenge is misalignment of the funds flow.

What are your biggest pressure points with your service lines? The anemic primary care infrastructure and emphasis that primary care is prevention and chronic disease outpatient management to the exclusion of other members of the community with acute and disabling conditions.