A practice model that puts primary care first

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Properly investing in primary care is the No. 1 lever we can pull to fix the U.S. health care system. Up until the 1970s, everyone pretty much agreed, and primary care was the anchor of our health system. But in response to new reimbursement rules put in place by the government and insurance carriers, hospitals began looking at primary care as a loss leader to get the more lucrative referrals in the door so they could consume expensive services like imaging, cardio work-ups, and colonoscopies.

So, hospitals bought up most of the independent primary care practices and layered on fee-for-service arrangements that compensated providers for volume but not value. A few decades into this test, everyone except the hospitals and the carriers are worse off. Americans are sicker and paying more than ever. Providers and health care workers are burned out and leaving the profession in droves. And fewer med students are electing primary care as their specialty.

Terry Layman, MD, graduated from Indiana University Medical School back in the ‘90s, completed his residency in family medicine, and dutifully returned home to the small town of Marion, Indiana, where he had visions of becoming a physician superhero, ready to change the world. After 20 years of playing the game, his dreams were dashed. “My income was determined by how cleverly I coded, which was determined by how many procedures I did or how sick my patients were. The sicker my patients and the higher my code … the more I got paid. I was continuously battling the hospital, the insurance company, and even my own patients. It broke my heart to leave, but I knew there had to be a better way to practice,” Layman said.

A new model of care delivery

The good news is there’s a new model of care delivery with independent primary care at its core that has the power to reverse all those trends. A care model where providers are encouraged to spend more time with their patients and where the scoreboard prioritizes health outcomes, not visits per day. The model is advanced primary care (APC) delivered directly through employers.

APC is different than traditional primary care for three reasons. First, the primary care provider is the true quarterback of care and proactively manages a panel of patients to help them keep up on annual physicals, close gaps in care, and improve or prevent chronic conditions. Second, the care team provides steerage in the form of data-driven referrals for specialty care, and third, the APC provider puts their fees at risk to increase their accountability for driving meaningful health improvements.

Think of it like an employer-sponsored accountable care organization (ACO). The two biggest health care payers in the U.S. are the federal government and employers. Nearly 150 million Americans get their health coverage at work and about 65% of those plans are self-funded, according to the Kaiser Family Foundation. So employers have some serious skin in the game to see their health economics change. Not only is it good for their business to pay less for health care, it’s also good for business when their employees feel better because it means less sick days and higher productivity. Employers are tired of waiting for the government to fix it, so they’ve begun partnering with employer-sponsored health companies to fix it themselves.

Physician Assistant Steven Gilles worked in a university health care system for 15 years before departing for the employer model two years ago. “The continued pressure to produce and see more patients with less resources was – and is – a recipe for burnout. I want to be in an environment that allows me to provide full-spectrum primary care in the way patients deserve – unrushed, authentic, and easily accessible. I love the culture at our employer health center. Every single person I interact with says, ‘It’s better here.’”

APC in practice

There’s a handful of companies today who deliver this type of employer health model. One of those is Marathon Health, where I serve as the CEO and cofounder.

We founded Marathon Health in 2005 with the express goal of delivering independent primary care to save employers money on their health expenses. Today, we do that by operating dedicated and shared physical and virtual health centers exclusively for employers. According to a 2021 Worksite Health Center Study by Mercer and the National Association of Worksite Health Centers, 31% of employers with 5,000 or more employees offer a health center as part of their benefit package. And we staff our health centers with advanced providers, including MDs, DOs, nurse practitioners and physician assistants, behavioral health specialists, physical therapists, pharmacists, health coaches, nurses, and medical assistants. Each of those specialists working as an integrated care team is a critical part of our model. We also have referral teams that manage any specialty referrals outside of our health center. Our referral team is armed with the patient’s health plan design, and ratings and pricing information from Garner Health, to ensure that we recommend a high-quality, low-cost provider. The team even secures any necessary preauthorizations and schedules the appointment. That white glove service helps deliver a 60% close rate on all referrals, with all the outside data piping back into our electronic medical record (EMR) so our primary care team remains the quarterback of care.

The other thing providers love about operating in this model is not having to deal with payer nightmares. “I don't have to click 100 buttons in my EMR because the payer is tracking my use and tying it to reimbursement,” explains Gilles. “And even if there is a payer situation, I don’t have to understand the quirks of 10 different payers because the employer only uses one.”

Cleveland-based National Director of Physical Therapy Jon Strychasz is hooked. “Having the ability to take the time to work with patients so they are engaged and have a say in their health care journey is what makes this a different type of health care.”

Fast-forward 18 years and we’re seeing incredible results. We’re far past the sandbox and driving toward real scale that can be the tipping point to reverse those trends we talked about earlier.

Empowering care teams

We use the Quadruple Aim of health care to gauge our success which measures outcomes in four key areas – provider experience, patient experience, health outcomes, and financial savings. To create a great provider experience, we want to empower our care teams to build trusted relationships with their patients, so they feel inspired to make behavior changes. Our providers spend an average of 32 minutes with every patient. Because face it, you can’t fix the macro health care problems by only seeing acute cases or only spending seven minutes with a patient like in a traditional setting. To transform health care, we must catch disease early and manage chronic conditions better. Those extra visit times allow for true conversation to happen, for better questions to be asked, and for root causes to be teased out. In seven minutes, you’re not going to learn that a patient with diabetes is also depressed and lives in a food desert. Among annual visits, 65% are preventive, and we have 93% provider retention. “I’m able to be the provider I went to school to be,” says Elizabeth Timpe, a nurse practitioner in Port Charlotte, Florida.

Those empowered care teams are an essential piece to delivering a great patient experience. Getting the employees to engage with our health centers is critical. If we don’t do that, then we can’t make them healthier and we can’t save our clients – their employer – any money. So, we invest a lot in driving strong engagement and have developed a repeatable recipe for success. When employers adopt our best practices, they see engagement of 73%. We’ve got some employers with engagement higher than 90%! Patients that visit our health center come 3.1 times per year on average and report 96% satisfaction.

Aligning with employers

Another reason this model drives such strong engagement is the close alignment our providers have with the employer population. Every workforce is unique – from the way they work to the way they consume health care to the biggest conditions that are driving their spending. Strychasz, the physical therapist in Cleveland, actually goes on the job site of his union laborers and electricians to understand how their physical work impacts their musculoskeletal health. Because of this intimate understanding, he’s able to develop tailored rehabilitation plans and preventive programming. That alignment also builds stronger trust between the employee and the provider. “They are certainly not accustomed to their health care provider taking such a vested interest in their workplace stressors,” explains Strychasz, who often parlays that trust into a successful introduction into the primary care provider.

Gilles agrees. “This setting has more variety and offers more opportunities to interact with patients on a regular basis in what feels like a community. Rather than fighting with employer demands, you become part of the culture.”

With strong engagement, we can drive great health outcomes. We use an 18-month look back to track longitudinal engagement. Through year-end 2022, 69% of engaged patients had improved on one or more biometric markers; 65% of engaged hypertensive members were at clinical blood pressure goals, and 55% of engaged diabetic members achieved their clinical A1C goal. We also saw a 19% reduction in emergency department visits among engaged patients.

Improvements in those categories, in addition to the referral savings we drive, have delivered more than $1 billion in health plan savings for our employer clients. Every engaged patient costs their employer $2,000 less per year than employees who do not engage with our health centers. We’ve also helped them recruit and retain great talent because employees love this free health care benefit.

Too good to be true?

Sounds too good to be true, right? It’s not. Our two biggest growth drivers are getting more employers to adopt the benefit and attracting more providers to deliver it. Today, about 30% of employers offer a health center. Our employer pipeline is bigger than it’s ever been, and we’re actively working to grow our infrastructure and talent pools to support all that demand.

“The traditional system just wasn’t designed to incentivize long term health and wellness, but the employer health model aligns the interest of the patient, the payer (the employer in our case) and the provider,” says Layman, who’s been working in the employer model for 11 years. “I’ll never practice the old way again. Preventive health care is my passion, and I shouldn’t be penalized for being successful at it.”

Jeff Wells, MD, MBA, is the CEO and co-founder of Marathon Health, an employer health company that specializes in delivering advanced independent primary care through onsite, Network and virtual health centers nationwide. Wells earned his MD/MBA in internal medicine from Indiana University. Learn more at http://www.marathon-health.com/careers