Big medicine is, understandably, nervous about the large number of seniors that will start coming into doctors' offices, especially since they will also be handling millions of more patients from the Affordable Care Act.
This is the second part of a three-article series about gerontology, which author Eric Anderson, MD, wrote as a MetLife Fellow.
Health delivery in southern California has long been delivered by large institutions. Physicians applying for employment were more or less told, “You get half your pay in money and half in sunshine.” It was hard for an individual doctor with the classic entrepreneurial spirit of the physician to survive, let alone compete, so the large medical groups grew bigger and bigger and finally dominant.
I wanted to see if such efficient groups had thought about the Baby Boomer challenge. The big players in San Diego are my former group, Sharp Rees-Steal Medical Group, and Kaiser Permanente, followed by the UCSD Medical Group and the fabled Scripps Clinic with all its history of treating Hollywood celebrities. The two latter groups were non-responsive to my emails and telephone calls, and I recall talking when I first came to San Diego in 1985 with a general practitioner who had somehow maintained a private practice in El Cajon, a separate incorporated town 15 miles to the east.
“On any medical issue” he said, “you will find UCSD too academic to understand the problem and the Scripps Clinic too elitist to care.”
More recently I reached out to him again about how I only received two out of four responses.
“The fact that two sources ducked you is telling to me,” he said. “Big medicine is very nervous about all the changes and their spokespersons don't want to be on record saying this or that!”
Sharp Rees-Stealy Medical Group
I start by calling on Donald Balfour III, MD, the medical director of Sharp Rees-Stealy, a group formed in 1923 when internist Clair Stealy and surgeon Clarence Rees fashioned the first such integrated clinic in the city.
Balfour, a balding, reserved former internist, supervises 1,850 employees and more than 400 physicians at 20 locations throughout the county. The group had more than one million patient visits last year.
A framed celebration of the group’s history going back to its 75th anniversary hangs on the wall outside Balfour’s office It shows photographs of Stealy and Rees and the date 1923 when the two came together. It shows other dates such as 1927 when Lindbergh took off to the east in his San Diego-built airplane and his flight into history. The date 1943 is listed when penicillin came into medical use and presciently the date 1944 when the first official baby boomer was born. A prophetic touch for this discussion and since health care has become big business the ceremonial shovel from an earlier expansion of the group in 1987 is a reminder that expansion has long been needed in health care delivery.
While increased numbers of Medicare patients might tax some physicians’ resources, Balfour is quick to point out that the Baby Boomers aren’t even the only concern.
“It’s not just more seniors coming into doctors’ offices,” Balfour said. “California physicians will see six to seven million more from the Affordable Care Act (ACA) alone.”
With numbers like that maybe a shovel, a spade, will be more useful for medical groups than a stethoscope.
Sharp Rees-Stealy’s original building sits across the street from its medical director’s office still gracing 4th Avenue. The group was named recently by The San Diego Union-Tribune as “San Diego’s Best Medical Group.” The copy of San Diego Magazine that lists the city’s Top Doctors is not the usual glossy magazine fluff piece but the result of an annual poll by the medical society seeking the opinions of the city’s practicing doctors. I sneak a peek to confirm that my family physician, David Spees, MD, is still there — and, of course, he still is!
“So how will we manage those additional numbers of ACA patients and Baby Boomers?” asks Balfour and answers his own question. “We’re already expanding as fast as we can. We’ve started to use extenders. We can’t find enough doctors even though we have already hired more than 40 new ones. Physician extenders work well in some areas like urology, orthopedics, OBGyn, pediatrics and urgent care, but not so much in internal medicine.”
I don’t ask why. I sense deep medical knowledge in such a field as internal medicine needs a full medical training and lots of experience.
Balfour used to golf “when he had time,” but I suspect the way medical services are growing, his hard hat will be more useful to him than a putter.
The group “physician extenders” has grown to include not only nurse practitioners, physician assistants, certified nurse anesthetists, but also, arguably, specialized nurse endoscopists, family nurse practitioners, paramedics, physical, occupational and massage therapists, lab technicians and, particularly, those in the surgical disciplines like abdominal and orthopedic surgery. Maybe they will be tomorrow’s “barefoot doctors” relieving today’s urgent care physicians.
Balfour has mixed feelings about the certification program for “medical homes.” Sharp Rees-Stealy Medical Group is going that way in principle with case managers assigned especially to chronic care and the follow-up care of post-op transplant patients. He’s proud of what his group has achieved: recognition as a Top Performing Group by the California P4P program, the largest non-governmental physician Pay For Performance incentive program in the United States.
There have been criticisms of this P4P Program and, in response, it has adopted improved value, which encompasses both cost and quality as the ultimate goal of P4P between 2011 and 2015. The primary initiative for reaching this goal is Value-Based Pay for Performance (Value-Based P4P), which will hold physician organizations accountable for the costs of all care provided to their HMO members, as well as the quality of this care to align health plans toward a more price-competitive HMO product.
“Sharp Rees-Stealy has won many awards and in 2001 transformed its culture to a rededication to its patients … to positively impact the lives of others,” Balfour said.
When the medical group addressed the P4P Pillars of Excellence, it saw huge changes.
“Our employee engagement index reached the 99th percentile for health care organizations, our physician satisfaction improved over 20% and, more important, our patient satisfaction rates shot up from 12th to 81st on national Press-Ganey ratings and we had a decrease in heart failure admissions, which, incidentally, resulted in over $1.5 million annual savings,” he explained proudly.
A plaque on the wall in Sharp Rees-Stealy’s new building across the street from the original 1923 one proclaims the group’s ambitions and how community philanthropy can make a difference.
Sharp Rees-Stealy took heed of the Commonwealth Fund report of August 2008 that identified the six attributes of any ideal health delivery system. They were not alone; many if not most medical groups found it imperative to study the characteristics of a well-run medical institution.
Essentially the attributes included a state-of-the-art electronic health record, better coordination between doctors and nurses — with the latter monitoring hospital and emergency room discharges — transparent outcomes across the team, accountability for total care, improved access for patients with an online portal of entry for patients and continuous innovation.
Eric Anderson, MD, lives in San Diego. He is the one-time president of the NH Academy of Family Practice. His commentaries on aging are part of the MetLife Foundation Journalists in Aging Fellows Program organized by The Gerontological Society of America and New America Media. Anderson was a senior contributing editor at Physician’s Management from 1983 until 1998 (when the magazine ceased publication). He wrote a monthly column for both Postgraduate Medicine and Geriatrics for many years. Anderson is the only physician in the Society of American Travel Writers. He has also written five books, the last called The Man Who Cried Orange: Stories from a Doctor's Life.