Successful Turnaround of a University-Owned, Community-Based, Multidisciplinary Practice Network

The special edition of the Annals focusing on the role of family medicine departments within academic health centers is welcomed and timely. Many of our universities developed primary care clinical networks during the era of managed care. In some cases, these networks were created to serve community needs, but most of them were created to insure an uninterrupted flow of referrals and admissions to the university hospital. The article by McGill et al describes how one such network has evolved and provides instructive lessons for other institutions. Utah seems to have developed their network somewhat later than many other institutions. Here in Oregon we developed our network in 1993-4 and began to shrink it's size by 2001. At its peak, we were operating 10 sites and are now down to only 6. Four of these six remaining practices are family medicine clinics and all of the closed clinics were staffed by general internists or pediatricians as the medicine and pediatric departments downsized their interest and activities in primary care. This paralleled rather closely the demise of comprehensive managed care insurance for most people in our area.

Our experience is similar to Utah's in that we have become profitable when educational costs are considered. But our practices are all teaching clinics and have residents and students assigned as part of the provider workforce. Our workload and efficiency have increased dramatically as has the demand for our services from patients searching for a comprehensive medical home.

In Oregon, like much of the rest of the country, the number of uninsured has grown dramatically. We have converted two of our four family medicine practices into a community health center look-alike and a rural health center. This has allowed us to expand the number of medicaid and uninsured people we serve. The remaining two clinics care for university employees and their families and others from the community. More patients are now paying for their care in cash as their deductibles and co-pays increase. And many more of them are opting out of traditional health insurance for medical savings accounts. This is clearly starting to change the commercial interaction upon which our practices function as businesses. This trend seems to be quite confusing to many of our academic health center's leaders. In response, we are focusing much more on making patients happy and serving their needs better rather than simply making health plans happy and seeking favorable contracts.

I think these financial changes in the market are the first stages of radical change in our health economy and I certainly agree with McGill and colleagues that our university health systems will be turning to anyone with a coherent plan during these challenging times. The Future of Family Medicine project is such a plan. But our department is by no means looking for permission or direction from our institution in pursuing these goals. We are asserting our own initiative and making our own clinical practices into models for the future. I think the rest of our institution will follow us in this direction and will be better off in doing so.

Competing interests:   None declared

This issue of Annals of Family Medicine‘s supplement “Shaping the Future of Academic Health Centers: The Role of Family Medicine Faculty and Departments” summarizes many reports on “best practice” presented at the annual AAMC meeting in 2005 and sponsored by the Association of the Departments of Family Medicine (ADFM). The case study by Magill et al describes the turnaround of a multispecialty-physician group at the University of Utah which had previously posted a loss of more than $21 million during the year of its inception and consecutive financial losses in the years following. In a five-year period, the university-owned physician network was turned into profitability.

Changes in the healthcare system were accelerated with the dominance of managed care companies that started in the early 1990s. All elements of healthcare delivery, from independent solo physicians to academic health centers (AHCs) felt the need to reinvent themselves in order to survive. One of the strategies utilized by AHCs was the development of physicians’ networks, mostly in primary care. The main objective was to align these physicians with the organization hoping to grow market share and generate referrals for subspecialists as well as tertiary and quaternary care. Throughout the country, there were multiple models of governance, employment, administration and financing. By the turn of the century, managed care influence was fading and many of these physicians’ networks were either incurring financial losses or abandoned altogether.

Magill and colleagues provide an excellent overview of the strategies utilized to reengineer their physicians’ network leading into an efficient patient-centered model and profitability. Lessons learned from this experience in Utah include: • The importance of the support, commitment and vision of the institutional leadership. Despite significant losses, the leadership in Utah affirmed their commitment to this endeavor and had the foresight to select proper leadership from among the physicians. • Physicians’ governance and establishment of teams of physicians and administrators both at the corporate level and at the local office sites, thus avoiding “us versus them” scenarios. This model paid attention to the clinical and financial aspects of the organization. • An outpatient delivery model was created to maximize efficiency, provide patient-centered services through innovative, open-access scheduling and leveraging information technology to improve communication and services. • Most importantly, the turnaround gradually integrated network physicians with the academic mission. Sites were utilized for students’ and residents’ teaching and selectively for research projects.

Our experience in the Cleveland, Ohio area, though different in structure from the Utah example, is comparable in many ways to the one described. Our health system University Hospitals Health System (UHHS) with its academic health center, University Hospitals of Cleveland (UHC) started developing a primary care network in the early 1990s through the acquisition of existing independent physicians, physicians' groups or establishing new practice sites based on demographic market analysis and/or strategic alliances. More than a decade later, our community-based network is now a major player in the delivery of ambulatory services in Northeast Ohio. The network has both primary care physicians and selected subspecialists to meet the demands of suburban patients and owned or affiliated community hospitals. From its inception, physicians in this network have taught our medical students and collected research data for our Practice Based Research Networks (PBRNs).

Many case studies presented in this supplement point to the important roles primary care physicians can play in leading institutional initiatives, delivering efficient patient care and meeting the academic mission of Academic Health Centers. It is critical for our policymakers to evaluate our failing health care system and implement changes to meet the growing demands of our people and communities. International data as well CMS experience among different states validate the importance of having a strong primary care base. AHCs can and should take the lead in reforming our healthcare system.

Competing interests:   None declared