Flatlined: Resuscitating American Medicine

Chapter 20. Prioritizing Primary Care

232 The Sumner Clinic is not much to look at from the outside. It is located in a strip shopping center on a busy street in the small town of Gallatin, Tennessee, about thirty miles northeast of Nashville. The clinic is managed by a general internist, Dr. Sid King. When I entered for my meeting with King, I was greeted by a trim, smartly dressed elderly woman sitting in a rocking chair near the front door of an expansive room. She was one among several patients who volunteer as greeters at the clinic. Inside, the Sumner Clinic did not resemble any doctor’s office I had ever seen. It was not posh, but it was spacious with a large, simply decorated waiting room. The floors were linoleum, the walls accented with faux wood. Two computer terminals and several telephones for the patients’ use were scattered among rocking chairs and upholstered chairs. A patient in a wheelchair could easily navigate the room, and one older woman in a wheelchair was logging onto her email account. In the middle of the room was a fireplace open on two sides. On the right was an open kitchen with a long dining table, where two elderly African American women were in deep conversation. The room adjacent to the kitchen was set up like a classroom so the clinic’s nurse and a dietician could teach patients healthy cooking and eating skills. On the left side of the waiting room was the ubiquitous check-in counter, not enclosed in glass but open. The staff often came into the waiting room to greet patients by name. 20 Prioritizing Primary Care Primary care doctors should be paid so that the savings from efficient medical practice are shared with them, and their quality of care should be monitored. CH020.qxd 10/7/08 10:14 AM Page 232 PRIORITIZING PRIMARY CARE 233 At the time of my visit, the only patients using the services of the Sumner Clinic’s internists were 1,200 Medicare beneficiaries who had signed up with a Medicare Advantage Plan offered by HealthSpring, a Nashville-based managed care organization. Seniors enroll in such plans so they do not have to bear the expense of purchasing a Medicare supplemental policy (which pays for the 20 percent of outpatient services not covered by Medicare) and because their co-payments and deductibles are lower than those with fee-for-service Medicare. Medicare pays HealthSpring, and HealthSpring pays the doctors and hospitals, keeping any remainder as profit. Republicans had hoped that this program, intended to demonstrate the private sector’s better coordination of care, would eventually result in cost savings to Medicare. But in order to get insurers interested, the new program had to pay them 12 percent more than traditional fee-for-service rates. Judging from the Sumner Clinic, the Republicans had not hoped in vain. What happens in this clinic is remarkable. Dr. James Geraughty, who is chief quality officer for HealthSpring, told me about the clinic when I visited his company’s Nashville offices. HealthSpring had enlisted the Sumner Medical Group to care for its Medicare Advantage patients in the Gallatin area. Geraughty explained that their target was to take care of Medicare patients for about 82 percent of what Medicare paid, though for most practices the number was closer to 87 percent. The remaining 18 percent is available to pay company overhead and profit, typically distributed as 10 percent for operations and 8 percent as profit. Medicare pays insurers based upon a patient’s severity of illness, so there is little reason for any insurer to hustle healthy Medicare patients in order to improve earnings. Geraughty had hired a nearby firm that specializes in management of chronic diseases to keep HealthSpring’s patients out of the hospital by improving their medical management. This firm’s nurses would phone the Sumner Clinic’s patients and ask why they had missed an appointment , inquire into their compliance with a dietary recommendation, or tell them how to change their medications. When I interviewed Sid King in his Gallatin clinic, he said that he had objected to this practice because it interfered with his management and that the patients did not pay much attention to a call from an insurance company’s nurses anyway. CH020.qxd 10/7/08 10:14 AM Page 233 REFORMING AMERICAN HEALTH CARE...