SEHBP pilots Direct Primary Care Medical Home program

By Sarah Geiger, NJEA staff

Personal experiences with physicians are not highly rated in New Jersey and around the country. Too often, patients are spending more time in waiting rooms than with their doctors. After being rushed through an appointment, patients are often left with more questions than answers about their health. Adding insult to injury, insurance premiums and other out-of-pocket costs continue to rise each year. Navigating the maze of the current health care delivery system is neither as easy nor as pleasant as it should be.

NJEA members have been vocal about what changes they would like to see in their health care and how the patient experience can be improved. This feedback was received in focus groups with members. Three areas of concern were consistently heard. Members want:

• Easier access to a physician.

• More time with a physician.

• Lower out-of-pocket costs.

In response, NJEA and other public sector unions in New Jersey launched an initiative to tackle all of these issues, and more. Last year, the School Employees Health Benefits Program (SEHBP), through which about half of the school districts in New Jersey provide health benefits, approved a pilot program to enhance primary care at no additional cost. This was the Direct Primary Care Medical Home (DPCMH) pilot program. The program officially began enrolling members in January.

The DPCMH model restores a cherished feature of American health care that has all but disappeared over recent decades: health care delivered by a trusted family physician who knows his or her patients and takes personal responsibility for their care and health outcomes.

What is the program?

The DPCMH program is voluntary for any individual enrolled in the SEHBP PPO plans and his or her dependents. The benefits of participation in the program include more time with your doctor at each visit, no out-of-pocket costs at the point of service, 24/7 access to your personal physician, and more. These services result in better health outcomes and high patient satisfaction.

Patient access to personalized care in the DPCMH option is made possible by limiting the number of patients under each doctor’s care to fewer than 1,000. Comparatively, the typical primary care physician practice has a patient-to-physician ratio of 3,000 to 1. Because of the increased pressure on physicians to see more patients as insurance companies lower their reimbursement rates, that ratio for typical primary care physicians is growing.

Physicians in traditional practices are stuck on a hamster wheel, continuing to churn out more visits per day and per month, in order to be able to receive enough payment from insurance companies to keep their practices open. Physicians in these circumstances do not have the opportunity to focus on their patients as much as their training and skills allow. The patient sees his or her doctor for less time and is often unsatisfied with the outcome of their visit.

The picture looks quite different for physicians in the DPCMH practices because they are not dependent on the traditional fee-for-service payment system. In this model, the reduced patient load gives family doctors the opportunity to spend more time with their patients, getting to know their individual health needs and preferences, attending to their patients’ preventative, acute, and urgent care needs. With the additional time, doctors can develop individualized patient care plans, cure illnesses and coordinate appropriate specialist and hospital care.

“The gift of time”

Dr. Suzanne Gehl, a primary care doctor who practices with Paladina Health—one of the two practices that are offering the DPCMH program in New Jersey—is a DPCMH provider. The other provider is R-Health.

Dr. Gehl observes that the DPCMH care model provides primary care doctors with the “gift of time.” They can build genuine, personal relationships with their patients, deepening their understanding of the individual lifestyles, preferences, and social factors that affect their patients’ health.

“I know from experience that when I have the time to build partnerships with my patients, we can produce better health outcomes,” Dr. Gehl says. “It’s why I entered family medicine.”

While the new DPCMH option restores the central importance of a personal patient-to-physician relationship in modern health care, it also sets out to assure that participating family doctors are equipped with tools of 21st-century medical technology that enable them to deliver high-quality care to their patients.

The DPCMH option gives each enrollee the choice of a personal physician who is accessible 24/7 by telephone, online, by email, and through secure text messaging.

Urgent care appointments are guaranteed, but the traditional physician’s office appointment is just one of the many ways patients can access their personal doctors in the DPCMH model. For example, patients typically have their physician’s cellphone number. Doctors in a DPCMH practice encourage patients to call them directly if medical questions or urgent care needs arise. For the patient, this means you are never wondering if you need to run to the urgent care center or emergency room, wasting the time to do so.

The DPCMH option gives each enrollee the choice of a personal physician who is accessible 24/7 by telephone, online, by email, and through secure text messaging.

Why is this health care delivery model important?

According to the U.S. Centers for Disease Control and Prevention (CDC), about 75 cents of every health care dollar spent by Americans goes towards treating chronic illness. Many of these chronic illnesses could be avoided with better care at an earlier time. More effective primary care and early intervention for these conditions will reduce the need for more extensive, and more expensive, care in the long run.

Studies undertaken by the CDC and the World Health Organization reveal that at least 80 percent of all heart disease, stroke, and Type 2 diabetes, and up to 40 percent of cancer cases, is preventable.

It makes financial and medical sense to encourage NJEA members and their families to access primary care on a routine basis. Our members and their families deserve a more effective and affordable health care experience with better outcomes. The DPCMH program is an opportunity for members to have regular, convenient, and cost-free access to high-quality primary care that will help them avoid illnesses later on that are expensive to treat and diminish their quality of life.

Who is eligible?

Through the pilot program, all SEHBP enrollees who participate in any of the PPO plans can enroll with a DPCMH provider at no additional cost. This benefit is part of their already existing network of doctors. Any other eligible dependents covered under the plan can enroll as well.

Pre-Medicare retirees and their covered dependents are also eligible to enroll. However, it is important to know that once you become Medicare eligible, you can no longer participate in the program at no cost.

Should any NJEA member who is not covered under these eligible SEHBP plans wish to participate, there are still some options. Members can enroll directly with a provider. There will be a membership fee to participate if you are not enrolled in an SEHBP plan. However, once you are a DPCMH patient, you get the same benefits at no additional cost as any other enrollee.

Enrollment and locations

Through the bidding process, there are two DPCMH provider groups that have created a partnership with the SEHBP and the SHBP. Those two providers are R-Health and Paladina Health. With offices in various locations throughout the state, interested members can enroll directly through the provider website.

Enrollment with R-Health can be accomplished through its website, www.r-health.md/nj, or call 800-797-1289. R-Health has four participating locations: Haddonfield, Moorestown, Ewing in New Jersey, and Washington Crossing, Pennsylvania. Each office has one provider in it. Members are encouraged to research which doctor and location would best fit their heath needs and the needs of their families. More can be learned about the physicians here: www.r-health.md/nj/#physicians.

Paladina Health is the second DPCMH provider in SEHBP. Currently, Paladina has one location in Hamilton, Mercer County and has plans to expand into the Passaic-Bergen County region. To learn more about Paladina Health and for information on enrollment, visit their website at www.paladinahealth.com.

Both R-Health and Paladina Health have agreed to the same terms with the SEHBP. Therefore, both will be limiting their practices to no more than 1,000 patients. They have each committed to opening more facilities when enrollment increases to accommodate the needs of NJEA members, other public employees, and their families. So, if there is not yet a location that is convenient for you, stay tuned. One might open soon.

Patient experience

The expanded role of the family doctor as a provider and coordinator of care in the DPCMH model does not involve gatekeeping or referrals. NJEA members who have SEHBP plans and choose to enroll with a DPCMH provider will retain the same choice among specialists and hospital providers that they have in their currently selected health plan options. The networks have not changed; in fact they have grown to include these new providers at no additional cost.

Should a member decide to see a physician who is not a DPCMH participating provider, he or she will still be able to do so. The difference is that when going to these providers, the patient will be subject to the same copayments, deductibles, and coinsurances that the plan currently designates for that provider – there is no additional cost beyond what the plan design is for seeing a physician who does not participate in the DPCMH program.

Members Benefit

NJEA members are already enrolled and seeing DPCMH physicians. Jaime Witsen is a retired educator from Somerset County. A few months ago, she received a flier in the mail about an open house for R-Health as a new benefit in her health plan. She receives post-retirement medical benefits through the SEHBP. Witsen was intrigued by the advertisement and was happy to see that NJEA was in support of the project.

Witsen had been with her previous primary care physician for 25 years. Even with the length of time she was a patient, she still was frustrated that the nurses and staff did not recognize her and her visits were so short. She felt her doctor was always rushed. After visiting the R-Health open house, she was willing to try it out. After her first visit, Witsen was sold on her doctor and the health care model.

Witsen loves that the conversations she has with her doctor are not rushed and that the visits take an approach beyond treating symptoms. She feels that her doctor is focused on wellness and improving her quality of life through a whole person approach, which no physician has ever had the time for before.

“What I really appreciated was that my doctor liked that I was a science teacher,” Witsen recalls. As a result, her physician talked with her about her DNA and other medical science. “No one before this has taken the time to extend their understanding of the science behind what they’re doing and talk to me about it. I feel like I’ve hit the lottery.”

Heidi Furman is a teacher in the Mercer County Special Services district and came to find R-Health a different way—her doctor left her previous practice and began working at the Ewing office. Furman followed her there.

At R-Health, Furman feels that she’s in a partnership with her physician.

“We work together to navigate my health and to keep me healthy,” Furman says. “We also work together for prevention. She’s also a great educator.”

Furman trusts and respects her doctor because they have been able to build a relationship based on mutual health goals.

When comparing her old practice to R-Health, Furman is very pleased with the access to her doctor and how she is recognized by the staff at the front desk.

“I’ve never waited in the waiting room for her at R-Health,” Furman says.

She noted that when she walked in, her first name was used and she was greeted warmly by the staff. Before, there were time constraints. Now, she never feels rushed and her physician gives her the time she needs to ask any questions and makes sure that she understands the answers.

Both Witsen and Furman encourage their fellow NJEA members to try out a DCPMH practice.

“This is a really good way to go for public employees,” Furman says. “It’s convenient. There’s no copay. It provides unlimited access to my doctor. There are evening and weekend hours with digital and cell phone access to her.”

“I feel valued as a person and as a patient,” Witsen asserts. “I feel like my concerns are my doctor’s concerns. I could never say that about my doctor of 25 years.”

DPCMH family doctors have the time and tools to provide valuable support to patients in managing their overall health care. They serve as partners and coordinators for their patients’ care. Rather than creating a physician gatekeeper, the DPCMH option provides SEHBP members with access to a physician who can help guide them through a fragmented and sometimes confusing health care system. In the DPCMH program, authority to make the health care choices remain squarely with the patient.

Sarah Geiger is an associate director of research in the pensions and benefits unit of the NJEA Research and Economic Services Division. She can be reached at sgeiger@njea.org.

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