Look within the halls of the 75 doctors offices held by ProHealth Physicians and you'll see an organization poised to take on the challenges of health care reform.
The state's largest physician group, which provides care to about 10 percent of Connecticut's population, has already embraced many of the hallmarks of a rapidly changing industry.
The company, for example, recently invested $14 million dollars in health information technology. Its also secured innovative contracts with major insurance companies that include pay-for-performance and medical home models.
ProHealth, which runs offices from Tolland to Guilford, has been on a growth spurt. Its added 34 medical providers in the past year, increasing its ranks to 266 total providers, which include mainly primary care doctors, as well as nurses and other staff.
Company officials expect more aggressive growth in the years to come, especially in Fairfield County and Southeastern Connecticut.
Of course, treading through the industry's ever-changing landscape won't be easy. ProHealth executives admit as much.
Health care reform is putting pressure on all providers to change the way they do business, especially primary care doctors, who are being asked to become the central figures in what has been a tangled web of care.
Meanwhile, pressures from potential reduced reimbursements from government payers are also creating concerns.
But in a state with a large concentration of small doctor practices, ProHealth's size and leverage gives it an advantage in trying to deal with future changes of the industry, some of which will be costly and resource intensive.
And, more importantly, ProHealth serves as a good test case for where the industry may be headed.
"We are positioning ourselves in a very proactive way to participate in all aspects of reform," said Jack Reed, the president and CEO of ProHealth Physicians. "That's been the nucleus of our business plan."
ProHealth Physicians, which is based in Farmington, is a physician-owned group, which means its primary care practitioners have a 100 percent ownership stake in the company.
It has about 75 offices, mainly spread out across Hartford, Middlesex, and Litchfield counties. But the organization sees opportunities to branch out further across the state, especially as small shop practitioners search for help and more resources to modernize their practices.
Its doctors, which provide care to about 350,000 residents in the state, also have affiliations with major area hospitals like Hartford and St. Francis hospitals.
And even though ProHealth is ahead of where some Connecticut physician practices are, they believe they are only in the first stages in what will ultimately be a transformed health care system, Reed said.
Health information technology is a key part of that evolution.
ProHealth is at the tail end of a $14 million investment to connect all of its physician sites to electronic medical records and a new billing system.
The two-year process, Reed said, is already providing clear benefits by allowing its doctors to track and share data. ProHealth doctors, for example, are updated any time one of their patients receives a prescription from another provider.
"That's a huge piece of information that was completely unavailable to me in the past," said James Cox-Chapman, ProHealth's chief medical officer.
Health information technology is seen as a linchpin to health care reform because of its ability to allow medical providers to share patient information, creating a much more coordinated system that could root out wasteful duplicative procedures.
But, Cox-Chapman said, the real potential for electronic records has not yet been realized. The ultimate goal, besides sharing data, will be to measure outcomes, find where gaps in care exist, and then institute programs for physicians and patients to improve the overall quality of care.
"There is a very powerful ability of electronic medical records to actually help manage a population of patients," Cox-Chapman said. "But no one has really experienced that yet because we are still working through the whole issue of how does this work in the office, which we will move beyond."
There is also a learning curve implementing the new technology, Reed said, which in some ways can actually reduce a physician's productivity.
"It creates another layer of process that, until we can actually improve the workflow around it, we won't be able to capture its full benefits," Reed said.
ProHealth has also been able to secure contracts for medical home pilot programs with all the major insurers in the state, a key step toward advancing payment reform and more efficient models of care.
That includes a contract with two insurers — Anthem Blue Cross and Blue Shield and United HealthCare — for a medical home pilot program that will provide service to about 35,000 state employees and their dependants.
The idea behind medical homes is to use primary care physicians as central figures in coordinating patient's care among specialists, hospitals and other health care providers.
That reduces costs in the long term, the thinking goes, by eliminating duplicative care and encouraging preventative services that help to root out serious diseases or health problems before they develop.
Reed said he views the medical home as an early step toward payment reform, because instead of solely paying doctors on the number of services they provide, they start getting rewarded on the overall quality of care.
In the case of ProHealth, its physicians are getting incremental payments from insurers for managing and coordinating care for their patients. That's a noticeable change for many doctors in Connecticut, which is still very much a fee-for-service pay environment, said Cheryl Lescarbeau, ProHealth's vice president of clinical performance and marketing.
"Over the last three years, pay for performance has become an increasingly larger part of the payment physicians are receiving," Lescarbeau said.
ProHealth has had contracts with pay-for-performance incentives for about nine years. On average those payments now make up about 8 percent of each doctor's total compensation, Lescarbeau said.
The added dollars have helped offset fee-for-service reimbursements that have remained relatively flat for the past 10 years. They'll become increasingly important as doctor's Medicare reimbursements face likely cuts, and Medicaid payments, which are largely state funded, remain stagnant. Doctors are already providing services for those government programs at a loss.
Meanwhile, Reed said he believes the medical home is only a temporary phenomenon that will, if successful, eventually evolve into even more advanced payment models like gainsharing agreements, bundled payments and accountable care organizations, or ACOs.
ACOs are joint venture arrangements between different providers like hospitals, physicians and other health care professionals. It is a much more formal system than a medical home, and together the providers agree to be accountable for the quality, cost, and overall care of patients, similar to a managed care company.
Such models are beginning to pop up across the country, but not yet in Connecticut.
"That probably won't happen in Connecticut in three years," Reed said. "But certainly it's on the horizons."
As physicians begin to change the way they do business, it's also creating a cultural shift in the workplace. Reed said electronic health records and medical home models have changed the workflow at ProHealth's clinical practice sites.
The process at ProHealth has involved reengineering care teams, putting more onus on the primary doc's office staff to coordinate rather than simply just provide care, while also ensuring each member of that team works to the top of their license.
Discussions between ProHealth staff and other providers is also becoming more common.
Providing more efficient care also means creating consistency in how all of its doctors interact with patients.
ProHealth is in the process of trying to earn national accreditation as a medical home care provider, requiring it to evolve even further. For example, to gain accreditation, ProHealth must improve access to care, so certain ProHealth physicians now have extended office hours and remain open on weekends.
ProHealth doctors are also changing the way they communicate with patients, using e-mails and even text messages to remind patients about appointments and treatments.
"It's a huge challenge because now we are changing our mindset on how we actually run and organize our workplace," Reed said. "It might even be frustrating for some people."
Reed said ProHealth is also having a noticeably different, more direct relationship with employers as well. He said companies are increasingly reaching out to them to try to come up with wellness programs and other ways to attack the key drivers of cost among employees.
It's important to employers, Reed said, because the health plans they offer their workers continue to escalate in price.
"We are finding out quickly that working with employers is going to become a major part of our business," Reed said.