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BizTalk: A new model for primary medical care

The front of the Urban Family Practice office on Jefferson Avenue looks as unassuming as it gets along a nondescript strip mall on the city's East Side.

But inside, Drs. Raul Vazquez and Chet Fox are building what they see as the primary care medical practice of the future.

They're following a recipe Vazquez is using on the West Side, where he recently opened a new $6 million building that serves as the headquarters for his Urban Family Practice, as well as an assortment of newer ways to deliver and pay for care. These include value-based arrangements in which doctors and hospitals take on more of the financial risk of ensuring that their patients receive the services they need.

One of the new payment models is the Greater Buffalo United Accountable Care Organization operated in partnership with YourCare Health Plan, a Rochester insurer. The organization, which includes doctors from throughout Buffalo, is responsible for thousands of Medicaid patients in a contract that imposes quality measures and puts the doctors at financial risk for costs.

Another model is a Medicaid Health Home. Health homes arose out of the Affordable Care Act as an option for states to offer as part of their Medicaid programs, with the idea of encouraging collaboration among health care providers to coordinate care for the most expensive Medicaid patients that have behavioral and mental health issues, substance abuse problems or multiple chronic conditions.

All of which is why inside the new building on Niagara Street you will find a fitness center, mental health specialists from Jewish Family Service, a kitchen where nutritionists teach healthy cooking, offices for specialist consultations and a call center with health navigators who assist patients with everything from getting medical tests to arranging transportation to appointments. It's a one-stop shop.

Urban Family Practice opened its second location recently at 1315 Jefferson Ave. in the former location of the University at Buffalo Family Medicine Clinic, filling a gap in basic medical services left by the recent closure of the UB clinic and Lifetime Health’s William E. Moser Health Clinic on Main Street downtown.

Vazquez, chief executive officer of Urban Family Practice on Niagara Street, purchased the clinic site. The new office will be operated by Fox, a former UB Jacobs School of Medicine and Biomedical Sciences professor who used to work at the clinic. They talked about their plans.

Q: How can you succeed here when the university did not?

A: Fox: It's the efficiency of the system. He (Vazquez) doesn't let us do anything until it's done right the first time. He also runs a true patient-centered medical home, so he maximizes the use of staff.

In a university residency program, with people coming and going, it is hard to have continuity. It is hard to get people to do things the same way, and every three years you are starting with new people. There are natural inefficiencies.

Having people here full time, we can organize the system – we code properly, we bill properly. When you code and bill properly, and do it in an efficient manner, there is enough money in the system to make the system work.

Vazquez: By coding, we mean giving the right risk score to an individual or an area. It means a lot because it tells the insurance companies and state that you are dealing with sick patients, as opposed to patients who are just here for physicals.

Q: Why did you open the new office?

A: Vazquez: I've always been committed to the East and West sides of Buffalo. My wife (Toni Vazquez) is African-American, and her father (the late William L. Gaiter) was really committed to the East Side. When this opened up, it was my opportunity. We are going to try to do the same thing on the East Side that we did on the West Side, and this office is a nice bridge for now. We may build something else around here.

Fox: The vision – what the facility is like on the West Side – is different than being in a doctor's office. We have nutrition and wellness programs. We have health care navigators and specialists in one building. The idea is to replicate that here.

Q: Why do you see value-based care as the future of medicine?

A: Vazquez: Based on data, we're really learning how best to use resources. It's about getting right what needs to take place in one location.

For instance, that means doing primary care with a collaborative behavioral health entity. For years in primary care, we've been managing disorders like depression and schizophrenia without behavioral backup because in medicine we all work in silos and never really work together.

We're trying to create more of an all-inclusive primary care model. It's more likely patients will get the care they need. That matters when it comes to things like HIV or mental health, where patients may feel stigmatized in the community.

Q: You are big on information technology and social determinants of care. Why?

A: Vazquez: You need an IT backbone and focus on care coordination to go after value-based contracts, in which patients' lives are attributed to you, and you can do better when it comes to finances by working with insurance companies. Really, in the long run you become an insurance product. That is the only way that physicians are going to be able to change the model of care.

Our call system is an example of what we're trying to achieve. We'll know what's important to our customers, almost like Amazon. We'll know what people like and what they don't like. What is their past history. Information about social determinants of health. Does a patient have food, transportation, housing? We'll learn that when they call in. If we don't take care of these things, the care we provide is not going to help.

Transportation is major. If you don't offer patients transportation, patients will call an ambulance, and that is going to cost the health system a lot more than providing a van.

Fox: We have found that until you take care of the social determinants of health, it doesn't matter what you do in the health system. You have to take care of food insecurity, social isolation, transportation. Raul understood this from the beginning. You need good IT so you have the data in front of you.

For the patients in our value-based plan with YourCare, we have the potential for savings of $3 million out of a $14 million budget for their care by just making changes to medications, such as substituting generics for brand names, and using drugs that you take daily or twice daily instead of extended-release formulations. Those changes have the potential to be significant because pharmacy represents 25 percent of the total cost of caring for those patients.

The data is there. But we have not been trained to use it. We all need to think that we are spending our money, not other people's money. That's when we will get the efficiencies.

Q: Can you give an example of how primary care must change?

A: Fox: It is easy to pay for universal health care. Take emergency room use. We dropped it by having someone call people and make contact. That's money we would have spent on emergency rooms.

We have universal health care in this country. It's just backwards because we offer it through the emergency room. What we need, is universal health care through the primary care office.

Vazquez: Doctors are going to have to be the people who look at data and change their patterns. We, as a health system, don't do that right now. The doctors in the field need to figure out how the customer, not a patient, gets better services. What are we doing wrong, and what do we need to do to retain that individual? It may be things that don't make business sense, but to keep patients happy that is what you have to do.

People want things on demand, like they get on Amazon. They want the same thing in health care.

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