Community News

Key Changes in Health Care Evident in The Rivertowns

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August 3, 2016

by Robert Kimmel

Health Care’s evolution has never stopped, and significant changes are taking place now in the rivertowns, just as they are across the nation. Having the family doctor, carrying a small black bag full of medications, making a house call, is an experience only a few can recall. For the most part, that way of delivering health care disappeared many decades ago. But now, even the primary care physician existing as a sole medical practitioner in his own office is becoming history.

Economics, technology, government legislation, and changing demographics are among the reasons behind a continually growing shift among health care providers toward both group practices and urgent care facilities, which are proliferating across the region. Some are associated with hospital groups, others are independently owned. The number of urgent care facilities across the country has grown to about 10,000.

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The urgent care center generally offers quick access to medical help for those who are encountering illness or injuries of a non-emergency nature which do not require assistance at hospital emergency rooms.

Go-Health-MAIN-STORY-PAGE-1 Earlier this year, a Northwell Health-GoHealth Urgent Care center was established in Tarrytown at 650 White Plains Road. “We are open until 8 o’clock at night, and we are open on Saturdays and Sundays and holidays,” noted Dr. Neal Shipley, Northwell-GoHealth Regional Medical Director. He explained that the facility was, “…not interested in competing with primary care doctors. We build relationships with them and we’re happy to be there when they can’t be. Directing his comments to those doctors, he said, “If your patient is not feeling well, or has a question or concern, when your office is not open, have them come to see us.” he said. “We will evaluate them, we will discuss their care.”

Dr. Shipley commented that, “For those persons who don’t have a primary care doctor and …need medical attention right now…they can call and say, ‘Can I come in within 15 minutes?’ “Up until recently,” he said, “the only alternative was to go to an emergency room and sit for four to six hours and compete with the people who are having heart attacks or strokes, or were in a car accident, and then pay more of a co-pay.” However, Dr. Shipley said that, “If you having a heart attack, the emergency department is the place to go.”

The medical personnel working at the Urgent Care Center are “fully credentialed through Northwell,” Dr. Shipley emphasized, “making it a “true joint venture partnership. That is the model you are going to see more of in the future, and one that I am very proud of, because it allows us to access Northwell specialists and expertise, providing a seamless integration of health care back either to the hospital or emergency department if the patient needs that, or to a primary care or specialist or sub-specialist.” The hospital would be Phelps, which is, with GoHealth, part of the Northwell Health system. The Urgent Care Centers are staffed by “family practice physicians, emergency physicians or physician assistants,” according to Dr. Shipley. They also have laboratory and x-ray equipment for diagnostic purposes.

Urgent care centers don’t keep seeing a patient with a chronic disease or medical problem over the long term, Dr. Shipley explained. “We may take care of them initially but what want to do is get them into the hands of a physician whose expertise is for the long term.”

The GoHealth Center is open 365 days a year, and is one of 21 Northwell-GoHealth Urgent Care Centers in the New York metropolitan area, including several in Westchester. GoHealth Urgent Care partnered with Northwell in October 2014 and plans to open from 40 to 60 centers within the next few years.

“With all mega mergers and individual practices being bought out by hospitals the field of private practice has disappeared,” Dr. Sundaram Ravikumar stated as his rationale why urgent care centers are proliferating. “Urgent care centers fill in that space.” He has picked a space in Tarrytown to open his third urgent care facility in Westchester. AppleMed Urgent Care is scheduled to begin accepting walk-in patients at 131 Central Ave. next month.

Dr. Ravikumar sees location as, “… the most important aspect for the urgent care. It should be in the middle of the community where people can walk over and not be dependent on transport,” and he added, that the location is “very convenient for commuters.” He anticipates that with the waterfront development, “we will be there to serve the people who are settling there.”

While staffed with family practice physicians, a family nurse practitioner, and pediatric specialist, there will also be a dentist at the AppleMed location from noon to 8 p.m., for dental emergencies, the doctor said. He also pointed out that, “patients are seen in a relatively short time as compared to the typical hospital run emergency room,” and that the costs to patients and their insurance providers are less.

The trend toward urgent care centers saw a reversal in Tarrytown recently when one such facility converted to a doctors’ group practice, the type of organization now providing most medical care.

Dwell Family Doctors was Urgent Care of Westchester until recently. Dwell promoted the point that while it will “…provide advanced immediate and primary care for adults and children…our mission is to become our patients’ trusted family doctor by delivering an exceptional healthcare experience.”

Vera Luthra, who with her husband, Dr. Jay Luthra, started the urgent care facility about nine years ago, and saw it expand to 11 centers, said that Dwell Family Doctors is now, “… providing primary care services, where one can become a patient on an onward basis.” Located at 155 White Plains Road, the facility as before, “…can handle small emergencies without an appointment, but you can also make an appointment, and you can come in for your regular check-up, things that we were not doing previously,” Luthra commented. “We provide more overall care for our patients long-term, on a continuing relationship with our doctors.”

Dwell Family doctors offers convenient access to care, Luthra said, noting that the office is “open evenings, on weekends, seven days a week. For those patients in need of more specialized care, Luthra added that, “We have had long-term relationships with specialists in the areas around all our centers, and work very closely with them.

While Vera and Dr. Luthra, an emergency physician, opened their original Tarrytown urgent care facility as sole owners, they have partnered with others in the formation of Dwell Family Doctors, which is planning to add two more New York area offices to the existing 11.

Affordable Care Act A Factor In Health Care Changes

An estimated 20 million people who had no health insurance before the passage of the Affordable Care Act, often known as Obamacare, are now covered by insurance. With its accompanying regulations, it is among the many factors that have caused the acceleration of medical practice consolidation. Another is the greater clout practitioners have as a group in contract negotiations with insurers.

Daniel-Blum-Health-Care-Story-P8 — Phelps Memorial Hospital President/CEO Daniel Blum

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In January, 2015, Phelps became part of North Shore-LIJ Health System, which changed its name this past January to Northwell, It is one of the nation’s largest health systems with 21 hospitals and more than 450 outpatient physician practices.

Under the Affordable Care Act, and its initiation of health insurance exchanges, Northwell became the first health care provider in New York to offer a health insurance plan, CareConnect. It now has more than 100,000 subscribers, Blum noted. That offers even a greater incentive to the goal of keeping people healthy, Blum said.

Still another factor influencing consolidation is accountable care. “Certainly hospitals and other providers are more accountable that we have ever been because data is now publicly reported,” Blum stated. “We are becoming more and more accountable for the cost of care and that is known as value based purchasing.”

The traditional pay-for-service payment for medical care, particularly within Medicare, is slowly transitioning toward a more value-for-care system whereby the overall treatment and quality of care a patient receives is the basis for payment rather than for each service separately rendered. By 2018, Medicare plans to have half of its payments based on value care models rather than pay-for-service reimbursement as part of its pursuit to lower costs as an aging population increases.

Medicare now provides financial incentives for both doctors and hospitals within Accountable Care Organizations (ACO), another provision designed to keep down expenditures in the treatment of Medicare patients. To qualify, an ACO must manage the care of at least 5,000 Medicare Beneficiaries for a minimum of three years. Creating the network of health care providers within the ACO to meet those requirements, is another force behind consolidation.

Volume purchases of equipment by large, consolidated health care organizations also lowers costs. “When we bought our new MRI, which is remarkable state-of-the-art equipment, we saved several hundred thousand dollars by virtue of the fact that we were in a health care system,” Blum said.

Health care providers are now also required to keep electronic records, and if they do not, they face loss of Medicare payment incentives. Patients also are getting greater Internet access to view their own records. Developing the electronic records and maintaining their security, adding to back office costs, are among the facets pushing consolidation.

Blum sees the development of electronic records as necessary, but added, “My perspective is that there was a tremendous opportunity for the government to create nationalized electronic health records, and what they could have done was to make this health record to be available to all health care providers and even patients.” His regret is that there is not a standard system, and that they are not interactive among different health care entities.

While balancing insurance payments it receives, co-pay from patients and the like, against expenses, Phelps also contributes more than $29 million annually in free, charitable care and community services. Blum stated that even with consolidation, financial help from kind-hearted community members is needed “…philanthropy continues to be extraordinarily important to us. It helps to fill the gap.”

In 19 locations, including some within the hospital facilities and in surrounding communities, Phelps Medical Associates, some 50 physicians and other clinicians offering primary and specialized care, saw their patient volume increase by 38% over the past year. Dealing generally with more acute care, Phelps Hospital’s emergency room still sees approximately 27,000 patients a year.

Hospital physician groups are expanding in the rivertowns. ColumbiaDoctors, with a recently opened location in Tarrytown, at 155 White Plains Road, is also increasing its care capabilities there with the addition of specialists in urology and pediatric dermatology.

P.9-Columbia-doctors “We are adding specialties in Westchester to meet the growing need for top-quality care in the region,” stated Dr. George A. Cioffi, president of the faculty medical practice of Columbia University Medical Center. The group’s providers are faculty at the Medical Center and are affiliated with New York-Presbyterian Hospital.

Dr. Cioffi said ColumbiaDoctors has been adding physicians to the group at the rate of six percent annually for the past four to five years. He sees more growth ahead, “but perhaps not at that six percent rate.” The group has “1,700 health providers at 90 different sites in the region,” according to the doctor. “I don’t think that physicians any longer are going into solo practices,” Dr. Cioffi said. That trend, he said, “is driven by several things. First off by the economics of practice, from billing to contract negotiations with insurers, to the complexities of delivering care.” He cited personalized medicine, advanced testing, and advanced diagnostics, as well as “the interdependence physicians have on each other.” Interplay between hospitals and physicians’ offices, in-patients and out-patients, is all better understood now within a group, Dr. Cioffi noted. He saw that as another reason for group affiliations with hospitals.

There is a push to “minimize time in the hospital,” the doctor explained. “We don’t want patients to be readmitted to the hospital, so we want to make sure they get continued care, and so there is a transition plan going from an in-patient setting to out-patient setting. We know which physicians are going to follow them,” Dr. Cioffi said, “and we know that leads to better care.”

He also attributed the Affordable Care Act as playing a role in the expansion of group practices. The uninsured numbers have gone down and there are now more people seeking care, he said. The insurers, and not just the federal government, “are looking to move away from pay for service toward the idea of value based service.” Dr. Cioffi said that “…now we have to struggle and figure out value based care versus fee for service care.”

As for the government mandate that requires physicians to have electronic medical records, and having patient’s access to those records, Dr. Cioffi believes it “helps medical care.” He also sees a greater push toward preventive care, “and the more preventive care we can provide, the more likely you are going to stay out of the hospital.”

“One of our primary focuses is to build long term relationships with the residents in the towns where we provide medical care,” said Kevin Smith, Administrator of St. John’s Medical Group, yet another such hospital affiliated service in Tarrytown.

With offices at 200 South Broadway, the group has practitioners in internal medicine, family practice, a nephrologist, and a nurse practitioner specializing in pediatrics. It is open Monday through Saturday and has extended evening hours as do many of the local group operations. It also operates offices in Dobbs Ferry, Hastings on Hudson and Yonkers.

“We all know that the dynamics of health care has changed,” said Lisa Patterson, the director of the Group. She sees the group practice as offering greater access to care for patients as well as more flexibility for the doctor. Patterson said “physicians realize their sustainability” is improved within the group situation. She also mentioned the requirement to move to value based care, “and that means that reimbursement is much more difficult for providers.” Value-based care is being driven by the insurance and Medicare universe because they are working toward being more efficient in how they reimburse all providers whether it is a hospital or a practitioner.”

Additionally, Smith noted that value care is also directed toward, “… making sure the patients getting the care they should be receiving.”

The impact the Affordable Care Act has had on patients, Patterson said, is that with insurance offered by managed and exchange plans, “…coverage is different, the consumer is paying a higher deductible. That is much more the standard now.”

“Technology has changed matters drastically,” Patterson asserted. “It is much more expensive and even staffing is more expensive, so for the single practitioner to continue in health care is much more difficult, and you still want to provide the best health care for your patients.” All the more reasons for physicians to come together in groups, she explained. “You have to meet your new quality measures as a care provider, and in order to do that, you have to have the technology.” Of one requirement, the electronic health record, she said, “The cost is high, not only to implement it, but to maintain.”

“We are hearing more and more discussions by physicians about joining groups and not having to deal with the business end of it anymore,” Patterson noted. “I think there are more coming.”

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