Turning theory into practice: When cutting-edge doesn't always cut it

Arlington, Mass. -- "Oh, my goodness! How lovely!" patient Lila Tulin said upon seeing a sunlight-filled space featuring two inviting couches, an overstuffed chair and large potted plants.

From the interior décor to the glass-encased conference room, from the relaxing jazz music coming from tiny speakers wired to a digital media player, from tweaks in care processes to offering patients coffee, water or tea, Renaissance Health tips off visitors that it wants to be considered different from the typical doctor's office.

Tiring of studying but not personally applying quality improvement concepts in the real world, Rushika Fernandopulle, MD, and Pranav Kothari, MD, opened an internal medicine practice to show that they could deliver better care by redesigning primary care processes, supporting those processes with appropriate technologies and getting patients actively involved in their care. To accomplish that, the doctors adopted recent innovative services that practices around the country have implemented one or two at a time and integrated them all at once.

Dr. Fernandopulle said he is frustrated with the "incremental" change he sees in primary care delivery. He said that he believes it may be better to change everything in a practice, rather than changing "one little part of a system" at a time.

Thus, Renaissance Health uses electronic medical records, offers patients 24-hour access to physicians via e-mail and telephone, and offers same- or next-day appointments. Patients soon will have online access to their health record and the ability to schedule appointments electronically, and will be offered group visits and classes.

Patients also are asked to pay a membership fee of $480 to "fund the innovation," Dr. Fernandopulle said.

The practice opened up Sept. 1 -- and not without some glitches.

The idea for the practice arose from research the two physicians had done while working at the Harvard Interfaculty Program for Health Systems Improvement. Until recently, Dr. Fernandopulle was executive director of the program and Dr. Kothari was an independent quality improvement consultant.

Renaissance Health is set up so that Dr. Fernandopulle and employed physician Amy Schoenbaum, MD, spend half-days seeing patients. The other half they spend on nonvisit-based proactive patient care, including returning e-mails and phone calls, and using technology and other tools to research, track and manage their patients' health. To achieve a balance between visit- and nonvisit-based care, Drs. Fernandopulle and Schoenbaum will limit their patient rosters to 1,000 each. Dr. Kothari is committed full time to working the business side of the practice.

"The way the reimbursement system is set up for primary care, I think, is fundamentally wrong," Dr. Fernandopulle said. "The only thing you get paid for is actually sitting down face to face with a patient. About half of our time is going to be spent doing things that are not going to be paid by insurance companies -- answering e-mails and phones calls, running database inquiries, running classes, group visits. None of those things, which are the right thing to do [clinically and economically], are paid for."

Not a concierge practice

Although groups that charge patients an extra fee are known as concierge or retainer practices, Renaissance Health is not that, Dr. Fernandopulle said.

Concierge practices typically don't redesign processes, he said. And those practices tend to target patients who can pay $2,000 to $20,000 annually while "the goal here is [to create] a new model of service that will apply to everyone. Our starting price is something that a vast majority of people can pay for: It's what people pay for cell phone, high-speed Internet service, Starbucks lattes. Forty dollars a month is something that is in the realm of the middle class."

Renaissance Health opened in June but did not start seeing patients until Sept. 1 because it took longer than anticipated to get major local insurers on board.

Medicare, Tufts Health Plan and BlueCross BlueShield of Massachusetts have agreed to reimburse physicians because the practice does not charge patients an extra fee for services the plans already cover, Dr. Fernandopulle said. Harvard Pilgrim HealthCare is on board, but only with respect to its PPO members.

At its Annual Meeting in June 2003, the AMA House of Delegates agreed that concierge practices are ethically acceptable as long as physicians follow certain guidelines, including being available for all emergencies, providing the same level of care regardless of the patient's membership status and giving the patient the chance to opt out without penalty.

Renaissance Health follows those guidelines even though -- as the practice emphasizes -- it does not consider itself a concierge practice, Dr. Fernandopulle said.

Renaissance Health isn't yet firing on all cylinders. "It's very much a work in progress, which is very much the point of the whole thing," Dr. Fernandopulle said.

Some services, including online scheduling and online health records, aren't yet available, but should be rolled out by early 2005.

So far, the volume of patient visits is low, ranging from one to three each day, well short of the maximum eight visits the practice wants.

For now, Drs. Fernandopulle and Schoenbaum enter progress notes into wireless tablets after patients leave the office. They intend to chart at the point of care, but first have to become more proficient with the technology.

The group continues to work with its EMR vendor, Greenway Medical Technologies, Carrollton, Ga., to adapt the software's functionality, look and feel to meet the practice's specific needs, the physicians said.

Recruiting patients

About 110 patients had joined the practice by Oct. 14.

The three physicians have asked specialists, friends and acquaintances for referrals. They also have mailed letters to Dr. Schoenbaum's 1,800 former patients. So far, more than 30 have followed her to Renaissance Health, she said. She hopes more will follow.

Dr. Schoenbaum and her employers also attend community events to get themselves in front of potential members. For example, while Dr. Schoenbaum treated patients on Sept. 20, Drs. Fernandopulle and Kothari went to a health fair Wyeth Pharmaceuticals held for employees at its office in nearby Cambridge.

Over four hours, dozens of Wyeth employees stopped by their table. And a few were intrigued by the doctors' vision of patient access and personal health care. Next-day appointments seemed especially appealing.

The $480 membership fee, the physicians agree, is the biggest obstacle Renaissance Health faces in terms of building a successful practice. And yet Dr. Schoenbaum took a 58% pay cut to join the group, going from $130,000 to $55,000 a year. "It's a pay cut partly because it's part time for now," she said.

Dr. Schoenbaum will earn $117,000 when she starts working full time, which under the terms of her contract will automatically occur when she has 500 patients.

"Year after year, there were more and more productivity requirements and ... I had less and less time to spend with [my patients]," she said, explaining why she decided to leave a higher-paying job at Partners Healthcare, a Boston system.

She talked to others about joining the practice. Her physician father was very negative. "He thought it was too risky, but all my [physician] friends were like, 'You have to do it. You have to try,' because everyone's miserable," she said. "I think it's worth taking the risk."

Giving it a chance

Dr. Schoenbaum plans to stick with the group for two years, thinking that will be enough time for the practice to show that it's going to be financially worthwhile for her.

The founders haven't set a deadline for when they will fish or cut bait. "In every business, you have that question," Dr. Kothari said. "I haven't really evaluated at what point I'll say it's not working. It's so early."

"Our goal is to create a sustainable practice that is economically feasible and has better outcomes. Just like any other practice," Dr. Fernandopulle said.

Ultimately, they acknowledge, the practice has to make money if it is to survive and offer a model other physicians can adopt.

"The only way to validly prove that this model works," Dr. Kothari said, "is [to show] that it is possible to make a profit."