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Dr. David Yehl admits he was a little nervous about the idea of treating six patients at once.
As a busy family physician in Eagan, he was accustomed to seeing a steady stream of people with aches and pains. But as a rule, they always showed up in the exam room one at a time.
Today, Yehl's clinic has become a testing ground for novel ways to practice medicine -- group medical appointments, nurse-only visits, video consultations -- that are starting to transform health care throughout the country. The ambitious pilot project is proving so successful at four Fairview clinics that it will soon be adopted at many of its sites across the Twin Cities.
With health costs under fire from all directions, the medical profession is starting to rethink many of its practices, including the time-honored tradition of the doctor-patient visit. For years, clinics insisted on face-to-face appointments -- even if they weren't always necessary -- because that was the only way they got paid, Yehl said.
But a combination of forces -- from the economy to health reform -- is pushing clinics to find cheaper and better ways to deliver care. "That's kind of the challenge," he said.
Now, some of Yehl's patients routinely get what they need without seeing a doctor -- sometimes without even leaving home. And before long, more and more patients are likely to have that option.
"I think we're witnessing a transformation in how health care is delivered," said Dr. Charles Fazio, chief medical officer of Medica, the state's second-largest health insurer and a partner in the Fairview experiment.
At first glance, the Fairview Eagan clinic, a one-story red brick building in a suburban office park, doesn't seem like a "living lab,'' as some call it. Patients still fill the waiting room, waiting their turn; the exam rooms look like any other.
But a poster on a bathroom wall announces one of its latest innovations: "Extreme Shared Medical Appointments ASTHMA EDITION!!"
Once a month, the clinic holds "shared appointments" for patients with diabetes or asthma. They meet with a doctor for 60 or 90 minutes as a group, doing just what they might do in a private office visit, minus the physical exam.
At first, the whole idea was a bit unsettling for Yehl, who has practiced medicine for nine years. He found himself rehearsing his lines before his first group appointment, wondering how his patients would react.
But he discovered he could cover more ground -- and save time -- in a group visit for diabetes. At the same time, he said, the patients help each other by trading tips on how to control their weight or blood sugar. "That's much more powerful than me ... saying, 'I really recommend it,'" Yehl said.
LeRoy Case, a diabetes patient from West St. Paul, wasn't too sure about it himself when he heard about the group appointment. But when Yehl invited him to try it, he did.
"It almost reminds me of group therapy," said Case, 71. To participate, he had to sign a confidentiality waiver; now he looks forward to spending an hour and a half with his doctor and a few strangers. "It can't hurt me,'' Case said. "And hopefully, at my age, I can learn a few things."
The truth is, many patients don't need a face-to-face visit for routine medical care, says Dr. Dave Moen, president of Fairview Physician Associates, who oversaw the Eagan project.
Sometimes, all a doctor needs are the symptoms and the patient's history to diagnose a sinus infection, for example. Or a lab test to confirm strep throat. "The majority of our work is exchange of information," he said.
Moen estimates that 30 percent of requests for routine medical care could be handled by phone, e-mail or computer. But the "business model" has kept clinics from doing it that way. "So much of the resistance to redesign has been the payment system," said Fazio, of Medica. "If all you get paid for are visits, that's pretty much all you're going to get."
Now, however, there's a "groundswell of interest" in these innovations, said Dr. Karen Boudreau, senior vice president of the Institute for Healthcare Improvement in Cambridge, Mass. One reason: Health care costs are pushing government and family budgets to the breaking point. "In the current environment, nobody is likely to pay them more," she said.
At the same time, doctors are stretched thin, she said, and they're starting to ask how they will handle millions of newly insured people as federal health reform unfolds.
At the start of the Eagan experiment two years ago, Fairview officials posed a question: How would you change the way you care for patients if you weren't bound by the old ways of doing business? The clinic was given free rein to experiment, with a Medica grant to help cover its costs.
Now, when patients call in, "they have a lot of options," said clinic manager Katie Holley-Carlson.
Depending on the medical problem, they can see a doctor, consult a nurse or go straight to the lab for a test. They can ask questions by phone or e-mail, and get lab results online.
In the last few weeks, Yehl and another physician started offering "video visits," on a test basis, to patients with cameras in their computers. He says it's ideal for follow-up visits, particularly for depression or anxiety, or to discuss lab results. Technology, he predicts, will only make it easier. Eventually video cameras will "be on everybody's cell phone," he said.
Meanwhile, says Holley-Carlson, the clinic is able to devote more attention to the toughest cases: people with chronic or multiple conditions, who often flounder between visits and bounce in and out of the hospital.
Now, instead of waiting for those patients to call, the clinic assigns someone to reach out to them. Teams of doctors and nurses are responsible for devising a plan to help them control their symptoms and reduce the chances of a relapse.
That's "a big culture shift," said Dr. Lynne Fiscus, another Fairview Eagan physician who took part in the project. "It's not good enough anymore to say, 'I wrote them a prescription, they never followed up.'"
In the short run, this new model can cost more because it requires more staff, says Holley-Carlson. But in the long run, "it is a better way to deliver care," she says. "We're keeping people out of the hospital."
Bending the cost curve
The results have been so impressive, says Moen, that Fairview has started spreading the new model to the rest of its 35 metro area clinics.
In one year, per-patient costs rose just 6.3 percent at the four experimental clinics (Eagan, Hiawatha, Northeast and Rosemount), compared to 12.2 percent at the other Fairview clinics. And hospital costs dropped a dramatic 17 percent for patients at the four clinics, while they climbed 12.5 percent for patients at the others.
Meanwhile, Fairview is changing the way it pays its doctors to encourage these changes. By the end of the year, they'll no longer get paid by the number of patient visits and procedures, but by a new formula that rates them on quality and cost of care.
In the past, many doctors have objected to "pay for performance" plans, calling them unfair or unworkable. But even groups such as the American Academy of Family Physicians and the Minnesota Medical Association say it's time explore new approaches.
We "recognize that, to deliver care as effectively and efficiently as possible, it does mean changes," said Janet Silversmith, director of health policy for the Minnesota Medical Association.
Fazio, of Medica, agrees.
"The practice of medicine, which is usually just steeped in tradition and very slow to change, might finally change more rapidly."
Maura Lerner • 612-673-7384