Ehab Sharawy, MD & David Cook, MD – What is Modern Primary Care?

In this episode, we hear the second in a series of conversations between Dr. Ehab Sharawy, Dr. David Cook, and Dr. Yates Lennon, where they discuss “Modern Primary Care” and how greater access to care generates savings and makes for a healthier, happier patient.

Welcome to the Move to Value Podcast. Dr. Ehab Sharawy, Dr. David Cook. Welcome. Glad to have you this afternoon. So, we’re back for our second session together and where I would like to begin is with modern primary care. I’ve heard you both talk about this now for quite some time, but I’ve never ceased to learn something new when I hear you describe it and your vision for modern primary care. What you’re trying to build at OneHealth. And so, I don’t know which of you guys wanted to take it and run with it first order. Dr. Cook, so we’ll start with you and tell us what you mean by modern primary care.

Dr. Cook: Modern primary care. You know, Doctor Lennon we’ve talked about this almost like taking a step back in time. Umm, you know, one of the things that we saw with healthcare over the past 12 to 20 years is again the erosion of that primary care individual relationship. That part that partnership with the patient. It became less than what it should be as a sacred connection and advocate for care. Partly because of how health systems, PE, VC, retail primary care is perceived. Partly because of what we did to ourselves as primary care physicians and partly because of the environment around us. It began to erode away, and there were so many things that were being done, and I used this often and I’m going to do it now because it’s a great place to use this analogy, it’s like the Titanic. We move the deck chairs around a lot in healthcare and the Titanic is still going down. Healthcare costs are going up, quality is going down, longevity is going down.

So, when you look at some of the data across the United States, including the Dartmouth Atlas data, wherever there’s a lot of primary care involved in care of the community and the individuals, quality goes up, cost goes down. But there’s never a lot of money that follows that. Right? There’s never been big money in primary care until recently. And it’s, I always say, it’s sort of a fault-centered way to get payment from primary care now. So, Doctor Sharawy and I began to look with others, that are now part of OneHealth leadership, and said what have we been doing for 30 years that that really is different. Besides the for all mission, besides the knowing the color of the individual’s eyes, besides some of the basic things that we thought and basic tenets of care that we thought were the right things to do. Well, it was that care evolved out of the primary care, uh, patient relationship. And we kept that sacred. We made it really sacred. And we almost built this hub and spoke mechanism, I always say that, where you have the provider of primary care, whether it be OBGYN, internal medicine, pediatrics, or family medicine, and the patient encircled by a team of people that that compress that relationship together. And from that relationship, you had ancillary services evolve out of that, you had home health, you had Hospice, and palliative care, and specialty care, and hospital care. But it all evolved out of that relationship. And so, it created this connectivity for the patient to someone who was always there for them. Not only in the moment for care, but long-term care. And the things that I saw escaping primary care were minute clinic work. Well shame on us primary care physicians, we couldn’t be minute clinics for our patients. Urgent care work, well I’ve always shown my patients up or done things to mitigate their acute crisis, why could we not do that. Mental health, we gave that away, we weren’t able to do that. It’s a muscular skeletal work, integrated specialty care work.

So, as we began to develop OneHealth over the past, really it began over the past 12 to 20 years, we looked at what it would look like to rebuild the ship differently from the ground up. Yet as you’ve said, it looks like the past. OK. Primary care physicians that that own the patients’ healthcare journey and are there for them. And if you take modern primary care, and you say our goal in modern primary care is to do three things: increase somebody’s life, longevity, improve their human experience through increased quality, safety, efficacy, consumer driven care, ease of care, and reduce cost of care. Then every time I go into a patient’s room, those things are top of mind. And that begins the essence or the basis of modern primary care. Then everything has to build from that. Digital tools have to build from that. Ancillary services come from that. All based on those three things that are aggregated, aligned, and advocated for by the primary care physician. Sounds so basic, doesn’t it? Right. It’s almost like what we all think we should be getting, but it’s very rare.

Now we’ve looked at some of the PE/VC model, I’m not going to speed up on those models and some health system models, where you’d go in, and it was a wound care doc doing primary care, waiting for that nine five shift to end. Never talking about the things we’re talking about here. And not that that’s not maybe a good place to get care. But it’s not where I want my family to get their primary care. So, we’ve coined this modern primary care because the medical home, and advanced primary care, they’re so sort of overdone. And we don’t want this to be overdone either. So, we’re really intentional about what does modern primary care mean. Well, it means this advocate, this alignment of care, this connectivity of care to do three things longevity, improve human experience, and reduction in cost. And we’re building a whole system around that that that Doctor Sharawy can explain that supports that that mission.

Dr. Sharawy: Yeah. Again, I’ve learned a lot from this guy over the years. OK, you know, this is one of them. But, when we think about, and again it is kind of an oxymoron to call modern primary care. I think the essence that starts with our ability to do everything that that Doctor Cook just described is to be accessible to the patients that we take care of. And to me a modern, you know, labeling it something different put puts a shining light on what are the gaps that exist now. If we’re not creating environments where we can first give access to everybody, equal access to everybody in the community, and then once they’re in, it’s not, again you’ve heard us say this before, it’s not just this episode. Let me take care of who’s in front of me and get them out. It’s wrapping them around their healthcare journey, and guiding them, and navigating them. I mean, I think about modern primary care, and another way is being everything for the patient. So, even navigating through a journey. So, say it’s an unfortunate diagnosis of cancer, you know, even today. So, everybody knows this, but I’ll say it again, you know, the United States, we’re the best in the world at the highest tech stuff, anywhere, nobody meets us as far as doing that. But my gosh, we’re probably one of the worst, you know, when it comes to ability for people to access basic care and basic health. For somebody with a cancer diagnosis and take them in through a modern primary care lens, you’re going to navigate them through that journey whether it’s whatever, insert service they need, specialist they need to interact with, mental health often comes with that. You’re going to guide that care. Where now, unfortunately that we all know too well, it’s a fragmented story. Right. And sometimes fragmentation means it’s just not going to happen. So, to me, you know, I just want to emphasize again it all starts with access. If you can’t get in, there’s nothing you do about anything to anybody. So really, I think that’s a critical differentiating step.

Yeah, and I was going to and to come to the access question. Tell us a little bit about your standards for access. What do you mean by that? And how can your patients access OneHealth? When? How?

Dr. Sharawy: Yeah, I’ll start with that. And I think there’s a lot of ways to tackle that question. But I’ll start maybe from kind of the economics of how practices are run. So, you can define success as a physician or provider by saying, you know, what I built a panel. So, I’ve got a panel of people I take care of. And then you can actually stop it, right at that point. So, what happens is, and this is a really important thing, as we talk about this, if you’re one of the lucky ones to be in that panel, and you’re lucky enough to get in to see your provider, you’re going to get wonderful care. They’re wonderful physicians and providers. My gosh, you know, we see them all too. I have to access healthcare a lot. But by that system when you reach that rate limiting step, two things happen. Number one is you you’re not going to see anybody new because you’re closed. By definition, the second thing that happens, is the people that you have in that panel are going to continue to struggle to get in for unplanned events that occur like that. So, just the economics of understanding that.

What we do at OneHealth is to say, we’ve done it from the beginning before we were called that, we’ve always been the same people, but now OneHealth, is to say that the number one thing is, and I’m going to coin a Doctor Cook term, same moment access. OK. So same moment access can look differently, but it’s actually identifying and addressing the patient’s needs the moment that they interact. So, that requires us to be really good at having communication with our patients. We do that in multiple levels. We that with human connection, we do that through the technology, leveraging that technology, those things. And then be available to see them when they want and or need to be seen. Because I think that’s a very critical thing. Sometimes them wanting to be seen also means they need to be seen because there’s more to it. So really creating that access model. What you have to do is grow. It’s pretty simple to figure that out, right. So, we continue to grow in multiple ways so that that mission of being there for all, openly accessible, is not diminished. OK. And so, you’ll hear us a lot our themes are that we have to grow, grow, grow. Grow with the right culture. And the good news about it is most people out there, David said it earlier, Doctor Cook said it earlier, about seems really simple doesn’t it. Most people that go into health care, they want to come out and they will flourish in that kind of environment. Right. But you have to have the environment created for them to be able to flourish to do that.

I think a lot of physicians don’t see growth as a success factor. I have my patients; I take care of my patients. The growth mindset is not poured into us in our training. It’s not part of what we were taught to do.

Dr. Cook: And, you know, when we talk about, and we’re going to value later, but when we talk about providing something for the patient that is better than what they have. So, modern primary care is when your patient, let’s say an 80-year-old patient you’ve taken care of for a long time, eats that Bojangles biscuits Sunday afternoon right. She has CHF. And by Sunday night, her pulse ox went from 98 to 92. She’s got edema. Gained 2 pounds and is struggling to breathe. Well, if she doesn’t have someone at that moment in time that she can call, she’s going to panic all night long. So, we’re typically open for primary care seven days a week. OK. We’re trying to make that a 24/7 opportunity, not all in the same place, but in pod type structure. The next thing is if Miss Smith, the next day, can’t walk into her doctor’s office, and it’s so unique to me, as doctor Sharawy, he described it, how many systems are set up to almost prevent a walk in. I mean I even see it on doors. No walk-ins. I mean this is healthcare. You know, when did you predict that you were going to get sick. So, if she could walk into an office that next day, she’s 80, she’s sick, her pulse ox now is 88, and if she could get in to see a modern primary care physician or primary care specialist through diuresis, rule out an abnormal EKG, or new EKG finding, some simple blood testing, follow up day by day, you can turn what would otherwise be an admission, readmission, and a $40,000 problem for the patient, plus a lot of other risk factors, into a couple $100 issue, and the patient stays at home, right. That’s modern primary care and that’s same moment access.

I love the access. You all told me about that months ago and it’s like that’s it. That’s where you got to start because you can’t deliver value-based care if you don’t have access to the system. You just can’t do it. One of the things you just mentioned, I think Doctor Cook, you said primary care specialist. That, for a lot of our audience, that might sound a little bit confusing. What do you mean by a primary care specialist?

Dr. Cook: I’m a non-apologetic primary care specialist called a family physician. You know, I love family medicine. I would say that that it is, I’m the luckiest guy in the world to have become a family physician for multiple reasons. But what we’ve done both as family physicians, internist, OBGYNs, and pediatricians is often have become that sort of second-class citizen for many reasons within the healthcare community. Mainly money. Where money flows, things change and operate. Right. But it takes a real specialist in primary care to understand how to do the right things, to advocate for the individual. And I believe we’re going to start using this term, we do as modern primary care and modern primary care specialist, to really invoke something different. There’re so many places where I see that they plug in different folks, whether it’s, again as I used the example before, we met at once wound care doc who just wanted to do something different, so became a primary care doctor within a VC program. And not that they’re not a great physician. They may be an excellent physician, but they don’t have a robust 10 to 15 years of training. And I always say that to be a really good primary care physician, you need to do this for five years at least. OK. And what better way, after I’ve done it for 5, 10, now 30 years to train other primary care specialists to do this as well. So, we want to create a specialty program for primary care doctors that can make them the best advocate for the patient. Understand prevention, lifestyle medicine, concierge medicine, corporate medicine, disease resolution, some of the most cutting-edge things with the medicine now and the technology now. It really is in the hands of the primary care doctor to do the things that Doctor Sharawy mentioned, to have someone live longer, higher quality of life, and reduce cost.

So, we’re going to continue to use this term primary care specialist. And I think Doctor Sharawy really said it well, once you make at denotation of something different, then you’re held to a different standard. And you know, I wanted the American Academy of Family Physicians and definitely North Carolina Academy, what a great thing to do. But I’ve not found the found them doing that as strongly as we want to do it through this. And again, I believe that internal medicine, pediatrics, family medicine, and OB are primary care specialist and can be that for the individual.

I’m very concerned, you said in our last episode Doctor Sharawy that we weren’t old, but we’re not all that young either, and I’m getting more and more concerned that as we get older, and my mother is elderly, there’s a shortage of primary care of any kind. How do we attract more Med students into primary care?

Dr. Sharawy: So, you have to drive the message all the way back down, I think, to the college level, medical school level, the residency level. We’re doing that at OneHealth. I’m proud to say that others on our team that are doing the strong work, that we have a lot of folks that come to us not only training but also work. And that’s another thing we could talk about that. We have freshman in college, people that are gap years, somebody that wants to go to medical school but maybe wants to take a gap or is still waiting to get in, PA students, people that want to be PA students, the list is long. We have to drive that message. Our goal is to number one help enhance their ability to make the right decision, what they want to do, but also show them and take away the notion of I wouldn’t recommend my son to go into medicine. Get rid of that. So we have to be able to take that message in multiple ways and multiple levels. This podcast will help.

I’ll add one more thing on the primary care specialist for a moment is that, here are factual statements, the facts today are that in certain specialties, even if you want one of your patients you have to see a specialist, they can’t get in. There is a need for more primary care, so an inability to get in multiple specialties, that’s the world we live in. So, what happens is the care gets diminished. But there’s many things the primary care specialist can do by changing the way we traditionally interact with a specialist, what kind of care we deliver. More in a collaborative model as opposed to a transactional model. Where the transactional model again has a rate limiting to it. Hey, I’m going to take care of these folks and I’m busy enough, and I don’t have that growth on my mind. So, that’s another piece of primary care specials is to really drive decision making at the level of the interaction between doctor and patient to provide the best care possible. And we all know that in the care that we deliver is that sometimes it takes a good conversation with a specialist to number one, validate what you probably already know the right thing to do, or be educated in here are the next steps, or at least get them on the path to where when they do engage with a specialist, they are two or three steps down the line. Top of mind for us. And that’s, I think, a big part of primary specialists.

Dr. Cook: Hey, two comments. One that Doctor Sharawy was only looking at you Doctor Lennon when he said you’re not old. He knows I’m old. And second comment, you know, how do you get people to go into primary care. You enjoy primary care. You have fun doing primary care. You bring people into your office, and they see happy primary care physicians, primary care nurse practitioners, primary care PAs. We love to make work fun. Work has to be fun. And to do that, it’s not about being resilient, it’s about having fun and about really creating an environment where you put that person, that individual, first. And it’s more about the mission and the vision, it can really be fun. And we bring people into our office, and they often say man I’ve never seen anyone as happy as you guys are. That’s everybody. Staff, you know, front office, back office, and in the provider. So, you got to make it fun, you got to make them enjoy what they do, and you got to make them want to tell their kids to be doctors as well.

So, I have one more question for you. As I’ve been listening to you talk about modern primary care, I’ve been around long enough to know or to have experienced the 90s when the HMOs first came out. And in primary care, in at least from my recollection, seemed to turn into almost a gatekeeper type program if you will, which I think diminished the value and probably diminished some of the satisfaction of primary care at the time. But it seems the opposite to me of what you’ve just described for us in terms of modern primary care. Can either of you just speak to that for a minute before we wrap up?

Dr. Cook: Yeah, and I’m glad you brought that up. I was around in the 90s and I am one who did not like the term gatekeeper. Still don’t like gatekeeper. We’re advocates of care. And so, back in the 90s it was all about cost reduction. They began to interweave quality, safety, human experience into that but it was about cost reduction. How can you be the gatekeeper to prevent somebody from going somewhere they don’t need to go or shouldn’t go. That just created a true debacle I think in American healthcare and a devaluing of primary care. It made a schism between the specialist and the primary care doctor. I think now as an advocate of care, and that health care is not as a zero-sum game, and one of our pillars is integration, is how do we become the advocate for the individual. So, if every time the individual comes to me, I can look them in the eye and say my whole goal is three things: longevity, improve your length of life, improve your human experience through quality, safety, efficacy, consumer driven healthcare, and reduce your cost to care. I can’t do it alone. We’re going to do it with a team. But that means the team is going to be integrated through me, so that integrated care with specialists, ancillary care, hospitalization, and other things to me is what a modern primary care specialist is for the patient.

The whole term gatekeeper creates enmity between the patient and the physician. Automatically implies you stand between me and the care I need. I’ve got to convince you that I need to go somewhere else and that just destroys the relationship.

Dr. Sharawy: I was kind of there in the 90s. Nah, I was there in the 90s. I was a young buck in the 90s. But when you think about HMOs, and you think about capitated cost. So, take C-section rates for instance was a good example. So, there was a time in the late mid to late 90s where hospitals would measure you on what was your C-section rate. And so, I remember a group in Jacksonville, you know, it would brag about a 4% primary C-section rate. That won’t mean much to some of the listeners, but that’s really low. What happened is by driving that singularly focused on the cost, litigation went up significantly, and outcomes were not improved, they were actually worse. So, when you capitate it just on the cost side like that, you tend to dilute what’s the most important thing. And most important thing is to take care of the patient the best way. Not the cheapest way. OK the best way. And if you do it through a modern primary care approach, you’ll also do it at most cost-effective way.

Well gentlemen. Thank you again. It was great being with you this afternoon. I appreciate your time and look forward to connecting with you later.