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On the Cutting Edge

Hamden doctor is state’s first solo practitioner to be certified as a ‘medical home’

Greg Bordonaro

March 21, 2011

Health care officials who predict the gradual extinction of small physician practices in Connecticut probably have not met Dr. Edward Rippel.

Rippel’s one-man practice in Hamden has all the hallmarks of where many believe the industry is headed.

He’s invested $50,000 in electronic medical records. His practice provides chronic disease management, preventative care, and also sets aside time to see sick patients. He closely coordinates his patients’ care between specialists and hospitals. He can even speak to them in three different languages.

And now Rippel has become the first solo practitioner in Connecticut to achieve national recognition by the National Committee for Quality Assurance as a certified Patient-Centered Medical Home, a model of care that is considered a key aspect of health care reform. So far, only 1,600 practices nationwide have achieved this status.

While Rippel’s case may be the exception in Connecticut, it shows that small practitioners with limited time and resources are capable of adapting to the changing health care landscape, even if the effort may be a daunting one.

“This is consistent with a vision I had a long time ago,” said Rippel. “The goal is creating coordinated care and having a simple method that is repeatable on an everyday basis.”

The idea behind medical homes is to use primary care physicians as central figures in coordinating patient care among specialists, hospitals and other health care providers.

That reduces costs over the long term, the thinking goes, by eliminating duplicative care and encouraging preventative services that help to root out serious diseases or health problems before they develop.

The concept has been around for awhile, but it’s become increasingly popular recently as the industry looks for ways to reduce health care costs and improve quality care.

Rippel said he’s had a goal of creating that coordinated system when he started his practice, Quinnipiac Internal Medicine, in 1993. Investing in electronic medical records (EMR) about five years ago proved to be a game changer because it allows him to keep better track of his 3,000 patients.

A simple database query through his EMR, for example, instantly reports which patients he needs to contact because their sugar is uncontrolled or they’re overdue for cholesterol testing or breathing tests.

And it’s leading to dramatic improvements in health outcomes.

When he started with electronic medical records, close to 50 percent of his diabetic patients had Hemoglobin A1C levels at treatment goal. Now that number is up to 70 percent. And of his 200 patients who have diabetes, not one is on dialysis.

Nearly 100 percent of his patients with cardiovascular disease are now consistently taking medications like aspirin to prevent stroke.

And while the $50,000 down payment for the EMR system seemed a stretch at the time, Rippel said he was able to recoup the investment in just two years, thanks to associated savings and revenue enhancements. Those financial gains stemmed from streamlined workflows that allowed for greater productivity and cost savings associated with doing medical billing in-house instead of outsourcing. He also gained additional revenue from government and insurance sponsored pay-for-performance programs.

In addition, the improved health of his patients is reducing health care costs for the entire system.

“If you have better control of chronic diseases you will avert dreaded outcomes like the loss of vision for diabetes patients,” Rippel said. “The risk of developing complications goes down.”

In terms of adopting other elements of the medical home, Rippel said the workflow in his office already mirrored most of the requirements, like providing increased access and better communication to patients (he has a 24/7 answering service and speaks English, Spanish and Italian) and providing responsive care management. Care coordination is also a key.

If one of Rippel’s patients needs to see a specialist, his office creates a digitized referral that automatically pulls information from the electronic medical record, including the patient’s medical history, demographic information and pertinent lab tests or x-ray reports. That referral is then sent to the specialist along with an explanation of why the patient is seeking treatment.

And when one of his patients gets discharged from a hospital, he schedules a follow visit within two or three days.

Of course Rippel’s case is not the norm in Connecticut.

A recent study by the Connecticut State Medical Society found that many of the core components of the medical home concept — like hiring a care manager — are not yet widely implemented by Connecticut doctors.

Only 20 percent of the 498 primary-care physicians surveyed said they have or plan to hire a nurse care manager and only 25 percent have or plan to establish primary care teams.

About 39 percent of those surveyed said they use electronic medical records, up from 25.8 percent in 2008. But physicians in larger practices are the ones leading the charge because they have the financial wherewithal to do it.

Thomas Meehan, the chief medical officer of Rocky Hill-based Qualidigm, a health care consulting and research company, said cost is the biggest prohibitive factor, especially for the smaller practitioners who still dominate the market place in Connecticut.

Although there is more interest among Connecticut doctors in moving toward the medical home concept, Meehan said, it’s an extensive process that takes a lot of time and investment.

And many of the medical home aspects — like additional staff work and care coordination — aren’t reimbursed by commercial or government payers, meaning financial incentives aren’t yet in place.

“There is still a minority of physicians going after this,” Meehan said. “It’s hard and costly and takes a lot of work.”

As small practices try to figure out how to move forward, there is speculation among industry experts who say there will be increased consolidation in the coming months and years, as pressure mounts under federal and state reform efforts to adopt new technology.

Many independent Connecticut doctors may need to affiliate with — or join — a larger physician group or hospital system to make ends meet, some industry observers say.

Already there is intense competition among Connecticut hospitals and large groups to recruit new doctors to their ranks, especially with the shortage of primary care physicians in the state.

Meehan said he can’t predict where the industry is headed, but he said many patients still prefer smaller practices. “But whether financially we can help small doctors adapt still remains a question,” he said.

“Time will tell what model becomes dominate,” said Meehan, whose organization along with the medical society works with physicians who are trying to move toward the medical home model.

Rippel said he believes increased attention will be placed on primary care doctors because, if done properly, their practice environment, with a focus on chronic disease management and preventive care, leads to better health outcomes and reduced costs.

That’s why he has moved aggressively in the medical home direction.

“We decided to make that investment and it turns out it was worth it,” Rippel said.