This doc has created a way for independent physicians to have a say in Vermont’s approach to health care
by Virginia Lindauer Simmon
Four years ago, family physician Paul Reiss, the original M.D. at Evergreen Family Health Partners in Williston, founded Healthfirst, a statewide association of independent practitioners. All this while continuing his day job.
Paul Reiss approaches the trials of his profession the way he addresses his pastime of climbing the 46 Adirondack peaks over 4,000 feet: He evaluates them and then summits.
The original doctor at Evergreen Family Health Partners in Williston, Reiss says he grew up “mostly in the New York City suburbs,” but his family still has a vacation home in Lake Placid, N.Y., birthplace of his father, Paul Reiss, president in the 1980s and ’90s of St. Michael’s College. Lake Placid is where Reiss, as chair of the Julian Reiss Foundation, carries on his father’s and grandfather’s tradition of providing a summer camp experience in the Adirondacks for inner-city New York middle schoolers.
Reiss is his family’s first M.D. He sought a field that included math and science because he was good at it and wanted to work with people. He joined his sweetheart, Joanne Melloni (they met in their senior year of high school), at Fordham University where they both majored in biology.
After graduation, he headed to Rochester, N.Y., to study for his medical degree at the University of Rochester; she worked at a Westchester, N.Y., pharmaceutical company. Two years in, in 1981, they were married. She joined him at UR and entered the nursing program.
Graduating together, they left for Vermont, where Reiss was accepted in the family residency program at what was then Medical Center Hospital of Vermont. “We were expecting our first child,” he says, “and five kids later, we have four that have finished college, one high schooler still at home, and one that’s married.”
After his residency, Reiss stayed on the faculty and had a family practice at Fanny Allen Hospital with a colleague. The practice was closed four years later.
It was 1990. Reiss was hired by Community Health Plan as associate medical directory for quality to open a second office in Williston, on James Brown Drive where Evergreen’s office is today.
Working with him as head of sales and service was Allen Nassif, now president of Northern Benefits in Burlington. They worked together for 10 years. “Paul is the best,” says Nassif, “smart, interested in the public good. All the feelings I dealt with from the medical side when we were in insurance, he was always on the side of the patient. He’s very forward thinking and committed.”
Reiss’s practice was cohoused with CHP’s administrative offices. “It started with just me and a nurse and receptionist. Now we are nine practitioners and a staff of about 30.”
In 1998, when CHP was having difficulty staying solvent in the market, Kaiser Permanente assumed the operations, making Reiss and his group part of the Permanente Medical Group. It lasted only two years.
Kaiser offered to support each of CHP’s practices, but only if they stayed together. Each of CHP’s health centers could opt to fold or continue as independent practices. Eleven offices in Vermont and New York decided to stay together.
It was a challenge operating 11 offices in two states, and these doctors, who had all originally wanted to be employed and on salary, were now self-employed. “Our partnership in that group, which continues as PCHP lasted two years, and we split out and became Evergreen Family Health. We owned our own building and became essentially independent of any other organization.”
At that point, there were three physicians (partners) — Reiss; Jan Ferris, D.O.; and James Dougherty, M.D., and one physician assistant. “The learning point — the important thing that happened right after that — was our realization that we should have done that long ago!” he exclaims, laughing. “To have just the one site be responsible for and accountable to your patients, your own contracts with payers, your own overhead and management structures, and not be responsible to other bosses or practices was rewarding and satisfying.”
Income and cash flow were tremendously better after just six months, he says, but it takes more than one person in a practice to watch the budget and run it as a small business. Independent practices that didn’t commit the resources to do this no longer exist.
In 2005, Mike Johnson joined Evergreen. He was on faculty, had trained in the UVM residency program, and was seeing patients as an employee of Fletcher Allen Health Care, but wanted to be in an independent practice. Within three years he was a partner. Last year, he agreed to take on Reiss’s duties of managing partner so Reiss could commit more time to his work outside the practice: as chair of Healthfirst, a statewide organization he started with seven other independent physicians four years ago “because there was no other organization that represents independent practices.”
A great many physicians don’t belong to the state medical society, Reiss says. “That’s a surprise to people, because there’s a belief it represents all physicians.” They do great work, but less than a third of their members own their own practices; most are employed.” At around a thousand dollars a year, the dues are significant. Reiss belongs, but no one else in his practice does.
“We [independent practices] don’t have an employer who can advocate for us, and that refers to all sorts of health care policy issues: contracting with health insurers, how we’re treated by both the state and Medicaid, payment matters, health care quality, and regulations.”
Being a group also offers purchasing power, which has proved overwhelmingly successful. Healthfirst was able to connect with a medical malpractice program for its members. “Interestingly, it was the same insurer we already had,” says Reiss, but because they entered as a group purchase through a physician cooperative out of New Hampshire, in the first year, at least a thousand dollars per physician was realized in savings on malpractice rates.
Next, Healthfirst formed a Medicare ACO (accountable care organization), a complicated program that offers a share of savings when the total patient expense is less than the expected total (or benchmark) for that group of patients. To help with the mass of federal regulations, reporting, quality measures, and required infrastructure, Healthfirst created a joint venture with a Texas company, which hired an executive (Amy Cooper) to help run the ACO, and paid for three care coordination nurses.
Because it was Vermont’s first ACO, it drew great interest from the Green Mountain Care Board, which sought to learn from Healthfirst’s experience. “That really gave independent practices a voice in determining how the state would address the delivery and financing of health care,” says Reiss.
Unfortunately, he continues, “even though the ACO model sounds good, the devil is in the details.” Benchmarks were set in each ACO based on what patients had spent in the previous year or two. “Because Vermont is one of the healthiest states in the country, we found that we were providing high-value care in a low-utilization environment already. So our experience was that our 7,500 Medicare patients cost Medicare just over $600 per member per month, whereas there are places in the country where the cost to Medicare is twice as high — as much as $1,200 on average.”
The ACO was closed last month, Reiss says, because there was little hope that shared savings would reward improved care management activities or even pay off the initial investments in the program.
The experience raised another question, he says: “Why are Vermont’s health care premiums so high if patients don’t use a lot of these services? We have arguably the second-highest premiums on the Health Connect Exchange, and I think the business community feels helpless like we do, as small businesses ourselves, because they don’t have a way to understand the reasons for the high costs.” The Healthfirst board is in discussion about ways to work directly with employers, particularly larger employers, to provide high-quality, lower-cost health care in a direct relationship with member practices.
Amy Cooper, who was hired to work with the ACO, was offered the position of Healthfirst’s executive director. Working with Reiss was one of the reasons she decided to stay. “It’s great to work with him, because you get both the high-level view and the detailed, operational, on-the-ground view from a doctor’s perspective.” One of those details is the disparity of payments for service between independent and employed physicians.
In January, Healthfirst made a presentation to the Legislature, which last session asked the administration to provide a report answering the question: “Should health care plans be allowed to pay independent physicians less than hospital-employed physicians for the same services?”
“The governor’s office responded with old data (before substantial changes that caused the report to be called for), and only for primary care codes, which account for only a quarter of total billings,” says Reiss. Healthfirst responded with a detailed letter outlining its concerns that the pay disparity is an urgent matter for independent practices and patients seeking to understand the costs of health care.
The organization has obtained bargaining group status with the state — the first group to receive it. “So we can negotiate with the state on behalf of our 170-some physicians on Medicaid issues and health care reform issues. Most other practitioners don’t have that ability,” Reiss says. Unfortunately, the group is prohibited by federal law from negotiating with commercial payers such as Blue Cross and Blue Shield, “although a hospital that employs over 1,000 docs can negotiate on their behalf.” Healthfirst is pursuing options to change that.
Reiss continues to see patients at Evergreen, and in his off hours plays “a lot of tennis” and a little guitar. He’s a skier, plays basketball, and enjoys writing. “I’ve got five kids, including one at home involved in three seasons of varsity sports. I’m looking forward to travel with my wife after the nest is empty.”
And he’s five peaks away from becoming an Adirondack 46er. •