A phone call with the leadership at GreenField Health of Portland, Oregon, can leave you excited and optimistic about the future of primary care medicine, and your mind racing with possibilities.
When we caught Steve Rallison, GreenField Health’s administrator, and Dr. David Shute, the medical director, on the phone to hear about their model of delivery, it was clear they have a mission to make a difference. USA Today must have noticed this as well when it featured them in a 2010 cover story as one of three innovative health programs demonstrating the future of primary care.*
Established in 2001, GreenField has never known paper records, having only used EMR. And while they are always looking for efficiencies in their use of EMR, that’s just the tip of their efficiency iceberg: They also use a “lean coach”— someone who works with them to get the waste out of everything they do. But their commitment to improvement doesn’t stop with the seemingly mundane (or not so mundane) efficiencies of clinic processes and protocols. It is much broader than that.
For GreenField Health, they believe that health care today is broken, but that they are precisely where the biggest impact can be made. “Our purpose of existence is to care for people and to inspire them towards health,” says Rallison. “We believe that the biggest area to make an impact is the delivery of primary care. Health care can be improved greatly if primary care physicians are allowed to do what they are trained to do.”
Enter the Membership Model of Care
The membership model and its various cousins have been known as the subscription model, concierge model, boutique medicine, direct care, or even “cash only.” GreenField charges an annual membership fee that is based on age, with discount rates for families or corporate groups, ranging from $12/month for youth, up to $65/month for those aged 70+. The membership fee helps pay for the customer-oriented parts of medicine that are not covered by patients’ insurance — same-day appointments, relatively no waiting, non-rushed appointments, attentive follow-up, phone and secure e-mail contact with a provider, and access to care 24/7/365.
“In essence, the fee covers the customer service and coordination of care that is critical to quality outcomes,” Shute explains. Specifically, these are the elements that enhance patient-physician relationships and patient health, while helping patients avoid unnecessary visits and costs. According to Rallison, these are the elements that enable GreenField to deliver on their core values — relationship, service, and reliability.
“Our clinicians spend 50% of their time seeing patients and the other 50% of their time doing non-visit-based care — on the phone and through secure e-mail — that builds engaged relationships and coordination of care,” says Rallison. A busy day for their physicians is seeing 9-10 patients, which is not much by today’s standards; many other practitioners report seeing up to 30 patients a day. GreenField Health has 30-50% fewer patient visits overall than most primary care clinics. Due to their delivery model and lower daily patient churn, Steve says they need approximately 1.4 exam rooms per full-time clinician, compared to 2-3 exam rooms that other primary care clinics require. “We need 25% less space than a traditional clinic, further reducing costs.”
GreenField also has a very egalitarian culture. Notes Rallison, “There are no white coats, our doctors go by first name — unless the patient prefers to call them ‘Doctor.’ Every team member here is valued and respected, regardless of their role, and involved in creating results—including patients.” It’s not lost on him that in a traditional, hierarchical structure, the system works to make the physician’s day efficient, so that there is no downtime in the machine—sometimes at great expense to staff and patient convenience. But GreenField finds there are greater efficiencies overall with an underlying foundation of respect and trust that comes in a less hierarchical culture. “It facilitates communication and is easier to share information, especially with a problem or an opportunity for improvement. It increases patient activation. Oh, and by the way,” he adds, “it’s more enjoyable this way.”
Another key difference for GreenField is that there are no incentives for physician productivity, and the clinicians are paid a flat salary. Says Rallison, “People put their time where you put the incentive — such as making the physician’s day efficient. If you remove perverse incentives around volume, the physicians can more easily focus on their patients’ needs.” Shute agrees, “This frees up the physician to do the job as they think it should be done. Rather than seeing as many patients as possible, they can focus on providing care in the best way possible for each patient, putting the patient’s needs first.”
Recalling a previous leadership role in risk management training, David notes the importance of asking health care professionals the pivotal question, “Who do you work for?” At GreenField Health, no doubt everyone on that team has the same answer: The Patient.
Shute says this model is not necessarily easier on the physician, as they might spend just as much time — if not more — on e-mail and phone contact as they would at a face-to-face appointment. They are just as time-pressed as high-volume physicians, but devote their time to different processes to deliver care. The key point here is that GreenField’s delivery process is geared to be easier and more convenient for the patient.
GreenField has long believed that delivering quality service and reliable care is efficient for the system as a whole. “We’ve always been focused on comprehensive, convenient care. With our service-oriented approach, we’re saving time for our patients, which saves them money — and, in turn, saves money for employers and insurance companies. At the same time, our model allows for high engagement, so we’re improving health overall — further avoiding unnecessary procedures or use of expensive technology, and general system abuse,” says Rallison.
* Rita Rubin, “Innovative Health Programs Counter Primary Care Shortage,” USA Today, August 6, 2010, accessed May 12, 2014, http://usatoday30.usatoday.com/news/health/2010-08-16-1Aprimarycare16_CV_N.htm?csp=obinsite.