There's No Place Like a Medical Home: Premier Medical Group Focuses on Full-scale Patient-Centered Care

Evan Goldfischer, MD, MBA

It’s not uncommon for a business to use a superlative in its name, but Premier Medical Group in Poughkeepsie, NY, truly lives up to its moniker. The multispecialty practice has three divisions— gastroenterology (GI), urology/women’s health, and the recently added internal medicine—representing nearly a dozen specialties. It has 13 offices in six towns in the Hudson Valley area.

The practice’s goal is to become a “medical home,” according to Evan Goldfischer, MD, MBA, director of the research department for the practice and co-CEO (along with Sunil Kunhara, MD), by offering patient-centered, comprehensive, team-based, coordinated, accessible quality care.

The Power of the Pod

Goldfischer, along with urologic oncologist Naeem Rahman, MD, discussed with Urologists in Cancer Care how the practice has grown and where it is headed.Nearly 5 years ago, the foundation for Premier was set when two practices—GI Associates and Hudson Valley Urology—merged, bringing 18 specialists together. “The thought at that point was that we could share resources: imaging equipment, pathology labs, etc,” Goldfischer explained. “By coming together, we could wield a lot more influence with contractors and hospitals.”

Indeed, the 29-physician practice is now affiliated with six hospitals in its area, including Vassar Brothers Medical Center, where Rahman is medical director of the robotics program.

But Premier’s leaders realized that more growth and expansion would be necessary to maintain a foothold in the rapidly shifting healthcare environment. Their first step was to invest in infrastructure, including adopting an electronic medical records system, implementing a protocol to maintain quality control, and establishing a marketing department, Goldfischer said.

The biggest change came in August 2013 when Premier merged with New Century Medical Associates, a 12-person internal medicine group (six MDs, six mid-level providers).

“We decided to take in primary-care doctors so that we would be able to firm up our referral sources,” Goldfischer said. “We are working toward becoming a medical home. We represent 11 specialties at this point: internal medicine, pediatrics, family medicine, urology, GI, pathology, anesthesiology, endocrinology, nephrology, pulmonology, and women’s health.”

The “pod model” that separates the specialties is the basis for Premier’s salary scale. Each specialty is an independent pod, and after each pays an overhead, it makes its own financial arrangements. “The urologists work with an equal share between partners; the GI group has some base salary with productivity bonuses; and the internal medicine group has a larger base salary with smaller productivity bonuses. Each group has figured out what works for them, and then all the pods are overseen by our financial department,” Goldfischer said.

What this pod model offers patients is “one-stop shopping,” with all their physicians located in a single practice. In addition, those physicians have access to all of a patient’s medical records, eliminating the problem of missed or conflicting healthcare information. Patients who visit Premier only for their urology care can also get much of what they need without going anywhere else, Goldfischer said. “Everybody can subspecialize. As a result, our providers are very good at what they do, so when a patient is referred for subspecialty treatment, whether it’s from a Premier primary-care physician or an outside provider, they can be assured that they’ll get the highest quality of care.”

But that doesn’t mean Premier views itself as completely insulated; in addition to building relationships with hospitals, the group has made it a point to establish strong relationships with other practices in its area. So for the practice’s urologic cancer patients who are referred to oncologists and radiation oncologists outside of Premier, the continuity of care is maintained.

“We’ve developed very strategic relationships with certain oncology and radiation oncology practices, and because of that, these groups are getting all of our business.” In turn, these cancer patients tend to come back to Premier for their post-treatment care, Goldfischer said.

Cancer Care

Creating connections rather than working in isolation has been one of the keys to the practice’s success, and it’s a philosophy that Goldfischer suggested other groups consider adopting. “Don’t have adversarial relationships with other practices in your area,” he said. “It’s important to get along with everybody, all of the larger group practices in the area. It’s the same with the hospitals. If you can, try to attain leadership positions at the hospitals, because that will help a practice survive in the long run.”Asked what he considered to be one of the major advances in prostate cancer care (his subspecialty) in the past two decades, Rahman singled out the use of prostate-specific antigen (PSA) for disease screening.

“The PSA came out in 1994 with FDA approval, so we’re right at the 20th anniversary of that test being in the clinic,” he explained. “Of course, PSA testing has been a source of controversy in terms of how effective it is for screening. We are screening a little bit less now, doing fewer biopsies, and conducting more observation [of early-stage disease].”

Since the US Preventive Services Task Force issued its recommendation against routine prostate cancer screening, urologists saw a drop in the number of referrals for PSA testing, according to a 2013 paper in the Journal of Urology.¹

But with an in-house internal medicine division, does Rahman expect that Premier’s referral rate will also move on that same trajectory? Rahman predicted that the practice will follow national trends to some extent and render fewer PSA screening tests. For patients referred for evaluation, there will likely be higher thresholds for performing biopsies.

Rahman expects the urology division to continue to follow American Urological Association guidelines: Screen men age 55 to 69 years who do not have risk factors for prostate cancer, and consider screening at younger or older ages if risk factors exist (http://tinyurl. com/k7uod66).

“I think each practitioner within internal medicine will need to decide for themselves regarding PSA testing—I don’t think there will be a single policy,” Rahman continued. “My sense is that the AUA guidelines will predominate.”

But he added that he doesn’t anticipate any conflict with his internal medicine colleagues as to who should be managing these patients. “The management for prostate cancer, early- or late-stage, has always been the purview of the urologists. I don’t think that will change with the merger,” he explained.

Another set of milestones in prostate cancer has been the introduction of therapies for advanced disease, such as abiraterone (Zytiga), enzalutamide (Xtandi), sipuleucel-T (Provenge), and radium-223 (Xofigo). But these new drugs also come with significant price tags, and the high cost of cancer care is another topic for debate. Rahman pointed out that even with these new therapies, the treatment avenues for advanced disease are still limited, and it’s too early to determine if one therapy is worth more than another in terms of dollar value.

“We are in the early stages of using a lot of these therapies; the proper indications and sequencing of these drugs is still being defined and reassessed. But there aren’t a lot of options for these patients, so we have to offer these therapies, regardless of the costs. Cost-effectiveness will improve as indications become better defined and clinicians more educated; however, the high cost for cancer care in general is a larger societal question,” he said.

Rahman said he looks to other areas of cancer care to gain financial ground, such as in the diagnostic stage.

“Costs are also going up for other reasons, such as the use of prostate MRI, MRI-guided prostate biopsy, and genomic testing of prostate cancer; it’s not just at the treatment stage,” he explained. “I’m a bit more conservative in using these technologies widely, as I think the subset for whom these newer technologies makes a big clinical difference is limited.”

One area where there is no cutting back is helping patients maintain healthy lifestyles, particularly in older men with prostate cancer who also often contend with cardiovascular disease, Rahman said. He and Goldfischer agreed that it’s incumbent upon urologists to keep tabs on health issues that may fall outside the scope of the specialty.

“These patients develop strong relationships with the practice, so they tend to come back for all their care,” Goldfischer said. “That means we need to make sure we are keeping an eye on all aspects of their health. I think they expect that level of care from us.”

That global viewpoint on health is key in all cancer patients, Rahman added, pointing out that much of his care strategy is based on maintaining quality of life. “If I have a young man with testicular cancer, this patient is going to be concerned about sexual health and fertility. These are issues that we discuss before, during, and after treatment.”

Future Plans

“Likewise, in prostate cancer, improving urinary function, sexual function, and discussing healthy lifestyle to ensure blood pressure and heart disease risk are mitigated is usually the major part of postoperative care,” he said. “A small percentage of the visit is focused on the cancer itself; usually the main emphasis is on how he can live a full, healthy life.”Goldfischer revealed that two growth areas for Premier are its quality- control measures and its primary-care division.

“We are very serious about quality metrics and reporting data back to our providers to make sure that we are providing the best care we can,” he said. “We collect tons of data on all of our providers, and we report it in an open forum so everyone can see it, determine how they are doing in the group, and how they measure up to the national standards.”

Building the primary-care division will require increasing patient and provider volumes. Goldfischer acknowledged the current manpower shortage in internal medicine and said the practice has found two avenues to address that: hiring more mid-level providers (the practice currently has a dozen nurse practitioners and physician assistants), and relying on current practice members to share their experiences with their colleagues.

“Our best source of recruitment is the doctors who have joined us,” he said. “They’ve been having a good experience and they’ve been telling that to their colleagues. So word-of-mouth has turned out to be a great marketing tool for us in terms of bringing in new physicians.”