By Dale Shaller and Susan Edgman-Levitan

Cardinal Primary Care Medical Group, Inc.

2415 High School Avenue, Suite 800
Concord, CA 94520
925-687-5210

The Cardinal Primary Care Medical Group is one of 12 primary care practices featured in Commonwealth Fund case studies of patient-centered practices. The site visit was conducted by Dale Shaller on Wednesday, January 31, 2007.

Key Personnel Interviewed
Elisabeth H. "Rusty" Renner, M.D., Family Medicine
Lori K. Danze, M.D., Internal Medicine
Praise T. Shang, M.D., Family Practice
Jean Renner, R.N., Lead Nurse and Referrals
Rowena Zamera, Receptionist

Overview

The Cardinal Primary Care Medical Group is one of 12 practice sites featured in Commonwealth Fund case studies of high-performing patient-centered primary care practices. Practices were selected from a sample of over 2,000 sites on the basis of their exceptional scores across multiple domains on patient experience surveys. The purpose of the case studies is to document models of high-quality, patient-centered care and to extract lessons regarding the organizational factors and specific processes used by these practices to achieve favorable patient experiences.

The Cardinal practice scored well above the 90th percentile in areas related to doctor communication, office staff, and coordination of care on a 2006 patient experience survey of over 260 physician practices in California, sponsored by the Pacific Business Group on Health (PBGH). These superior survey scores appear to be related to the compatible pairing of the practice's two lead physicians, which in turn has fostered a cohesive team approach involving the other clinicians and administrative staff. The common background and training of the physician leaders has facilitated a strong partnership committed to service, and these values have been embraced by all staff. An exceptional office manager and highly competent, personable nurse help to cultivate strong ties with patients and their families.

Characteristics of the Local Market

Concord is a city of approximately 120,000 residents located north of Oakland, between Walnut Creek to the south and Antioch to the north. The resident population is relatively middle class, and becomes more affluent moving toward Walnut Creek and less affluent in the direction of Antioch and Pittsburgh.

History, Structure, and Governance

This practice was gifted to Elisabeth Renner, M.D., in 1992 by a retiring internist, Charles Williams, M.D., who had been searching for someone to take on his remaining patients. When Dr. Renner took over, Dr. Williams was working only part time and had a panel of about 800 aging patients. Most of the female patients stayed but many of the male patients left or were referred to specialists. The relatively small panel that Dr. Renner took over allowed her to gradually build her own patient base, attracting many patients from referrals through her network of colleagues in Berkeley, where she had previously worked. Lori Danze, M.D., joined the practice in 1996. Praise Shang, M.D., was recruited in 2006.

The mission of the practice, as stated by Dr. Renner, is: "To provide high-value modern primary care with old-fashioned caring." This mission statement rings true in the way the office is structured and managed as an independent practice with a small, cohesive staff.

Approximately half of Cardinal's patients are covered through Hill Physicians IPA, which pays the practice for HMO patients for which Hill receives capitation from the health plans. This is an important affiliation, since Hill reimburses Cardinal on an incentive-based schedule (see the Compensation section, below). Hill also provides a number of support services, such as an electronic billing and an administrative information system called RelayHealth.

At the time of the site visit, Cardinal was in merger discussions with the San Ramon Valley Primary Care Medical Group, a larger practice in San Ramon, California, with about a dozen physicians (www.srvpc.yourmd.com). Cardinal is considering merging because of their desire to offload administrative responsibilities such as billing and human resources and to take advantage of information systems and other support services available in a larger group. The larger group also appears to offer a compatible culture. Hill has encouraged this merger as part of a strategy of getting smaller independent practices to align and therefore fend off competition from the large health systems in the region such as Kaiser Permanente and Sutter Health.

Payer Mix and Patient Population

Other than the Hill Physicians IPA relationship, which comprises over half of its patient base, Cardinal has limited data on its payer mix. The practice has a very small percentage of self-pay patients, some Medicare, and no Medicaid patients.

Physical Characteristics of the Site

The practice is located next to a large hospital and medical center owned by John Muir Health Care. It is one of several medical buildings surrounding the medical complex. The practice is on the second floor of a two-story building with an interior, open-air courtyard with natural vegetation. The parking lot is limited and many patients end up with street parking.

Patients enter the practice through a glass door into a waiting area that is attractive and nicely furnished. A large glass sliding window separates the waiting area from the receptionist area. Beyond the receptionist area, a hallway leads to a number of small exam rooms connected in a large square. Surrounding the entire practice are large banks of windows that brighten the rooms with natural light. Drs. Renner, Danze, and Shang share a common office space in the rear of the practice.

Systems and Practices Supporting Patient-Centered Care

Following are selected systems, practices, and organizational supports identified by physicians and staff as key factors in promoting patient-centered care at Cardinal:

• Patient resources, such as ADA fact sheets for people with diabetes and the Hill Physicians Web site (www.hillphysicians.com).
• Test follow-up. Patients are advised of results within two weeks; they receive a letter regardless of outcomes. These paper forms will change as they move to a full electronic medical records system, with the help of subsidies provided by Hill.
• RelayHealth, an electronic information system provided through Hill that provides access to patients' insurance eligibility, address, and credit verification; claims processing; remittance advice; and statement processing. This system gives patients access to up-to-date account information and the ability to pay their bills online, and enables them to create a personal health record. The system supports patient e-mail, although it is not used very much in this practice. The physicians primarily use e-mail for electronic prescribing, drug refills, and accessing lab results.

• Making the effort to return patient calls to the office on the same day. A deliberate effort to change work flows made this possible.
• Same-day appointments.

  Staff Training

  Education and training interventions are sponsored through Hill Physicians IPA, including consultant-led sessions on communications, access, and how to balance work and personal issues.

  A major challenge in this practice is finding the right mix of medical assistants. The practice's medical assistants are often inexperienced, and there is high turnover among them. This is a tough market for recruiting medical assistants.

  Physician Performance Scores and Incentives

  A strong theme emerging through the site visits was the importance of physician performance scores and incentives. Dr. Renner, in particular, believes this is a powerful motivator for changing and reinforcing behavior.

  Physician Staff

  The physician staff consists of three primary care providers. Drs. Renner and Danze are contemporaries, having both gone to undergraduate school at Stanford University. They decided to name the practice Cardinal because of the Stanford mascot, the "Cardinals." Dr. Shang recently joined the practice.

  "Rusty" Renner, M.D.: Dr. Renner comes from a family of physicians, including her father and brother. After graduating from Stanford, she completed her medical school training at UC–Irvine and did her residency at Merrithew Memorial Hospital. She currently serves as the primary care medical director and secretary of the board for Hill Physicians; she works in this position half time, which primarily involves teaching courses and counseling physicians about their performance measurement scores. When asked what factors she believes help account for her own high patient survey scores, she offered the following:
• A dedication to timeliness.
• A focus on asking patients, "Do you have any questions that I have not covered today?" This often leads to additional concerns that can be addressed in the visit.
• The influence of her mother in instilling a desire to take care of people, and the model of her father (a physician who was cost-conscious, well read, and held significant community standing).
• A strong personal drive for efficiency.
• A great professional match with Dr. Danze. Dr. Renner handles research and personnel issues in the office and Dr. Danze focuses on administrative issues.

  Lori Danze, M.D.: Dr. Danze also completed her undergraduate program at Stanford and medical school at UC–Irvine. She spent a year at Kaiser in Colorado. Although she thought highly of the staff and level of care at Kaiser, she did not thrive in the corporate environment. She wanted a smaller practice where she could get to know her own patients. She started working with Dr. Renner in 1996. Factors Dr. Danze considers key to her patient-centered practice include:

  Praise Shang, M.D.: Dr. Shang completed medical school and her residency in Columbus, Ohio. She spent six years at a practice 40 miles south of Columbus. It was not a good experience; the practice was very bureaucratic with a top-down management style. Although she has been at Cardinal only four months, she offered the following observations about what makes the practice work well (in contrast to the Ohio practice):
• A small office setting that allows for personal follow-up with patients and the ability to get to know her patients.
• A phrase she tries to keep in mind at all times is: "Just remember that every one is a mother, grandmother, sister, or someone significant."
• Coordination with other clinicians for specialty care. The practice has good relationships with a small group of specialists in the area. The nurse in charge of referrals, Jean Renner, is exceptional at networking with these other practices.
• Paying attention to details.
• Longevity and loyalty of the core staff.
• Great balance with Dr. Renner.
• Importance of standardization. While each doctor has her own approach, they agree to do some things in common to maintain consistent messages to patients. These include: use of evidence-based medicine, a focus on prevention, and an effort to engage patients in decision-making (but without use of formal tools).
• Dr. Danze is not as interested in performance data and feedback as Dr. Renner; she considers some of it helpful, some not.
• The role Rowena Zamera plays in the front office. The front office makes or breaks the practice. Key factors include how the phone is answered, screening calls for doctors, and scheduling. All of these issues contribute to the overall office flow and help both patients and physicians manage.
• The role of Jean Renner as nurse. She knows all the patients, their families, and all the physicians in town. She is very effective at triage.
• The ability to pay staff well enough to attract the right people for these positions.
• Familiarity with local resources. For example, you may need to refer someone with diabetes to an endocrinologist.
• Drs. Renner and Danze "know their stuff"; she can learn much from them.
• It's all about people: there is no simple algorithm. Patient-centered care requires experience, judgment, and the right temperament.

  Other Staff

  In addition to the three physicians, the office staff consists of one full-time nurse (R.N.), two medical assistants, and a receptionist. The practice is not big enough for an office manager, but this may change when they merge with San Ramon.

  Rowena Zamera: Ms. Zamera has been the full-time receptionist since 1998. She knew Dr. Renner before coming to work for her. She handles appointments, billing, filing, forms, and more. She uses the terms "my doctors"—as if they were family—and "my patients," many of whom she knows well. Patients know when they call they can always get to Rowena. "We are in the service business," she says.

  Jean Renner, R.N.: Ms. Renner is Dr. Renner's mother. She has a background in hospital care and helped her husband with his practice (e.g., bookkeeping) while raising kids. She began helping Dr. Renner here and there and it turned into a full-time position. She is responsible for insurance questions, referrals, patient rooming, troubleshooting, triage, and whatever is needed to make the practice work. She loves her job. She is very interested in her patients and follows their families. She believes she can advocate for patients because she knows them so well. She is very protective of the doctors, acting like a "mother hen" at times. She will not let a patient chart leave her desk until any pending issue or problem is resolved. She believes the doctors at the practice go the extra mile.

  Human Resource and Compensation Policies

  Physician compensation for Drs. Renner and Danze is based on the amount of billable services for which they are able to receive payment from the various mix of payers. Dr. Shang is salaried. Staff are paid on an hourly basis. Bonuses have been paid to staff two times per year, based on revenues.

  Hill Physicians IPA, the largest payer for Cardinal, pays physicians 85 percent on the basis of RBRVS (Resource Based Relative Value Scale), which is a system for reimbursing physicians according to the relative value of services provided. The remaining 15 percent is subject to potential bonus payments of up to 120 percent of RBRVS, according to physician performance on a combination of utilization, clinical measures, patient survey scores, and "participation" points (such as attendance at quarterly meetings, use of e-prescribing on RelayHealth, etc.). Physicians receive monthly and quarterly reports comparing their performance scores with other physicians (who are identified in the report) in their region.

  Conclusion

  Cardinal Primary Care has achieved high levels of patient-centeredness through a compatible pairing of the two lead physicians, which in turn has fostered a cohesive team approach involving the other clinicians and administrative staff. The common background and training of Drs. Renner and Danze has facilitated a strong partnership committed to service, and these values have been embraced by all staff. An exceptional front office manager and highly competent, personable nurse help to cultivate strong ties with patients and their families. Dr. Renner's personal interest and expertise in performance measurement provides an important link to the larger Hill Physicians system, in which routine monitoring of patient experience scores factors significantly into physician bonus compensation.

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  This study was based on publicly available information and self-reported data provided by the case study institution(s). The aim of Fund-sponsored case studies of this type is to identify institutions that have achieved results indicating high performance in a particular area, have undertaken innovations designed to reach higher performance, or exemplify attributes that can foster high performance. The studies are intended to enable other institutions to draw lessons from the studied organizations' experiences in ways that may aid their own efforts to become high performers. The Commonwealth Fund is not an accreditor of health care organizations or systems, and the inclusion of an institution in the Fund's case studies series is not an endorsement by the Fund for receipt of health care from the institution.