Health Texas Provider Network: the power of fairness and trust

Large groups of employed physicians were not common before 2000. Thirty years ago, 75% of all physicians in America practiced their trade in solo practice or small groups. Today, the numbers have reversed, and up to 75% of all physicians in this country now work within the structure of large employment models. This article explores the challenges and opportunities that stimulated the migration of physicians into collaborative groups to provide patient care.

The business side of a physician’s practice was less challenging before 1990. Uncomplicated bookkeeping systems were available and affordable. Medical practices were bound by fewer rules and regulations. Insurance companies were less intrusive. As the business of medicine changed, many physicians found it more appealing to focus on the care of patients and let someone else manage the regulatory and financial aspects of a medical practice.^1–7 This was a factor which gave rise to the origin of a physician employment division of Baylor Health Care System (renamed Baylor Scott & White Health after a merger in 2013).

The insurance industry with its escalating requirements and burdensome oversight provided the final impetus toward the collaboration of physicians within large groups. Physicians historically considered the autonomy of their medical practice to be inviolate. Yet in the early 1990s it became increasingly difficult for physicians to order blood tests, throat swabs, radiology studies, and electrocardiograms without being questioned or “precertified.” As insurance companies increased their control over medical payments, physicians’ influence on patient care dwindled. This stimulated a series of meetings among a group of internal medicine physicians at Baylor University Medical Center in Dallas, Texas.

Frustrated with the insurance companies’ overbearance, initial meetings among the Baylor University Medical Center physicians were stimulating and full of positive anticipation. Over time, the meetings became less and less productive. In response, one of the leaders independently drew up bylaws and operating rules. These were presented to the original trailblazers during a seminal meeting in 1993. Unable to reach unanimity due to a solitary hold out, the other future founders walked out of the conference room. As the elevator doors closed, at the very last moment, the decliner acquiesced and a new organization was founded. This initial group searched for a name that could be copyrighted. Initial proposals had already been taken and certified. A popular song at the time, Soul Provider, led to the name MedProvider, which was available and accepted by the state.

MedProvider quickly grew, reaching 37 physicians in total. Other physician groups had been developing around the city, and talks with several of them took place. The discussions between MedProvider, Family Medical Center of Garland, and Dallas Diagnostic Association culminated in a collaborative association.

As these physician groups were integrating, the chief executive officer of Baylor University Medical Center, Boone Powell Jr., asked to meet with the physician leaders. His idea was that physicians and hospital systems could be even stronger and more influential together. Initially, not interested in employment, the physicians were hesitant. Nonetheless, the physician leaders agreed to consider the offer and met frequently to debate the terms of a potential alliance. Legal counsel to the physicians proved to be pivotal. After many unproductive months, the legal advisor challenged the physicians to reflect on whether or not the chief executive officer was trustworthy and whether or not the proposed alliance was fair to the physicians. Focusing on the issues of fairness and trust, a lengthy and pivotal meeting concluded in the affirmative. HealthTexas Provider Network (HTPN), a division of Baylor Health Care System, was thus founded in April of 1994.

Associations among physicians and hospitals at that time became known as physician hospital organizations and began springing up throughout the United States.⁸ A decade later, however, many if not most of them unraveled. The HTPN/Baylor Health Care System alliance has survived to this day, and its primary care physician and specialist members now number 1250. Advanced practice providers, including nurse practitioners, physician assistants, and clinical nurse specialists, add another 510 members to the group.

Why were HTPN and Baylor successful when others were not? The organization was set up with a physician board of directors that serves as the conduit to the “member,” which is the hospital system. Both sides have continually worked together toward mutual benefit. Early wins were chalked up in negotiations with the insurance companies. On one occasion, the hospital became satisfied with the terms of a new contract but delayed final approval until the physicians’ negotiations were completed. Several years later, the converse occurred: HTPN contract negotiations were satisfactorily completed but the insurance company refused the terms of the hospital administrators. The doctors held out until the details of both contracts were accepted.

Starting out, HTPN was composed of primary care physicians: internists, family practitioners, pediatricians, and geriatricians. It did not take long before specialty physicians became interested in the organization. The specialists recognized value in an affiliation with a large group of primary care physicians from whom they could potentially receive referrals. Today, more than half of the physicians in HTPN are specialists. Advanced practice providers—physician assistants, nurse practitioners, and clinical nurse specialists—have also steadily increased in numbers as the organization has grown.

The physician hospital organization of Baylor Health Care System, now Baylor Scott & White Health, has seen added value from the alliance that directly benefits patient care.⁹ Quality metrics have been established, monitored, and enforced.¹⁰ Not initially popular, the “slow-to-change” attitude of many physicians presented a challenge. As an example, a senior physician objected to measurements of his mammogram screening rates, explaining, “I encourage my patients to get a mammogram, when appropriate, and when they do not, it is their responsibility.” Physician leaders in HTPN emphasized to him that early detection of breast cancer has high cure rates and that advanced stage breast cancer is often deadly. It was also pointed out that many of his partners were much more successful in screening patients for breast cancer. As a result, he and his staff began to work harder on this metric.

Other quality measurements, such as immunizations, diabetes management, cholesterol control, and blood pressure control, were also initially met with resistance. “Don’t tell me what to do; you know that I am a good doctor” became a common mantra. The competitive nature of physicians was again used to counter this. Motivation became intense when everyone’s results became transparent to all. No one wanted to be seen as lagging in the care of their patients. Overall, results have demonstrated that you can indeed influence what you measure, and HTPN scores have become among the best in the country.

The same outcome occurred with measurements of patient satisfaction scores. As one physician complained, “I don’t want to be judged on what I tell patients because I often tell them things that they do not want to hear—for example, ‘You need to lose weight, quit smoking, and exercise more.’” When his less-than-optimal results came out, he found a way to communicate in a more effective and accepting manner. Satisfaction scores of HTPN physicians have also become some of the best in class on a national basis.

Improvements in quality and service scores are not only advantageous for patient care; financial rewards can also accrue. Pioneered by Michael E. Porter and Elizabeth O. Teisberg, so-called value-based care models give bonuses to physicians who meet and exceed established quality metrics and reduce payments to those who fall below established goals. Such programs ideally provide better care for individuals, improve population health management, and reduce health care costs.^11,12

As Baylor Scott & White grew organically and through a merger, HTPN has blended with other employed physician groups. Four separate physician groups from around the state are now aligned in a limited liability corporation known as the Baylor Scott & White Medical Group (BSWMG). Sharing backgrounds, experiences, and cultures has helped advance the way health care is delivered to their patients. The total number of employed physicians working alongside Baylor Scott & White now approaches 3000, and the total number of patients cared for annually is almost 800,000.

In recent times, the health care industry in America has been challenged by the entrance of well-financed disruptors. More and more physicians are becoming employed by venture capital companies, hospitals, health care systems, retail enterprises, private equity firms, and insurance companies. Some have questioned whether this may compromise the values of the physician profession.¹³

Patient expectations have also changed. In response, BSWMG, along with its administrative partners, has adopted a customer-centric strategy that allows patients to access and receive care on their own terms with an emphasis on personalized experiences. Included in this are 24/7 virtual visits for medical advice, care managers to assist patients with navigation through our facilities, online scheduling for patient appointments, hospital-in-the-home programs, previsit financial estimates, and the addition of urgent care centers throughout the state. This has been made possible by the close alignment of the employed physicians and advanced care providers within BSWMG, along with the dedication and skills of its partnered health care administrators.

W. Edward Deming, an engineer and management consultant expert, has proselytized that when variability in a process exists, it should be studied. Opportunities to optimize results are often discovered. HTPN has been a believer in this philosophy, which has continued with the BSWMG. Capitalizing on the philosophy of Mr. Deming, the entirety of Baylor Scott & White Health, with its dedicated group of employed physicians, advanced practice providers, clinical teams, and administrators, continually investigates ways to improve patient care. Hence their motto: “We make care better.”

Disclosure statement/Funding

The author reports no funding or conflicts of interest.