Primaris Healthcare Business Solutions

Preferred Family Care

In 2009, Dr. Curtis Long was among a list of private practice physicians who joined the workforce at Bates County Memorial Community Hospital, but the employment move lasted only four years. After all, he’d opened Preferred Family Care at 200 W. Chestnut St. in Butler, Mo., in 1964, and that’s where his heart was. Though the clinic remained open when Dr. Long went from private practice to hospital employee, he wasn’t a fan of the changes.

Four years later, when the hospital wanted to vacate the Butler clinic that Dr. Long had owned for 50 years, that was the last straw.

“That would have meant losing three-quarters of the staff,” said clinic manager and registered nurse Gay Nissen. Dr. Long wouldn’t let that happen. He was ready to be in his own practice again. He decided to go back on his own and do it the best way for his patients.” Nissen has been with Doc Long since 1983. She added, “Dr. Long has been a very, very big influence on the community.”

Unique challenges for rural practices.

But the return to private practice was fraught with challenges. During his four-year stint as a hospital employee, the hospital provided auxiliary staff for Dr. Long’s Butler clinic and implemented electronic health records. The increasingly technical and regulation-heavy Medicare reimbursement requirements were daunting. [1]

The flurry of acronym-laden reimbursement regulations included the Medicare Access and CHIP Reauthorization Act (MACRA), the Merit-based Incentive Payment System (MIPS), and meaningful use (MU, which is now part of the Promoting Interoperability segment of MIPS). The torrent of evolving payment rules pinched the clinic staff for time. As Nissen put it: “All those things that I as a practice manager or RN don’t have the time to assimilate or practice as we should.”

The clinic already had an impressive bevy of services for a rural practice: in-house lab and radiology, for example. “We have a very fantastic private practice,” she said. “Many don’t have this level of service.”

The hospital had wanted the clinic to stop taking x-rays and doing lab work, instead farming those diagnostic tasks out to the hospital. But the clinic has numerous elderly patients with mobility issues – they use canes or wheelchairs – or perhaps they need to have oxygen at all times. Going to the hospital and then coming back to the clinic for the results wasn’t in the best interests of patients, Nissen said.

“Our patients wouldn’t have that easy access,” she said. “They really appreciate that service from the clinic.”


A decision that ‘made all the difference.'

But what about those technology and quality reporting challenges?

That’s where Primaris entered the picture. A team led by Primaris Program Manager Abhi Ray was under contract with the Missouri Department of Health and Senior Services to help rural practices optimize their electronic health records (EHR) systems by improving workflows to capture quality data that, ultimately, would also boost Medicare reimbursements for rural clinics. Nissen connected with Primaris and Ray for help to make “the clinic run more efficiently.” [2]

“The main reason why we felt like Primaris would be a good fit for us was because of all the government rules and regulations. They’re difficult to keep up with, much less understand,” she said. “That was one of the greatest things Primaris has provided for us. Primaris understands and can explain those things.”

That decision “made all the difference,” Dr. Long said, summing up the benefits with a succinct conclusion: “Without Primaris, I’d have to quit. I couldn’t pay the bills.” [3]

Take time with patients or make time for reporting?

Dr. Long lamented the reality that small, rural practices and doctors have no support system when it comes to learning and complying with new quality reporting and payment rules, reiterating Nissen’s summary about the staff not having time or training to take on those tasks.

“They’ve been a great help to us. Without them, we wouldn’t have known all the government regulations coming down the tube,” Dr. Long said. “That’s how it was until we got Primaris to assist us. It’s been a great benefit for our practice.”

Ray further confirmed that point, noting that he and his team helped the practice comply with quality improvement initiatives and MIPS reporting requirements. The experience is a vivid, real-time illustration of the Primaris motto: We’ll take care of your data so you can take care of what matters most – your patients.

The true value of a phone call.

One of the more telling examples of the Preferred Family Care-Primaris quality healthcare partnership was implementing Transition Care Medicine (TCM) codes. For instance, on a patient’s discharge from the hospital, the clinic staff must call the patient within two days of discharge to check medication compliance – does the patient have the meds, is the patient taking the meds? – and a post-hospital clinic visit must occur within seven days.

Nissan recalled that in one case, a patient was discharged from the hospital and the follow up call revealed that the patient hadn’t picked up a prescription. As a result, the meds were picked up and taken. “The TCM phone call in that case probably averted a hospital readmission,” she said.

Before Primaris came on board as a quality improvement help, the clinic had not been making TCM calls.

“It’s very difficult to even know about some of those things when you have so many things going on at the same time,” Nissen explained, describing another example of how a small clinic’s staff is pressed for time.

Meanwhile, the benefit to patients is perhaps incalculable. The benefit to the clinic’s bottom line is also significant. The clinic receives Medicare payments for TCM calls: at least $122 per call. That factor is among the workflow changes and additions that helped the clinic achieve an 8 percent positive bump in reimbursements.


Building workflows. And a relationship.

Ray also helped clinic staff design a workflow to provide Prevnar 13 shots, which are well-reimbursed by Medicare. He connected the clinic with a vendor that sends postcard reminders to patients who need to consider getting immunized against a serious form of pneumonia. In addition, Primaris performed a MIPS-required Security Risk Analysis of the clinic’s EHR and digital connections.

“We really, really appreciate Primaris being here,” Nissan said. “I appreciate everything they’ve done for us.”

The TCM code addition also helps the clinic meet MIPS payment and reporting rules that could result in “a raise in a couple of years” in Medicare reimbursement, she said.

That fact certainly isn’t lost on Dr. Long.

“It’s been excellent” working with Primaris, he said. “They tell us what we can do to increase our reimbursement.”

Nissen also beams over the relationship.

“It has been a pleasure working with Dr. Long and Gay,” he said “We try to support the providers in the rural areas, in particular smaller areas that are in need of our services.”

He recalled first connecting with the clinic two years ago.

“They didn’t know the specific problems, but they knew they couldn’t afford a quality improvement team,” Ray said. At the time, the Primaris team was reaching out to rural, single-provider, and small independent clinics as specified in the DHSS contract. [4]

There is a doctor in the house.

Nissen said the clinic hired a second doctor in October 2017 and has also added a nurse practitioner.

“We’re hoping to continue growing and seeing more patients – and thriving,” she said. Nissen is not only the practice manager, but also perhaps the clinic’s biggest supporter. After all, she is part of a five-generation span – one of several such families – that has called Dr. Long “Doc.”

The good doctor, who is also a well-known cattle rancher, still does hospital work, nursing home work, and “some house call work.”

“I still do general medicine,” he said. “There’s very few guys left like me in the country.” Dr. Long reflects for a moment before answering what he would have done if he hadn’t gone into medicine.

“Probably spent it at the farm, taking care of black cows. Certified Angus beef,” he said, adding, “Be sure you’re eating CAB and everything will be alright.” Doctor’s orders.


The MO Provider Community Linkage Program

Connecting individuals with health resources and education while also creating referrals to primary care physicians is a goal of the Community Linkage program that Primaris has undertaken under a contract with the Missouri Department of Health and Senior Services. [5] The program has been especially successful in the Butler, Mo., community. [6]

Jormond Burch, Community Linkage project coordinator for Primaris, said the program is a community-based support model to help individuals understand and manage their health conditions.

“We have heard doctors say, ‘We are doing the best we can, but can’t do everything’ to help patients manage their health,” Burch said. The team also has Community Linkage programs in other rural communities. Community Linkage was launched two years ago in Butler with connections to the Butler Senior Center and the local food pantry.

“We were able to tap into some good community organizations,” Burch said, noting that the Senior Center, for instance, already had ongoing programs and events – such as a daily noon meal and monthly birthday celebrations – where volunteers could connect with individuals to provide blood pressure, weight, and BMI screenings, along with education about chronic care management and other timely topics. Individuals receive a “scorecard” that they can take to a physician for follow up or ongoing regular care.

“It’s a way to help monitor their health conditions outside of normal clinic settings,” Burch said. “It’s really just an extra support for the community to help them understand what healthy living is and to promote lifestyle changes.”

In Butler, Community Linkage has created even more relationships between local residents and Dr. Curtis Long, who has practiced at his Butler clinic since 1964. Burch said the program has been a resounding success.

“It’s the community as a whole supporting community members,” he said. “Volunteers helping out their fellow community members.” [7]


[1] The release of Medicare Access and CHIP Reauthorization Act / Merit-based Incentive Payment System (MACRA/MIPS) regulations focused on changing the care delivery from volume to value based system. This reimbursement structure which rewards performance based reporting and cost saving incentives is more appealing and amenable to larger groups, but extremely challenging to the rural smaller providers.

- “Final Report – MO DHSS EHR Optimization and Provider Community Linkage”

[2] Barriers to quality improvement initiatives for rural providers, include:

  • Lack of knowledge of current recommendations on non-face to face interaction with patients particularly as required for transition care management and chronic care management.
  • The staff of the clinic was not trained for or aware of additional reimbursement for chronic care management and care coordination.

- “Final Report – MO DHSS EHR Optimization and Provider Community Linkage”

[3] All eligible recruited MIPS providers successfully submitted data to Quality Payment Program and will receive incentive payment. All five recruited practices eligible for MIPS received positive adjustment.

- “Final Report – MO DHSS EHR Optimization and Provider Community Linkage”

[4] Financial resources are limited in small practices. Thus small practices have great difficulty implementing the HIT and other changes to improve their MIPS score.

- “Final Report – MO DHSS EHR Optimization and Provider Community Linkage”

[5] The Missouri Provider-Community Linkage Program was designed to provide this type of support to enable small rural physician offices to better serve their clients. The Missouri Provider-Community Linkage Program provides a framework that enables rural communities, residents, and providers to connect preventive care and information that residents can use to improve and manage their health.

- “Final Report – MO DHSS EHR Optimization and Provider Community Linkage”

[6] Through trial and error, the community linkage program has proven to be a sustainable model for population health support in each Missouri target community (Kirksville, Milan, Butler, and Kansas City).

- “Final Report – MO DHSS EHR Optimization and Provider Community Linkage”

[7] With the collaboration of community partners (i.e. YMCA in Kirksville, churches in Butler and Kirksville, senior center in Butler), this project brought together community volunteers and participants to perform tasks such as monitoring blood pressure and glucose levels and raising awareness about individual health. As a result, the blood pressure of the community members were controlled.

- “Final Report – MO DHSS EHR Optimization and Provider Community Linkage”



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