Monday, July 18, 2016

The Octopus As Analogy for Healthcare Innovation


“ 'When an octopus settles on a coral reef, it changes colors to provide protection from predators. But the color changes are not directed centrally … Each cell has the innate capacity to recognize its surroundings and change color to match.

We need that type of decentralized innovation in medicine today – innovation that starts with the provider and the patient.'

"In the last chapter of his landmark book, Fixing the Primary Care Crisis, Stephen C. Schimpff, MD FACP, introduces the above, unusual but striking analogy, for the current healthcare conundrum.
Innovation is ubiquitous in the healthcare community. We have come to expect it from our medical professionals, scientists and pharmaceutical companies. What sets Dr. Schimpff’s cause célèbre apart is his understanding that the healthcare delivery system itself is most in need of innovation.

"It is impossible to disagree with Dr. Schimpff’s compelling argument: The solution to the American healthcare conundrum should be decentralized and begin at the bottom!

"Innovation From the Bottom Up”

Quoted from Michael R H Stewart founder of Crowdfunding For Good and available  in its entirety at this link: 

Wednesday, March 9, 2016

A New Way To Improve Primary Care Yet Reduce Total Costs

PCPs in the current reimbursement model are obliged for business reasons to see too many patients per day which of course means less time per patient. PCPs are frustrated and patients are less satisfied. With less time it is hard to build a strong doctor – patient relationship and without it there is less opportunity to build trust. Readers of my posts know that I am a strong advocate for primary care and for granting the PCP added time per patient but doing so with no decrement in income. Here is an innovative experiment by an insurer to incent PCPs to offer more time to those patients with chronic illnesses while enhancing preventive care to all. 

Added time and good care coordination will improve the quality of care for the individual patient with a chronic illness and yet will reduce costs by eliminating excess specialists visits, tests, procedures and, by improving care quality, it will reduce the need for hospitalizations. That was the assumption underlying a program by a large not for profit BlueCross/Blue Shield plan - CareFirst. Fundamentally the plan incents PCPs with opportunities for increased income in return for giving added time and good care coordination to those with chronic illnesses along with enhanced preventive care to all patients. 

The insurer calculated that about 80% of their medical expenditures went towards the care of just 15% of patients. These were patients with complex chronic illnesses. Knowing that primary care physicians receive about 5% of total healthcare expenditures it was hypothesized that they are in a position to strongly impact much of the other 95%. The insurer also wanted to raise awareness of healthy lifestyles to assist all of their enrollees to remain healthy. So the agenda was to create incentives for PCPs to have an impact to reduce the total cost for those with chronic conditions while improving the care and concurrently maintain the health of the remaining enrollees. 

Oversimplified, the new program works like this. PCPs form into actual or virtual groups or panels of 5 to 10 and enter into an agreement with the insurer which then increases their reimbursement by 12% for each visit. The insurer also agrees to pay the physician within one business day, reducing the doctor’s need for working capital.  

An actuarial analysis of the PCP group’s patients is done using claims data from the prior year to create an anticipated “global budget” for the coming year.  The 15% or so of patients that need chronic illness care coordination are “flagged.” The PCP’s obligation is to give those patients whatever added time is needed per visit, to create a complete care plan and to post it in an electronic medical record (for which the PCP gets an additional $200). This serves as automatic preauthorization; no further calls will be needed for tests, procedures, etc. – a major time saver for the PCP and the office staff. The concept also anticipated that with extra time per patient, the PCP would be able to handle most issues including those of patients with complex chronic illnesses, reducing the need for specialist referrals. Finally, the insurer makes available a nurse “care coordinator” at its expense  to call the patient as often as necessary to check on medication use, medication side effects, weight gain or whatever else the PCP has built into the care plan. The expectation starting out was that this approach of incentives for giving the patient with a chronic illness the intensive primary care and the care coordination needed would enhance quality yet reduce the overall expenditures for that patient.  

If, at the end of the year, the PCP groups’ total claims came in under the projected global budget, the members of the virtual group would get back a portion of the savings. With these incentives, it was anticipated that the PCP would be sure to carefully coordinate care so that there were no excess specialist visits, no unneeded tests or procedures and, with better care overall, less ER visits and less hospitalizations. The end result, it was hoped from the start, would be higher quality care, lower total expenditures for that care, enhanced income for the PCPs and a more satisfying practice. It could be a win for everyone. Now three years in, the plan seems to be working. The physicians are pleased with the added income and the insurer is pleased that total costs have dropped. 

The whole concept was to coordinate the care that the patient receives with the expectation that the patient will be better served, the providers will be more satisfied and the total costs will be reduced. It is a transformational change in how the PCP functions. It is an equally huge transformational change for the insurer –a change that accepts that extensive primary care with care coordination costs extra money but recognizes that the end result is better quality at a lower total cost.  

After two years, it was reported that it saved $136 million with the 297 panels of 3,600 PCPs that had joined the program caring for about one million individuals. All of the PCPs enjoyed the added income in their reimbursements and two thirds received end of year incentive payments as a result of the savings. Overall the average PCP in the program received about 29% more than they otherwise would have under the standard fee schedule.  

At the end of three years and with enough data to be actuarially credible, there have been quite definite improvements in ten measures such as costs per member per month, number of emergency visits, admissions per 1000 members, length of stay, cost per admission, and readmissions within 30 days after discharge, etc. while maintaining or improving quality measures. Not all panels of PCPs were as successful as others and those that were tended to be successful in each of the three years in the program. At the end of the third year, about 60% of the panels were granted an incentive award for beating their projected global budget. The successful panels tended to be those in small private practices and, interestingly, had sicker patients under care yet they maintained higher quality scores. Another important finding was that some specialists tended to much higher utilization (and therefore costs) than others despite similar patient problems. PCPs who tended to refer to high utilization specialists were much less likely to achieve an end of year incentive payment. 

Of course, there are some questions to raise. If the PCP is spending more time with these patients but still has the same total size practice, then where is the time coming from? Does it mean less time for other patients? PCPs have now learned which specialists expend more dollars per patient than others. Will their referrals gravitate to these specialists regardless of known or perceived quality? Patients will likely in the future be offered incentives for choosing the PCPs that are most effective with this program; is that appropriate? And what about those PCPs who have converted their practices to direct primary care? They are actually saving the insurer considerably, probably much more than the incented PCPs in this program. The insurer should consider paying all or part of the DPC fee for their insureds since the insurer is benefiting substantially yet at no cost to itself. 

Perhaps the most important outcome, from my perspective, is the recognition by a major insurer that it is possible to create a new incentive-based approach to reimbursement – in this case within the old fee-for-service model – which actually costs more for primary care (up from about 5% of total costs to about 7-8% of total costs) yet significantly reduced those total costs of care while improving quality. 

Note: I talked to CareFirst's CEO, the former chairman of the board and a vice president about the program but I have no financial relationship; this program is used for illustrative purposes only and is not meant to be an endorsement.

Tuesday, February 23, 2016

Employer-Sponsored Comprehensive Primary Care

Patients need doctors that take time to listen which means a limited number of patients under care. Employers need programs that reduce costs and ideally improve the health of their staff. These apparently disparate needs can come together in a new model for effective company-sponsored primary care programs.

Those of you who have followed this series know that I am an advocate for PCPs finding ways to have a smaller patient panel so that each patient can receive more time for comprehensive primary care. When properly designed, company-sponsored primary care clinics can do just that.

Some employers are turning to outside firms such as QuadMed to initiate care models that can serve both smaller patient panels yet reduce their total costs toward healthcare. Although there are many such firms (or local practices) that will take on the role, real success hinges on a program that is well organized and allocates adequate time for the PCP to give truly comprehensive primary care. It also means that the employer has accepted the concept that it is no longer just trying to hold the line on healthcare costs but is actually looking at employee health as a strategic business imperative.

Successful programs tend to include not only PCPs, NPs, nurses and other providers but, if the employee base is large enough, a pharmacy, laboratory, and radiology suite. Other key resources are health coaches and nutritionists to maintain wellness and reduce risk factors. The typical employer in these arrangements is generally self-insured, has a large enough employee base to justify the clinic resources and is committed to employee health and wellness while wanting to reduce its total costs of health care.

A full service primary care clinic is funded by the company at or very near to the employer’s site of business. Services include routine episodic care but also extensive preventive care, intense management of those with chronic illnesses and care coordination when a patient does need to visit a specialist and sufficient time with the provider that trust can develop; in other words, this is comprehensive primary care not just limited function urgent care centers.

Employees are informed that they are welcome but not required to utilize the clinic and do so at no cost or perhaps a modest fee per visit. Some but not all employers make the clinics available to family members. Each participating individual is assigned a primary care physician (PCP) or in some cases a nurse practitioner or physician assistant. The PCP/NP/PA is paid by salary by the vendor company, not fee-for-service. In the programs that truly develop comprehensive primary care, the PCP/NP/PA has a limited number of patients in his or her panel, does a full initial evaluation usually lasting 60 minutes or more and then sees the individual thereafter as often as necessary for as long as necessary.

The expectation is that the patient and PCP/NP/PA will develop a long term trusting relationship just as they would in a private office setting. Individuals can schedule appointments often on the same or next day and there may be extensive use of mobile technologies, an electronic medical record, telemedicine and other advanced techniques. For those individuals with a chronic illness, the clinic nurses often work with the PCP to coordinate care and (often and hopefully always) the PCP communicates directly with any specialist before referring and after the visit.

The clinic manages wellness and preventive programs with health coaching and lifestyle behavior management. This might include but is not limited to nutrition counseling, fitness counseling, stress management and smoking cessation. It depends on the provider company selected to develop and manage the clinic, but if the employer already has an effective wellness program ongoing with another provider, the primary care company may agree to partner with that wellness provider to create seamless programs. It can thus be an employer wellness program and a comprehensive primary care program rolled into one. It may even be population health to the extent that the PCP and the team proactively interact with each participant to address risk factor and incipient chronic illnesses rather than waiting for an employee/patient to call or visit with a problem. To repeat, a very key ingredient is assigning no more than a reasonable number of employees and family members to each PCP/NP/PA. What is “reasonable”? – it depends – on average age, whether many individuals have chronic illnesses, etc.

Some provider companies such as WeCare TLC call their model “medical risk management,” a term generally thought of in medicine as programs and policies to reduce the potential for malpractice claims. Here however it has a completely different meaning. It is called medical risk management because the driving principle is identification and management of ongoing medical problems while at the same time addressing potential health risks for the future. It is really an employer-sponsored (although not directly involved) companywide approach to population health management. It is taken from the concept of enterprise risk management which seeks to identify and mitigate corporate risk as a strategic advantage. It is management of risk not just from a downside perspective but from an upside or positive perspective as well. The employer therefore needs to be thinking about health risk management as a strategic perspective, not just as a tactical effort. In other words, a healthy workforce is available to be productive and a healthy workforce creates a very substantial savings in medical costs for both the company and the employee.

Note that it is not just “episodic” visits but rather comprehensive primary care in a medical home type model with proactive population health concepts.

The provider company and the employer usually agree up front to a set of performance measures such as utilization/penetration of the clinic (are employees actually using it), patient satisfaction (do they like what they get), quality outcomes (standard measures used nationally such as blood pressure control, diabetic control, immunizations up to date, etc.) and of course functioning within budget and a return on the employer’s investment at a pre-agreed level. Companies that engage in these clinics, provided that the services are actually comprehensive in nature as described, tend to find that their return on investment very good.

Since in these models of comprehensive primary care where the employer fully pays for the primary care services, there can be a significant savings for the employee (patient) and family members.  Importantly, the employer pays the bills, perhaps offers incentives for participating but is otherwise kept at a distance. The PCP and other staff members work for the provider company, not for the employer, and cannot be expected to share patient information. The employee gets quality healthcare with a strong emphasis on maintaining wellness, active prevention and on chronic illness early detection, management and care coordination. The result is a healthier workforce leading to greater productivity, greater workforce satisfaction, reduced or no employee costs for primary care and reduced or at least limited health insurance cost increases for both employers and employees.  Definitely a triple win.

But there are potential downsides to consider. Some KevinMD readers will certainly comment that it is best to keep the employer completely out of healthcare. Another downside would be if the employer wanted to be intrusive and learn medical information about individuals. A third would be the loss of a trusted PCP when a person leaves the company for other employment. So in the end, each person offered the option needs to make an informed decision.

Note: I have interviewed principals at both QuadMed and WeCare but have no financial or arrangements with either. They are used as examples only; their use does not represent an endorsement.

Wednesday, February 3, 2016

Reducing Healthcare Costs Through Company Wellness Plans

Employers have seen their health care costs rise dramatically over the years. To compensate, they have expected employees to pay an increasing portion of the healthcare insurance premium, expected employees to pay significant co-pays with each physician visit and have purchased policies that restrict individuals to a narrow network of doctors and hospitals. Largely these have not worked. They have offset some of the expenditures but it has not done much to slow the inexorable rise of health care costs. The reason is because they attack the wrong “problem.” What is needed is to institute approaches to improve health and maintain wellness of the employee (and the employee’s family) and to assure that the employee (and family) get outstanding primary care including proactive population-style health care. Add to this patient engagement – a stake in the financial arrangement. That combination will reduce costs considerably. Here is one approach that progressive companies are following.
Large companies such as General Mills and Safeway have demonstrated the utility of wellness programs. Employees are invited to voluntarily participate in company sponsored programs that are designed for behavior modification such as nutrition, fitness, chronic stress reduction and smoking cessation. The employee (and sometimes the employee’s family members) who participate are rewarded with a reduction in their share of the health care premium. Given that employers are continually increasing employee share, this reduction can be a real benefit to a person’s paycheck. Large corporations often create these programs in house but smaller and many larger companies can turn to wellness companies such as Orriant that will do a turnkey approach for a single larger company or a group of smaller companies in a defined geographic region. Workplace wellness programs logically should improve employee health but until now results were mostly anecdotal; there was no definitive proof. Now, evidence has been published in the International Journal of Workplace Health Management that an opt-in program encompassing biometric testing and a personal wellness profile to guide individualized telephonic health coaching combined with financial incentives led to improved health parameters, improved health age and reduced healthcare costs. The authors concluded that “health coaching effectively improved biometric scores among high-risk individuals and narrowed the difference between current health age and achievable age, more so among those with the greatest health risks at baseline.”

Here are some of the specific findings: Compared to nonparticipants, the participant’s claims paid increased at a lower rate and they had fewer claims per person. For those with elevated blood pressure, the average systolic pressure was 170 mmHg which was reduced by 34 over the three year study; for diastolic it was 105 down by 18 mmHg. For those with elevated glucose the starting average was 164.4 and dropped by 31(58%) over the three years. Those at the greatest risk for cancer improved their lifestyle score by nearly 32 points, or 41%.

According to those in the company wellness field, there are few key ingredients that make for a successful wellness program. The majority of employees (and spouses) need to be working one-on-one with a health coach to develop their own self-directed plan for behavioral improvement. Individual care and concern by the health coach is the most effective intervention. Employees need to like their coach (which I interpret to mean they trust their coach.) Coaches need to be well trained with a significant healthcare background. Individual accountability needs to be an integral part of the program. This implies that the participant needs to call the coach; not the other way around. That is part of accountability. The focus needs to be on those with health risks, which most Americans have. Getting the men in the company involved is important; women are more likely to volunteer early so there has to be extra effort to attract the men.

Some readers will not like the idea of health coaches “meddling in their affairs.” But no
one is obliged to join into the wellness plan; it is always an option although for
sure the employer often offers a financial incentive to do so. Whether in a
wellness plan or affiliated with your PCPs office, health coaches (when properly trained and focused) have been found to be powerful advocates for improved health.

Major health risks from life style factors are being overweight (two thirds of the American population), lack of adequate exercise (probably more than half of people), chronic stress (it seems like everyone is stressed today) and smoking (still about 20%.). High blood pressure can be in part lifestyle directed as is obesity. These in turn lead to chronic illnesses such as heart disease, stroke, chronic lung and kidney disease – just the diseases that account 75-85% of all claims paid by healthcare insurance.

The cost of wellness programs, whether done in house or with a consultant, can be self-funding, i.e., those who opt in get lower premiums and those that do not have higher premiums. But the larger more valuable benefits accrue to both the employer and employee. Staff become healthier – that is good for them. But healthier employees use less total healthcare resources. This in turn lowers company insurance costs or at least slows the growth of premiums, often dramatically. The employee benefits from better health, will likely be more productive, will have less absenteeism and will have greater job satisfaction. That is a win-win for employee and employer alike.

My next few blogs will relate what some companies are doing to offer a complete package of wellness, prevention, consumer-directed insurance, on site primary care clinics, prefunding a HSA or HRA, price transparency and more to manage costs while improving employee health.

[Note: A look at the Orriant web site will show that I am quoted. I am a proponent of wellness programs but I have no financial or other association with the company. If you go to the link for the article on wellness plans noted above you will find that you need to pay to read more than the abstract. I read it and thought it was useful information which why I used it here. You can also find the details on the Orriant web site. As with any study there can be criticisms but I think it was pretty well done. The graph is  claims paid per participant]

Thursday, January 28, 2016

Highly Effective Business Approach To Reducing Healthcare Costs

“Helping employees improve their health is right for the company’s bottom line and is doing right by our employees.  Healthier employees are happier, demonstrate less absenteeism and presenteesism, and are more productive.  This is a win for everyone involved.”  Quoted from John Torinus, Jr., in The Grassroots Healthcare Revolution; he is retired CEO and current board chair of Serigraph, Inc., a mid-sized Wisconsin company with about 500 employees in the USA.

In my earlier posts in this series I have written primarily from the perspective of what primary care physicians can do to not only improve the health of their patients while reducing total costs of care yet also reclaim their right to practice in a non-frustrating environment with a limited number of patient visits per day. Torinus approaches improving health care from the perspective of a business leader faced with rising health care costs. Here I will quote and paraphrase from Torinus’ book and, since I basically agree with his recommendations, will amplify with some of my own thoughts.

He argues that company CEOs must make health care a strategic priority since it is one of the top three costs for any company. Healthcare costs can make the company noncompetitive if not managed aggressively. However, strategic priority to him also means it is essential for the company to attend in a proactive manner to the health and wellness of its employees, not just be the provider of an insurance plan.

CEOs need to think of the long term for their companies and therefore for their employees. The company and the employee together spend about $16,000 per year for a family for insurance today.  An employee who works for a company for 25-40 years represents an insurance expenditure over a lifetime career that could be as much as $400,000 to $640,000 in today’s dollars.  This drives home the point that it obviously only makes sense to have a long term view of employee health beginning with an aggressive approach to maintain wellness, actively reduce risk factors and  manage disease as it occurs.

He observes that the current health care system focuses on specialty care whereas it needs to focus on the care recipient with high quality primary care – the patient/consumer/employee.  But to be effective, the patient/consumer/employee needs to be engaged.  The current healthcare system disengages the patient – it removes responsibility because the patient is not the customer of the doctor.

In his company, expenses were rising to double digits by 2003 but with their new plan in place, it dropped to 2% or less per year.
Torinus’ “prescription” for all companies (and what his company initiated beginning in 2004) follows:  First, every company, including small companies, should self-insure with an added stop-loss catastrophic policy.  Second, employees should be offered only a consumer directed healthcare policy (CDHP), in essence a high deductible plan (often about $2500) with either an associated health savings account (HSA) or a health related account (HRA.)   The company should prefund the account with an amount (often about $1500) that the individual can use for any health care needs with the assumption that since it is now the individual’s money, he or she will spend it more wisely – employee/patient engagement.
Third, the company should insist that each provider have price transparency. Since that’s often difficult to obtain Serigraph uses various companies like Alithias Inc. to provide that for them so that they can compare one provider to another.  For example, they determine the all-inclusive (gastroenterologist, anesthesiologist and facility fee) price along with quality data of colonoscopies at the nearest five centers and then rank them. The employee or family member who needs the colonoscopy is told that, for example, the company sees it as appropriate preventive care and so will cover the cost, in this case up to $1,500.  [His book appeared before the ACA became law so colonoscopy would be covered now by the insurance component but the principle is still valid.] This is an amount that will pay for say, four of the five local centers; but if he or she selects a provider that charges more, they are on the hook for the remainder. 
Fourth, if the company is large enough, it should provide an on-site primary care clinic at no cost to the individual.  At Serigraph, the clinic includes a concierge-type physician (meaning that the physician is salaried, has a low number of patients under care and gives extensive time and energy to each employee/family member patient consistent with some of my previous posts) plus a nurse practitioner, a health coach, a dietician, and a chiropractor.  If the company is too small to justify a full-fledged clinic then the company can pay the retainer for a nearby direct primary care/membership/concierge physician who works with others such as the health coach.  Fifth, the clinic, with special attention by the health coach, gives all employees a health risk assessment annually and then works one-on-one with each employee (and family member) at no cost to maintain wellness and health including the use of behavioral change programs around diet, nutrition, exercise, stress management and smoking cessation.
Sixth, there is very intense management of chronic diseases by the clinic staff and coordination of specialist visits when needed.  Seventh, Serigraph uses what Torinus calls Centers of Value for procedures beyond those that are done by the primary care physician. These are doctors/institutions that have outstanding quality records yet a competitive price for, say, a knee replacement. Serigraph gives their employees $2,000 toward the deductible or totally covers the deductible for the surgery when they make use of these Centers of Value.  Seventh, his company gives (and he recommends others do likewise) generic drugs for free and all of the above prevention and wellness programs are supplied free of charge.  Finally, the company makes free counseling available for developing advanced directives and in the event that an individual requires end of life care, hospice is available free of charge.

I notice that his company spends considerably on extensive/comprehensive primary care including wellness maintenance, proactive prevention and chronic care management but it is rewarded in return with lower total costs and healthier workers.

Given that healthcare has become a company strategic priority, then it needs to be managed and that requires data. Hence, he urges all companies to develop health-related management dashboards including both a financial dashboard (how much is the company spending) and a health dashboard (how many individuals in the company have uncontrolled blood pressure, uncontrolled asthma, uncontrolled cholesterol, have not had appropriate mammography or colonoscopy, etc. – all information collected from the clinic in an unidentified manner to protect individual privacy). 

These approaches are based on fundamental principles including individual responsibility; market place discipline – installing consumerism, steering business to the best quality and price (“do good work and you get our business”); proactive care – maintain employees’ health and wellness and give extensive care to those with chronic illnesses; and sound management – putting those who pay, i.e., the employer and the employee, in charge. 

Torinus suggests there are multiple rewards for following this basic approach (I added number 2 since he implied but did not write it.)

1)     The reward for business is a healthier work force and more affordable healthcare expenditures. 

2)     The reward for individuals is more health and wellness, less illness and fewer dollars spent. 

3)     The reward for high value providers is more business.

4)     The reward for entrepreneurs comes if they innovate with better care provided at lower cost

5)     There could be a reward for tax payers - if government (federal, state and local) were to utilize these approaches

Sound advice.  Your thoughts?

The next post will delve into company wellness programs.

Monday, January 18, 2016

Direct Primary Care – A Response To Your Comments

Over the past few months KevinMD has posted a series of articles by me on what I call the “Crisis in Primary Care.”  (BTW, I was not a PCP.) Most recently have been a few posts related to direct primary care. They have generated many comments – some pro and some con. I have greatly appreciated everyone’s interest; it makes it worth the time to write. So thanks.

My fundamental belief, contrary to some comments, is that PCPs are much more than providers of “simple” stuff. They are more correctly specialists that deal with the very complex. Comprehensive primary care includes wellness and health maintenance, prevention and risk management strategies, attending to the episodic events that occur in life, and the care of those with complex chronic illnesses including coordination of care when a specialist is needed. It also includes developing a strong relationship between doctor and patient, building trust along the way and offering true healing. This means that the PCP can competently handle the vast majority of our health needs. 

But all of this takes time and when the current practice business model forces the PCP to see 25 or more patients per day, there is just not enough time. Direct primary care (DPC) is one way to regain that time. It is not the only way. I plan to discuss some other approaches in later posts. 
A few themes have arisen repeatedly in comments from these posts about direct primary care. One is that there is a difference among the terms DPC, membership, retainer, and concierge.  But to me, they all mean essentially the same thing - fewer patients per doctor and therefore more time for the patient with the doctor which equates to better care.  There does seem to be a degree of concurrence that DPC and membership are terms most often used for those practices that cost less per month or year and retainer and concierge for those that cost more. (There are a very few that charge a huge fee; I discount these as giving the term “concierge” a negative connotation to many.) 

Among the most common other themes from the perspective of a patient are: DPC is too expensive, especially for those of lesser means. DPC is an added expense if you already have primary care coverage by your insurance (e.g., Medicare or company policy). The PCP “abandons” patients when converting to DPC and does it because he or she is greedy. And the question - Is the care quality really better and are costs really lowered? Some thoughts on each.

First, DPC is certainly not for everyone – patient or doctor. But it is one model and it has proven very effective for some. 

Expensive? It’s relative. The average American family spends $2237 per year for cable TV, internet and phone. A Starbucks a day adds up. A parking space per month in a downtown lot is probably more than the DPC doctor. It is about prioritizing our personal expenditures. I also posted an article using as examples three practices that have been termed “blue collar” in the popular press because the costs per month are relatively low, the service is high and with the added benefit of generic drugs at wholesale prices many patients can save handsomely. Two of them have noted that they have many uninsured patients. These practices are cheaper than urgent care clinics and much cheaper than the ER. One person commented that I cherry picked cheap Midwest practices; DPC in urban areas cost much more. That is likely true if only because rent and staff cost more. Here is a chart from Concierge Medicine Today related to costs across the USA.

Why sign up if you already have insurance that covers primary care? The question to answer for each person is whether it is worth the extra money to get more time with your PCP? A lot more time. My PCP converted about five years ago. I was ticked off that I had to pay an extra $1500 a year since I am on Medicare and primary care is mostly covered. Some of my friends decided to not convert with him. Others decided as I did to pay up. My wife’s PCP converted to a retainer approach a few years ago. Same thoughts. But it has been worth the price – to us. But probably not for everybody. Again, it is a question of your priorities.

What about abandonment? It is another of those questions where the answer depends on your perspective. A group practice I know planned to convert and announced it to their patients. Soon articles appeared in the local paper about “greedy” doctors and patients who would be left without a doctor. But everyone who wanted to find a new PCP did so quickly – often with help of their former PCP who guided them to an appropriate doctor. Of course, in say a rural community where there is just one provider, it would be a different story. An analogy given me by Dr Josh Umbehr might be useful. Consider a 60 watt bulb. Try to push more voltage through it and it will burn out and there is no longer any light at all. Run it as it is supposed to be and it will last a long time. If the doctor is burned out and gets sick or just quits, that is not abandonment. It is actually worse. 

And the greedy doctor issue? When a PCP with a busy practice converts, they often end up with a much lower income, at least at first. Read some of Dr Rob Lamperts posts about what happened to his income including a one about his application for health insurance and for Medicaid. Later their income may rise and sometimes it will be more than before. From that same Concierge Medicine Today article – 73% of concierge or DPC physicians earn less than $200,000 per year. But it is really not about more money; it is about more time for each patient.

Quality up and total costs down? I wrote about this in my last post; here is a summary. It is hard to find other than anecdotal data with individual practices or even group practices. MDVIP [which is not a DPC practice since it still takes insurance in addition to a retainer] is a practice model that lowers the number of patients to doctor to about 500:1. Among the about 700 affiliated doctors there are about 215,000 patient members, enough to do some observational studies. They have found that quality measures like blood pressure control, diabetes control, immunization percentage, screening for cancer, etc. are substantially better than a comparable group of individuals not in their network. Similarly, there is a very substantial reduction in total medical care costs of $2551 per capita as a result of fewer referrals to specialists, fewer prescriptions, fewer hospitalization and fewer trips to the ER. As to satisfaction, perhaps the most important marker is that few individuals leave the practice. 

Similarly, Iora Health, Qliance and AbsoluteCARE, organizations that like DPC practices lower the number of patients per provider, can demonstrate better outcomes with lower total costs. Here again the cost reduction is from fewer specialist visits, fewer hospitalizations and fewer ER visits among other parameters. Qliance, for example, has noted 35% fewer hospitalizations, 65% fewer emergency department visits, 66% fewer specialist visits, and 82% fewer surgeries than simi­lar populations. (And before you tell me, I know that this reduction in costs may not directly accrue to the patient although it could convert into a substantial dollar savings for those with a high deductible policy. My point however is that fewer patients means better care which in turn means lower total costs.) 

What about doctors? Is DPC for every PCP? I doubt it. When a practice is converted a lot fewer patients convert with it than might be expected – maybe 15-20%. Income will probably go down, at least initially. Some patients will feel the doctor is being greedy as noted above. There can be legal issues; the insurance commissioner may say it is essentially an insurance policy for primary care; a doctor is not an insurance company. Some sound advice would be important before embarking.  Doctors are a cautious bunch; this is a big change. My bet is that, until patients actually start demanding more time and agreeing that this is a sensible approach, the total numbers of PCPs who convert will be modest.

Next time will be a different topic; what employers are doing to assure better care yet lower company costs. In many cases it too amounts to getting the PCP more time.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).