Saving Relationship Medicine with Direct Primary Care

The fundamental problem in health care delivery today is a highly dysfunctional payment system that leads to higher costs, lesser quality and reduced satisfaction. It also means less time between doctor and patient with the loss of “relationship medicine.” The core problem? Price controls and regulations that reduce the trust and core interactions between doctor and patient. The patient is no one’s customer and visit times are all too short. I have argued in the Washington Times as an Op-Ed that paying the doctor directly is better for all concerned.

I believe that some of the best attempts to improve this dysfunctional delivery system have been accomplished by primary care physicians themselves.   They have essentially said “I won’t take it any longer; this is not good for my patients or for me.” They have also said that it is time to “stop tinkering” and make a fundamental change. They have opted for a new, better system – direct primary care - rather than wait for others to fix it for them.

The concept with direct primary care is to reduce the number of patients in a PCPs practice so that each patient gets added time as needed. Often this means removing the insurance system as the payer from primary care and always it means a payment model that compensates the PCP directly by the patient. Direct primary care takes many forms. There are two principle payment systems. One is for the patient to pay the doctor directly for each visit, usually at a rate far below what would have been charged in the insurance model since the overheads of billing and coding have been eliminated. Many such PCPs post a defined price list – transparency. This is sometimes called direct pay or “pay at the door,” not unlike the way it was until a few decades ago before insurance morphed from being only for major medical or catastrophic issues to being essentially prepaid medical care.

The second model is for the patient to purchase a package of care for the year paid by the month or annually. This basic model comes with many variations and may be called membership, retainer or concierge. Despite the various names, they all have certain characteristics in common but there are many variations in how the practice functions.

All of these models offer a reduced patient to doctor ratio: instead of the typical 2500-3000+ patient panels, the PCP may adjust the number of patients to a low of 300 when the panel is very ill or to a high of about 800 for a panel that has mostly low risk patients. Some accept insurance and also charge the retainer; others just charge the monthly or annual fee.

With a reduced patient panel size, the PCP commits to offering same or next day appointments lasting as long as necessary, a comprehensive annual examination, email communications, and an invitation to contact the PCP on his or her personal cell phone 24/7. Some make house calls and nursing home visits for no extra charge; others add a modest fee. Some see their patients in the ER and some follow their patients in the hospital.

There may be an arrangement to obtain laboratory testing, imaging and procedures at highly discounted rates from selected vendors. Some practices offer a limited number of laboratory tests at no charge. Some PCPs are supplying medications at no or wholesale costs. For the patient on multiple prescription medications, the savings on drugs can more than offset the monthly/annual subscription cost of direct primary care.

Many only work with specialists who are willing to discount their fees for those of their patients who pay cash and have high deductible plans or no insurance at all.

Often regarded as highly expensive and only for the “elite,” the rich, or the “one percent,” in fact membership/retainer/concierge practices can be of quite reasonable cost and very appropriate for those with no or limited insurance and for those with modest incomes – “blue collar” concierge medicine.

Fees range from about $500 to $2000 or more per person per year. [I will ignore those doctors who charge a very high fee for “exclusive” services.] By some degree of common usage those on the lower price end often refer to their practices as direct primary care or membership whereas those at the higher end often refer to their practices as retainer or concierge. To the extent that there is any real difference, it is probably in the number of patients in the panel or seen per day, the extent of the annual evaluation and added values such as following one’s patients in the hospital and in the ER.

For those who have high deductible insurance policies from work or from the exchanges, connecting with a direct primary care physician can offer a significant savings. The individual and the physician now have a direct professional business relationship. The person begins to take a much more active role in the entire care process. And the doctor can allot meaningful time for patient interaction – a return to “relationship medicine.”

With little to hope that government or insurers will improve the lot of primary care physicians, direct primary care is a rational manner for PCPs to change the paradigm and return to relationship medicine. It means better medical care, less frustration and more satisfaction for doctor and patient alike and an encouragement to medical students to consider primary care as a career option. It also means that total medical care costs go down. A triple win.

Next post – more on the costs of direct primary care

Solving the Crisis in Healthcare Requires Solving the Crisis in Primary Care

There is a crisis in the provision of primary care in the United States. If you are a patient, a primary care doctor, an insurer, an employer or a policy maker, this crisis is exceptionally important to you. The crisis means that Americans do not get the level or quality of healthcare that they deserve and need. This crisis is the major reason that healthcare in total is so expensive and why costs keep rising. This crisis needs to be fixed and fixed as quickly as possible. Fortunately, a solution exists that is within reach. It will be a disruptive and transformative change so it will not come easily to a profession that is “conservative” by nature. My new book Fixing The Primary Care Crisis, addresses all of these issues in easy to read language.

Contrary to what many assume, 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 especially 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. To appreciate this is to begin to understand why the current system just does not and cannot work and why it needs to change.

The fundamental problem is that primary care doctors (PCPs) care for too many patients with too many short visits per day, and as a result do not have the time they need to provide high level care. They need time to listen, time to think, time to give quality preventive care and time to offer care of complex chronic illnesses and to coordinate care for those actually do need a specialist referral. They also need to be able to build a trusting relationship with the patient and to offer true healing, something that also takes time. In other words, they need time to practice their profession, something they currently are unable to do fully or effectively.

This crisis has led to a culture of highly frustrated doctors who feel they are on a never ending treadmill, and are leaving private practice or retiring early. It means that patients are equally frustrated at the long waits, short visits, high costs and no sense of being listened to, of not receiving empathy, of not being actually cared for. The crisis means that there are currently not enough primary care doctors, and it will only get worse because students in medical school see the impact of this crisis and choose not to enter primary care as a result.  It’s a downward spiral that needs to be reversed.

The crisis began a few decades ago when insurers, beginning with Medicare, held reimbursement rates low (cost control through price fixing). At the same time, doctors’ office costs were rising. In order to meet basic overhead expenses while maintaining their incomes, PCPs began to see more and more patients per day. The average PCP’s income in 1970 was slightly more than today (in inflated dollars) but the PCP was seeing only one half the number of patients as today. Now, with about 25 or more patients per day, a visit is often only 15 to 20 minutes: actual “face time” with the doctor is just 8-12 minutes. If you’ve been a patient recently, I’m sure you’ve experienced this. While this amount of time is long enough for a simple problem, it is much too short for someone with a complex issue, or someone with multiple chronic diseases and taking multiple prescriptions. And it is not nearly long enough for an elderly person with impaired vision, hearing or cognition. There is no time for compassion, to build trust or to be a healer. Since there is too little time, the tendency is to send a patient off for tests or to a specialist when a bit more time with their history would provide the answer. There is not enough time to discuss lifestyle changes, meaning it is easier to just write a prescription and hope for the best. It is these steps that are the major cause of higher and higher medical care costs in the United States: unnecessary referrals, unnecessary tests, unnecessary X-rays and unnecessary prescriptions. And with it has come the loss of the close and trusting doctor-patient relationship and the lack of true healing.

When PCPs do have time, they can develop a trusting relationship and then give superb preventive care. This type of care will reduce serious chronic illnesses in the future, the diseases that today account for 75-85% of all medical costs. When they do have time, PCPs can treat the vast majority of issues brought to them by their patients without the need for specialist referrals or excessive testing. When PCPs do have time, they can coordinate the care of those patients that truly do need to be referred, ensuring high levels of quality at a reasonable cost. When PCPs do have the time, they can appreciate the underlying stress and anxieties that propel so many illnesses and trips to the doctor. When PCPs do have time, they can give truly proactive preventive care – population health - by reaching out now rather than waiting for the patient to arrive with a problem.

To address this crisis, both patients and PCPs will need to take charge and change the paradigm of primary care. Government will not do it. Insurers will be slow at best to do it although there are some examples to the contrary that we’ll explore in this book. A few enlightened employers are beginning step up as we shall also explore. But if there is to be real change—change that works—it will take PCPs and patients to force the issue. Patients need to demand the time they deserve. PCPs need to be able to give them the necessary time. This means fewer patients per PCP. Patients will need to migrate toward doctors that have 800 or less patients (compared to today’s standard of 2500 or more) and can therefore give them more time as needed.  The actual number per doctor should depend on the demographics of the doctor’s patient panel (the doctor’s patient load)—for example, a panel of mostly older individuals with chronic illnesses means fewer patients. Fewer patients means more time for each patient and much better access to the PCP. We’ll take a look at what some innovative physicians, insurers, and employers are doing—separately—to transform primary care and bring it back to being “relationship medicine” with a heavy emphasis on health and wellness and the care of complex chronic illnesses in addition to typical episodic primary care: true comprehensive primary care. One of many innovations is to not accept insurance and charge a reasonable amount per visit according to a posted price list. Another is using some form of “direct primary care” (DPC).  DPC comes in many variations and is known as membership, retainer or concierge medicine, but in essence it means charging a flat rate by the month or year for all primary care services, reducing the number of patients under care to about 500 and offering same or next day appointments for as long as necessary and access to the PCP via his or her cell phone twenty four hours per day and via email. It means comprehensive primary care not just episodic care: attention to health and wellness, reduction of risk factors, preventive actions, intense management of chronic illness and coordination of specialist care when needed and a return to relationship medicine with trust and healing. The latter is essential if we want to move from a reactive to proactive approach to healthcare. That means much improved care quality and satisfaction, and lessened frustrations for patients and doctors alike. Often it means generic medications at wholesale prices and laboratory and radiology at deeply discounted rates. Despite a widespread belief to the contrary, DPC is not just for the elite, the rich or the 1%. In fact, it can be quite reasonable – “blue collar” –  and, when DPC is combined with a high deductible health insurance policy (which is much less expensive than typical policies,) the savings for patients are substantial and the total costs of all care decline quite dramatically.

Among other options is capitation, as in some Medicare Advantage plans, but where the payment to the PCP is sufficient per patient that he or she can afford to have a reasonable total number of patients. Another is for insurers to create incentives for reducing patient numbers. Yet another is for employers to create their own primary care clinics with a low employee to physician ratio or to offer a payment into a health savings account (HSA) to purchase the membership in a direct primary care practice. One additional example is to place extensive primary care resources for the management of the “sickest of the sick,” often the socioeconomically disadvantaged with insurance via Medicaid – a team of PCP, nurse practitioner, nutritionist, mental health therapist, etc. We will explore each of these and other options.      

In all of the examples cited in the last two paragraphs where the PCP to patient ratio is reduced to a manageable level, the care quality goes up and the total costs of care come down very substantially. Throughout Fixing The Primary Care Crisis, we’ll look at the details of how that can be.

Fixing The Primary Care Crisis explains the crisis and its origins. It details what outstanding primary care can be for patients and society as a whole. It explains how and why illness has changed from the acute infectious diseases of the past (e.g., typhoid, pneumonia) to complex chronic illnesses (e.g., heart failure, diabetes with complications, kidney and lung disease) of today and why chronic illnesses now constitute 75-85% of all healthcare costs. It reviews how healthcare insurance went from covering unexpected expensive medical care (“major medical” and the catastrophic) to now include primary care; how employers have adjusted their assistance by expecting employees to pay a larger and larger portion of premium plus co-pays and deductibles. It then delves into some of the approaches referenced above that are being taken to return primary care to true relationship-based medicine.

Finally the book ends with a chapter that gives explicit recommendations to patients, doctors, insurers, employers and academic medical center leaders to effectively transform primary care to achieve the outcome of the very best care in a cost effective manner that improves quality yet reduces the total costs of care.

Together, this crisis can be solved with much better care, much improved satisfaction, much less frustration by patient and doctor alike, much less total money spent and with many more students selecting to become primary care physicians thus resolving the PCP shortage. It will be a win for everyone. But the change will only occur if and when patients become educated and then advocate for the new paradigm.  Fixing The Primary Care Crisis provides the information needed to make that transformation happen.

Most Medical Decisions Are Not Risk Free

Interpreting Your Benefits and Risks of Medical Decisions

Patients and doctors need to be a team in making important health care decisions. Good decision making requires solid, appropriate information but all too often it is either not available or presented in a format that is not of great value. Well grounded decision making is critical because every action has not only the hoped for outcome but also the risk of an adverse outcome. No medicine is devoid of side effects. A diagnostic test may produce a false positive or a false negative. A procedure may or may not cure. For example, choosing statins may lower cholesterol but may also cause muscle damage. A decision to have a mammogram may lead to a suspicion of cancer leading to a biopsy which turns out to be negative – a false positive. Choosing to have a stress test that turns out negative may lead to a sigh of relief and yet the patient dies of a heart attack the next week. A false negative.

These and others like them are high stakes decisions so doctor and patient need good data in order to reach a well informed decision. The information needs to be presented in a manner that is easy to grasp and to visualize in one’s mind’s eye.

Eric Rifkin, PhD and Andy Lazris, MD address these in Interpreting Health Benefits and Risks– A Practical Guide to Facilitate Doctor-Patient Communication. For each of twenty commonly encountered decision points they offered well informed information. Should I get a mammogram at my age? How likely is a stress test to clarify if I have coronary artery disease? What are the risks/benefits of taking a statin? Do I need an annual examination with my primary care physician, and if so what should it include? If I have atrial fibrillation should I take a blood thinner?

To each of these and sixteen others they give a concise overview of the data available, pointing out where it is strong or weak. They also include a patient vignette from Dr. Lazris’ internal medicine practice, thus giving each decision issue a compelling connection to real life situations. They then add a third and critical layer, a visual representation that adds clarity to the complex issues.

The visual is called Benefit Risk Characterization Theater (BRCT). It uses the floor plan for a thousand seat theater. Each seat represents a person. So for example, if a person smokes regularly, the question might be what is the risk of death at 25 years of doing so? The theater shows a thousand seats with 198 of them blackened out. This of course means that compared to 1,000 non-smokers, this group of smokers will experience 198 extra deaths compared to the other group. Seeing the blackened seats is a strong statement of risk – more compelling than just indicating  a percentage. As the authors state, “the graphic should do the math for the patient.”

 

Implicit throughout the book is the understanding that great controversy exists within the medical community about the risks and benefits of many screening tests, diagnostic procedures and therapeutic approaches. The BRCT allows the patient to become a co-equal with the doctor regarding the data and thus a real contributor to the decision making process.

For the purpose of shared decision making, the combination of factual data, a patient’s story and especially the visual BRCT allows patient and doctor to approach the question at hand with substantial assurance that whatever decision is made, it was done so in the context of real knowledge.

I have only one criticism of the book and it is leveled squarely at the publisher (Springer), not the authors. It is a paperback priced at $89.99, apparently assuming it will be of interest to a limited number of academics. In fact, it should be in the consultation room of every primary care physician and available to all patients who want to participate in their health care decision making. My recommendation: It is too expense for the average person to buy so ask your library to get some copies and then avail yourself. You may be surprised at what you learn. You will certainly be better equipped to talk with your doctor.