Concierge Medicine – For the Masses or the Elite?

Is concierge medicine (also known as direct primary care, retainer-based, membership) for everyone or is it just for the rich, the 1%? Most people assume it is for the elite and cannot be afforded by the common man, the masses. That is unfortunate because in many cases it can be quite affordable. Here are three examples.

AtlasMD in Kansas City and others like it think of themselves as “blue collar” concierge practices. According to AtlasMD physician Dr Doug Nunamaker “We realized that insurance paying for primary care is akin to using car insurance to try to pay for gasoline. ‘It’s something that’s otherwise fairly affordable until you try to pay for it with insurance: My premiums would be much higher because they wouldn’t know how much gas I would need, they would tell me where to get gas, and I’d have to preauthorize trips out of town.” AtlasMD physicians have 600 patients each. Monthly fees: 20 to 44 years - $50 a month, 45 to 64 - $75 a month, 65 and older - $100 a month, children to 19 years - $10 a month. Generic medicines are available at wholesale prices.

In Erie, a working class city in northwestern Pennsylvania, the Izbicki brothers also began such a “blue collar” membership practice. Just out of training in Family Medicine in 2005, they first worked for another practicing physician and then the local hospital, in each case being frustrated that they could not spend enough time with each patient.  They started their own practice using the typical insurance-based business model and soon had about 4000 patients between them. They were back to seeing too many patients for too short a time each. Dr. Jon Izbicki told me, “We were bitter, frustrated. We were in a failed profession. It was so bad that we really had to take a risk. We knew that what patients want more than anything else is uninterrupted time with their PCP and with that to build a level of confidence. They want relationship-centered care.”

They converted in June, 2013. They chose to call their practice direct primary care given the fiscal conservatism of Erie. Not all of their patients were pleased; less than 20% joined initially. But over time their practice numbers have climbed.

The Izbicki brothers charge $780 per year for unlimited primary care, payable as $65 monthly or annually with a discount. Visits are as long as needed and usually the same or the next day. They have developed contracts with clinical laboratories for highly discounted testing and radiology. They purchase generic drugs at wholesale prices and sell them to their patients at the same price. For many patients, especially those with multiple chronic illnesses who are taking 5-7 prescription medications, this can save as much or more than the annual membership fee. It is this latter factor that especially encourages Medicare enrollees to join.

Dr Jon Izbicki put it this way, “Perhaps the term ‘complex care physician’ would be better than primary care physician as it more closely relates the work of the doctor, especially with these patients with highly complex, serious illnesses.”

Not everyone has a sizable practice from which to convert. For younger physicians, with no base of patients to draw from, it can be a challenge to get started. In Lawrence, Kansas, Dr Ryan Neuhofel began a membership practice called NeuCare right out of his residency training in 2012. He had decided while in medical school and residency that he did not want to be in a typical insurance-based practice. He told me, “I saw that most PCPs did not have fulfilling careers; they spent enormous time in administrative tasks rather than actually working with their patients. I knew I wanted to do primary care but it had to be in a model that let me earn a decent living yet let me give real quality care in a compassionate manner.

“It was a real gamble to go straight into this. I had no patients and no reputation in Lawrence. My practice built slowly at first but is gaining momentum now.” The demographics of his locale are individuals with less than the national median income so his practice is “more like a safety net clinic.” About 70-80% are uninsured and a very large number have complex, chronic illnesses – “a lot more than I anticipated.” His monthly fee is $30 and $40 rising to $50 for those over age 60; he charges $100 for a family of four with $10 more for each extra child. He buys medications from wholesalers. He finds that the savings for some of his patients with multiple prescriptions can be literally hundreds of dollars per month for a family, far outweighing the monthly membership fee. Now a few employers have noticed and decided to offer his services as a benefit to their employees who take out a high deductible policy. “I see this as a real source of growth for my practice and the real long term growth for the whole direct primary care concept. It allows employers to initiate a high deductible policy yet give the employee access to quality primary care at no added cost. This is especially important for the person with lots of chronic illnesses personally or in the family.”

Asked about income once his practice is filled out, “I will be earning about average for a family practice physician in this area and that is just fine with me.”

These three practices demonstrate that direct primary care by whatever name can be affordable to most individuals and families and in many cases actually save money – not to mention a return to relationship-based medicine.

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.

A Humble Opinion

Book Review - Readers of my posts know that I am a strong advocate for primary care and especially a primary care physician (PCP) that provides each patient with sufficient time. Time for the PCP to listen, to think, to treat and to prevent. This allows the patient and doctor to reclaim relationship medicine, a standard tenet of care in the past but now largely lost in our financially driven medical care system.

Dr Jordan Grumet is a primary care physician in Ohio who tries to assure his patients of a strong relationship, one in which they can build trust. Recently he has reduced his practice to about 600 patients and become “concierge.” Now he has more time for his patients and even some time for his family. For years he has written a blog entitled “In My Humble Opinion” in which he records his thoughts of events in his practice, in his home life and in his wide ranging mind. His posts are thoughtful, thought provoking, engaging, emotional and educational. Recently he published book curated from his posts and arranged into meaningful sections such as “The Grateful Death” or “In Sickness or in Sorrow.”

Dr Grumet’s book is a must read for anyone who cares – cares about their health, cares what they or their family receive from medical professionals, cares about what the doctor or nurse offers to  their patients. I have read Dr Grumet’s blog intermittently for the past few years. Always it leaves me with the sense that here is a real human being doing what he does best – caring for patients, one at a time and in the process trying to care for himself and his family. His book title - “I Am Your Doctor” - implies not a fact but a responsibility that he accepts when you come to him. The cover picture is equally powerful – a hand holding another’s, a clear and compelling symbol that this is a physician who wants to have a real relationship with you, his patient. Relationship medicine has largely been lost to today’s business and economic imperatives but doctors like Grumet are trying their best to retain it in their everyday practice. Dr Grumet brings us back to the true calling of what it is to be a physician and in his humble manner but compelling writing style reminds us that physicians are human with of the frailties and foibles as everyone else – the longings, the joys and the sorrows. But especially they want to be there with you as you experience those joys and sorrows, those exhilarations and frustrations that come with life, living and eventually dying. Here are two excerpts:

“Two weeks from now I will tell a man he is going to die. He will sit calmly in my exam room as he shifts his weight from side to side. Although his hair has grayed and his body has weakened, his face will sparkle with youth and vibrancy. He’ll stare deeply into my eyes and I'll detect a hint of mirth. "We're all dying, my friend." He will draw in a deep breath and put his hand on my shoulder. "The trick is learning how to live!" 

“It's not exactly Dr. Jekyll and Mr. Hyde, but everybody knows my level of patience varies from time to time. So I was surprised to find myself happily telling the emergency room that I would assess the patient shortly. The kids were horsing around on the playground, and I knew I would have to call my wife and ask her to come home. It would be my second 45-minute trip to the hospital on an otherwise busy Saturday afternoon. For some reason today, I was able to sublimate the automatic annoyance and return without emotional drama. I slowed down, calmly listened to the patient and reassuringly put a plan into place. Driving home, I felt both relieved and saddened by the joy that overcame me. Why didn't my life's work make me feel this way all the time? I guess it starts with one simple fact. I blame myself for every heart attack, stroke or new diagnosis of advanced cancer. As disturbing as that sounds, how could I not?”

 

Read this book and you will want him to be your doctor. Or at least you will want to find a primary care physician like him who practices real relationship medicine the way he does and who assures you that you will have his or her  undivided attention

Aging Gracefully – Part 3 The Importance of Comprehensive Primary Care

Most people misunderstand what constitutes really good primary care.  We can slow the aging process with appropriate life style and behaviors as discussed in my last post. That is good but it is not enough. As we age it’s also important to have comprehensive primary care.  The usual expectation is that primary care is just for the “simple stuff” or for episodic care when we have a problem but that is a gross misunderstanding. 

Comprehensive primary care is actually much different. It means a close relationship between you and your PCP which is of course required to build trust and to heal. It means dealing with the episodic medical problems which occur from day to day and month to month throughout life. It also means actively managing serious chronic illnesses (a specialist in fact is rarely needed). It means coordinating that care however when specialists are needed. It means helping you to maintain your wellness and your health and working with you at chronic illness risk factor detection and reduction. And it means preventing acute illnesses through vaccines and other approaches.  This is comprehensive primary care and when it is comprehensive it can deal with perhaps 90+% of all of our health care needs.  Specialists are rarely needed, prescription use goes down and hospitalization rates fall substantially.  

 

The key requirements of comprehensive primary care include some basics – a well-educated, well-trained, up-to-date PCP who is committed to relationship-based care and uses a proactive team-based approach.  But the second key ingredient is time – time to listen, to think, to diagnose and to treat and to prevent.  Unfortunately most primary care physicians just do not have enough time today and the result is a tendency to refer to specialists. But with that time, they could have dealt with the problem themselves. 

Overcoming this time limitation is perhaps best done through some form of direct primary care -sometimes called membership, sometimes called retainer and sometimes called concierge medicine.  But whatever the name, the fundamental ingredient is to reduce the practice size from today’s standard of 2,500-3,000 down to about 500 individuals.  This allows the primary care physician to offer you same or next day appointments which last as long as necessary; the time necessary to listen and listen intensively; the time to give a truly extensive annual evaluation; the time to offer expanded preventive and wellness care.  Direct primary care physicians usually give out their cell phone number for the patient to use any time day or night and they respond to emails. 

 

Comprehensive primary care certainly costs more, but it offers better health and wellness. It offers better quality of care. Patient and doctor are more satisfied and in the end it substantially reduces the total cost of care because of the reduced necessity for specialists, testing, prescriptions and hospitalizations.  

To summarize this series of posts on aging, there is a steady slow loss of physiologic function in most of our organs over time. It is possible to slow this average of 1% annual decline and with it the ultimate functional impairments. It is also possible to avoid or certainly delay age-prevalent diseases.  But in both cases it’s up to us.  It’s up to us to adjust our lifestyles and we preferably need to do so beginning at a young age. It is never too late to begin a preventive program.  We can slow physical decline with exercise, diet and reducing stress.  We can avoid many diseases via nutrition, exercise, less stress and by not smoking. We can slow cognitive decline with physical activity, intellectual challenges and social engagement.  And we will definitely benefit when we make good use of comprehensive primary care.

Frustrations Among Primary Care Physicians Should Be a Wakeup Call

Primary care physicians (PCPs) are incredibly frustrated. This level of frustration should be a wakeup call. The greatest frustration is “Time, time, time”- or more precisely, a lack of time. From in depth interviews with over 30 PCPs, everyone said lack of time was the greatest frustration of their practice (or was previously if they now were in a practice that limited the patient number to a manageable level.) Each knew that they could not give the time needed to give the level of care that they were capable of giving and that their patients deserved.

Stated somewhat differently, they said that it was very frustrating to always be focused on meeting overheads and trying to earn what they thought was a reasonable income because to do so meant less time with patients and a sense of frustration and perhaps even guilt. New practice patterns have meant not being readily available to patients, not visiting them at the hospital or ER, and no longer being the “captain of the ship.”

In a Daily Beast article, Dr D Drake wrote about “how being doctor became the most miserable profession….Simply put, being a doctor has become a miserable and humiliating undertaking. Indeed, many doctors feel that America has declared war on physicians—and both physicians and patients are the losers…It’s hard for anyone outside the profession to understand just how rotten the job has become—and what bad news that is for America’s health care system.”

The complexity of the healthcare delivery system was a common frustration refrain in my interviews. In such a fragmented system, “I need to go an extra mile to communicate with my patients but there is not enough time to do it.”

Other frustrations were dealing with insurers for preauthorization of a test, procedure or referral; trying to figure out what drugs were or were not on an individual insurer’s formulary (and each has a different formulary) and in dealing with their reimbursement methodology. Some insurers are very slow to pay reimbursements which mean carrying high working capital – difficult for a small practice.  One noted the amount of time required to arrange for something like home care which, if the insurer was logical, would actually prevent more expensive time in the ER, doctor’s office or nursing home. PCPs find it exceedingly frustrating to deal with non-medical people at the insurance company who deny tests or medications that the doctor feels are very much in the patient’s best interest.

So PCPs were frustrated by government and insurance regulations, polices and roadblocks to care; by the fragmentation of the system; and by many others things but the root problem that was most frustrating was the lack of time with each patient. 

Kevin Pho MD, a primary care physician and founder of KevinMD.com a very popular blog posted about physician frustration following Dr Drake’s article. “So it’s important to have the conversation on physician dissatisfaction.  It’s important to discuss the cost of medical education, physician burnout, and the myriad of paperwork and bureaucratic mandates that obstruct doctors from giving the best care they can to patients. Left unchecked, the physician profession will become completely demoralized.  Whether you care or not, it matters.   Demoralized doctors are in no position to care for patients.”

What is very clear in this extremely dysfunctional healthcare delivery system is that the primary care physicians  (and most other providers as well) are very frustrated that they cannot give the level of care that they believe they were trained to do  and would like to do. Most of their frustrations come down to the lack of time.

They need to take back the time and give it to patients, perhaps via direct primary care or with other models that offer a higher reimbursement for a patient visit or per member per month.  But medicine is a very conservative profession; change comes slowly. Doctors will make the switch to something better only if they feel comfortable that their patients will follow them and approve. Otherwise they will retire early or go work for the local hospital and medical students will continue to shun primary care as a career. If patients want to benefit from much better care, if they want a doctor that is not frustrated and can spend time with them listening, if they want their total costs of health care to decline rather than rise, then they will need to educate themselves and then to advocate  – to legislators, to insurers and to doctors. Concerted patient action will force the issue and make change occur. When the PCP has more time, care gets better, frustrations come down, satisfaction goes up and costs come way down. Everybody wins.

Next time: The value of integrative medicine in primary care.

 

Causes of the Crisis in Primary Care

The Crisis in Primary Care –Part 2

Primary care physicians (PCPs) have too little time per patient which means too many referrals to specialists, too little time listening and thinking, no time to delve into the stress or emotional causes of many symptoms and substantial frustration by PCP and patient alike.

In my last post in this continuing series on primary care, I described a patient with a straight forward if unusual symptom who was bounced from specialist to specialist at great expense, with no one offering a diagnosis, with no resolution of her symptoms and with no physician ever exploring the actual underlying causes of her symptom – stress related to a long ago family issue. Why did this happen? Because the PCP had only 15 minutes, not enough time to listen and to think and from there delve into her psyche.

Why so little time? The short answer is the insurance system, attempting to manage costs through price controls. Medicare has for years set a low reimbursement rate for regular office visits to the primary care physician. Commercial insurance always follows Medicare’s lead and has done likewise. Reimbursement rates have remained fairly steady for a decade or more (Medicare has very recently begun to raise rates a bit as a result of the Affordable Care Act) but office costs have risen each year. Overhead includes not just the nurse and receptionist but also the billing and coding people, accounting and legal needs, malpractice and disability insurance, health care insurance for the staff, supplies and rent and utilities for the office. With costs rising and income steady, the PCP tries to “make it up with volume.” This means seeing more patients per day, usually about 24-25, often even more. In order to see that many, the PCP has generally stopped seeing his or her patients in the hospital or ER and has shortened the time per visit – most visits being about 10-12 minutes of actual “face time” with the patient.

This is enough time for a strep throat, a quick blood pressure medication check or possibly to diagnose and treat Lyme disease. But it is not enough time to deal with a more subtle problem like the patient described in the last post experienced. It is not time to explore family issues, personal stress or anxiety that so often lead to or accompany symptoms and sickness. This lady had a straight forward issue that primary care physicians encounter frequently and those that are experienced know well what it implies. But it still requires time – time to carefully listen to the patient’s story, time to put it into the context of the patient’s life situation, time to do an examination and then some time to think about how to proceed. And once the management decision is made, it takes time to talk to the patient, reassure her and yet explain that she should call should are any further concerns arise – and to come back soon for a further follow-up and attention to the underlying issues.

The situation is compounded when the PCP has a patient with multiple chronic illnesses who is taking multiple prescription medications. Chronic illnesses like diabetes, heart failure, chronic lung disease, kidney failure or multiple sclerosis by their nature are difficult to manage, persist for the patient’s lifetime (some cancers excepted) and are inherently expensive to treat. These patients need very close attention and often need the benefit of a team approach to care. The diabetic patient for example may need an endocrine consult at some point, a podiatrist, an ophthalmologist, a nutritionist and an exercise physiologist, to say the least. But any team needs a quarterback and this is or should be the primary care physician. But here again, care coordination by the PCP requires time, the one thing the PCP most lacks in today’s reimbursement environment. The result is fragmented chronic illness care, disjointed care and care that is much more expensive than it needs to be. From a total healthcare system perspective, this is critical because chronic illnesses consume 75 – 85% of all claims paid by insurers.

But with little time to listen and think, the action step of many PCPs, as with the patient described last time, is to send the patient to a specialist. Indeed, according to an article in the Archives of Internal Medicine, about nine percent of all visits to PCPs result in a specialist referral, far far higher than truly necessary. This is up from about five per cent a decade earlier; 41 million referrals per year then compared to 105 million in 2010. Something needs to be done. The push for accountable care organizations, medical homes, population health and a switch from fee for service to a salaried or capitated system are noble but unless the PCP is given time and enough of it, these changes – no matter their apparent utility – will prove valueless.

Meanwhile, fewer and fewer medical school graduates choose to enter primary care. They are smart and see that PCPs are very busy and very frustrated. They know that given the PCP’s average income it will take many years to pay off their high educational debt load.

PCPs are looking for ways out of their dilemma. Many are retiring early. Others are closing their practices and beginning to work for the local hospital. But the hospital wants the physicians to earn their keep. That means high productivity. So it is still 24 – 25 patients per day, albeit without the administrative hassles of a private practice.

It is clear that the resolution will not come from commercial insurers, not from the government insurances (Medicare, Medicaid), nor will it come from the Affordable Care Act. It will likely be in the actions and decisions of the primary care physician himself or herself to change the paradigm to allow and encourage better quality of care with lessened frustrations for doctor and patient alike.

For starters, many PCPs need to look carefully at their practice patterns and determine if they can adjust their own workload by maximizing the talents of their team of nurses, nurse practitioners and others and with better use of technologies. This requires a change in thinking about how to organize the practice and who does what and when.

Beyond that, some PCPs have decided to no longer accept insurance. Instead they expect the patient to buy care directly. And since they no longer have the expense of coding, billing and collection (one estimate of this is $58 per patient visit!) they can charge a quite reasonable amount. This can take the form of a set fee for any visit, a sliding scale depending on the type of visit and its length, or of a set amount for all care for the year, a retainer-based (concierge) approach. In each of these models and others the patient replaces the insurer as the actual customer of the physician and as such has a more appropriate professional-client relationship. The patient also becomes a purchaser of services directly and thus begins to ask questions, to challenge and in general to bring down the costs of care while receiving a higher level of quality along with greater satisfaction and less frustration for both doctor and patient.

These are but a few of the approaches being taken by PCPs today in an effort to overcome the current non-sustainable business model so that they can not only give better quality of care but reduce their sense of frustration and increase their patients’ satisfaction.

In the posts to follow I will review what primary care is all about; the characteristics of a good primary care physician and a true healer; who does primary care and why and why not; the critical role of the PCP in managing chronic illnesses; the need to listen and think – both requiring time; the use of teams in the primary care doctor’s office; the importance of care coordination, wellness promotion and disease prevention; the current non-sustainable business model; what approaches are being taken to overcome the current business model; and finally how primary care can once again take its rightful place as the backbone of the American healthcare system offering superior quality, outstanding service and greatly reduced overall costs.

The next post in this series will address the critical shortage of primary care physicians.

The Coming Disruptive and Transformational Changes in Health Care Delivery

There will be some very disruptive and some transformational changes in the way health care is delivered, not as a result of reform, but as a result of the drivers of change described previously. They included an aging population, an obese society, shortages of doctors, and emerging consumerism, among others.                       

I interviewed in depth about 150 medical leaders from across the United States to collect information and then distilled it down to a few key observations for my book “The Future of Health Care Delivery - Why It Must change And How It Will Affect You.”. 

As a result of those previously discussed drivers of change, here is some what we can expect to occur in the coming years. 

First, there will be many more patients needing substantial levels of medical care. These won’t be just any patients but two specific groups that are growing rapidly. Americans are aging. “Old parts wear out” and there are impairments in vision, hearing, mobility, bone strength, dentition and cognition that become more prevalent with age. And of course our society has many adverse lifestyles such as consuming too much of a non-nutritious diet, being sedentary, being chronically stressed and 20% still smoke. These all lead to chronic illnesses like diabetes type II, heart failure, cancer, chronic lung and kidney disease, etc. So there will many more individuals with chronic illnesses. The especially sad thing is that many of these individuals will be moderately young as a result of obesity since one third are overweight and another one third are frankly obese. (And now that the AMA has specifically listed obesity as a disease rather than just a predisposer to disease, then the number of Americans with chronic illnesses jumps dramatically.) This increase in chronic diseases and the impairments of aging will have huge impacts on care delivery.           

Of course, more and more care is and can be done out of hospital. But with many more patients in need of care for serious chronic illnesses, there will be a need for more high tech hospital beds, ICUs, ORs, and interventional radiology. This is different than the mantra of recent decades which proclaimed that there are too many hospitals and too many beds. Now it is the just the reverse. This too is a big change. 

But building new hospitals or new wings or renovations costs a lot of money. So does technology such as the electronic medical record, new CT or MRI scanners, and the needed technology for the operating rooms or radiation therapy equipment. To garner the required money, hospitals will need to access the capital markets. What will smaller hospitals do that have less ability to enter the credit markets? Merge with larger systems to get access to capital. So there will be more and more smaller hospitals merging into larger systems. Indeed there will be few stand alone community hospitals in the coming years. This is quite a disruptive change. 

There is already a shortage of primary care physicians and this will undoubted accelerate since few are entering primary care today after medical school and training.  In part to compensate, there will be greater use of NPs and PAs, especially in primary care. Notwithstanding the debate as to whether NPs can serve as well as MDs in primary care, they can be very effective and allow the MD to do what he or she is best at doing. Together they can create an excellent team.  

Primary care doctors are caught in a catch 22. They are in a non sustainable business model. Reimbursements from insurers have stayed level for years but office and other expenses have gone up each year. So in order to keep their personal income at least flat, they need to “make it up in volume” by seeing more patients. This means no longer visiting their patients in the hospital and in the ER. Instead they wait for the hospitalist or the ER doctor to call with reports. And they shorten the time with each patient so they can see 24 to 25 patients or even more each day.  

But seeing this many patients means they cannot give comprehensive preventive care  and cannot adequately coordinate the care of their patients with chronic illnesses – two of the key things a PCP should be doing for optimum quality care. It is the absence of time – time to listen, time to prevent, time to coordinate and time to just think – that is the critical issue. 

There are at least two approaches PCPs are taking to counter this dilemma. One is to no longer accept insurance and rather expect patients to pay a reasonable fee at each visit. Pay at the door. It cuts out a lot of haggling with the insurer and means they can spend more time with the patient. Importantly, it recreates a normal, typical professional-client relationship since the patient, not the insurer, is paying the doctor directly.  But this is certainly a disruptive change to not accept your insurance! It is like going back a few decades.   

Another approach gaining rapid popularity is to switch to retainer based practices, sometimes called concierge or boutique practices. The basic concept is to limit one’s practice to 500 patients rather than the typical 2000 or more. This means more time per patient. So in return for a fixed fee of about $1500-2000 per year the PCP agrees to be available by cell phone 24/7 and by email. He or she will see you in the office within 24 hours of a call. You get as much time as needed for the problem at hand. And the PCP will visit you in the hospital, the ER or the nursing home – maybe even do a house call.

The result is better quality. But there is more. Since the doctor now has the time – the patient now gets much more preventive care attention. And if a patient has a chronic illness, the PCP will take the very real time needed to coordinate that care. This will mean much better care from the specialists and will avoid unnecessary tests, scans and procedures. Better care at less expense.  – One more very disruptive and I would say transformational change occurring in medical care delivery.

 

 

 

A Crisis in Primary Care

We are entering if not already in a crisis of primary care. Each of us needs a competent, caring and available primary care physician but that is less and less possible. Many can’t find one; others cannot afford one; and others have one but cannot get adequate time and attention from him or her. PCPs will tell you that they do not have enough time with each patient; are overwhelmed with paperwork and mandates; and are earning less and less per year. There are about 1000 graduating physicians entering primary care per year in the USA but about 3-4000 retiring. Average income after about ten years in practice of $150,000 has been stable or decreasing for some years while the costs of practice including staff wages, rent and utilities, malpractice insurance and supplies has been rising. Most medical school graduates have about $155,000 in debt to pay off. To make ends meet and retain the same income, PCPs are seeing more patients with longer days and shorter visits. This is not good for them and it definitely is not good for you. Basically they have a non-sustainable business model today as a result of the reimbursement system through our commercial and governmental insurance system.
To counter the problem, more and more PCPs are taking steps to increase their income while decreasing the number of patients seen per day. Some approaches are frankly disappointing such as the doctor with a sign in the waiting room that you may “only raise one problem per visit.” A colleague told me last week that her internist is no longer taking Medicare. She will have to pay for each visit. Perhaps not a problem if you only go for an annual exam and then once or twice for minor problems. But if you develop a complex chronic illness that requires multiple visits it could add up quickly, especially for someone on a fixed income in retirement. Other PCPs are opting for “retainer-based” practices, sometimes called concierge or boutique practices. Here you pay $1500-2000 [or more] per year and in return your PCP reduces his or her practice from 1800 patients to 500 and guarantees that you can be seen the same or the next day, that he or she will be available by cell phone and email 24/7, will visit you at home, will meet you at the ER as needed, and will care for you in the hospital and the nursing home. And each visit will be as long as needed for you and your issues. This is the way it used to be and is the way it really should be now but is not. Another advantage of this type of system is that it becomes a true relationship again between the doctor and the patient with the patient contracting directly for services from the physician – not through a third party. The downside, of course, -- this is extra money out of your pocket since you will still need your insurance for specialists and hospitalization.
What is clear is that the current system does not work and either PCP reimbursements by insurers will go up or more and more PCPs will either retire early or switch to retainer-based practices.