Saturday, November 1, 2014

Patient Enrollment in Direct Family Medicine aka, Direct Primary Care- Family Medicine Style

When figuring our charges for Direct Family Medicine (using the Direct Primary Care business model), we consider the context in which we relate to our patients.  Family Medicine is a relationship based specialty defined by the American Academy of Family Physicians (AAFP) as :  "Family medicine is the medical specialty which provides CONTINUING, comprehensive health care for the individual and family. It is a specialty in breadth that integrates the biological, clinical and behavioral sciences. The scope of family medicine encompasses all ages, both sexes, each organ system and every disease entity." (1984) (2010 COD)

The specialty has been cut apart by the current nit picking approach to physician reimbursement that distracts both patient and physician.  The relative value units used to determine billing codes is a key element of the distraction.  The DPC business model, generally anchored by a monthly payment after an enrollment fee, frees patient and physician from many distractions related to the RVU's and the Electronic Medical Record. The focus of clinical encounters is dependent on the relationship of patient and physician instead of physician and reimbursement rules, EMR and employer.  The patient doesn't have to be concerned about their insurance company preventing them from acting on the plan agreed to with the physician.

OK, you may be sensing less clutter in the office visit.  In fact, the office visit doesn't have to be the center of the activity.  Without the focus on  RVU's and traditional coding and billing, the office may be omitted from being the venue where we solve many problems.  Many follow-up visits may be accomplished online, or on the phone or via home visits.  With fewer patients, more time and less office "lock", more home visits may fit in.

The enrollment fee allows the physician to have some front money to prepare for patients and to offset the Ohio end of the month mandate for the monthly membership charge.  They cannot prepay or we would be seen as an insurance company and arrested for not following the Ohio rules.  Each state has the potential for making similar unusual rules that may stifle this business model.

What if patients enroll and never pay the monthly fee at the end of the month?  Or only pay for one month and never show up again or pay again?  We require a three month initial enrollment to get the relationship established and to guard against doctor shoppers or people who may not appreciate the value of Family Medicine and the patient- physician relationship.  If the patient drops out after the initial enrollment, we figure that they gave it a good try and it just didn't work out.  If they re- enroll, they are charged the enrollment fee again and signed up for a minimum of three months.  They are allowed to drop out and re-enroll twice unless there are unusual circumstances (such as, they moved and came back).

Another twist for our practice, Neighborly Family Medicine, is that we take "Families Only" as patients. That means the whole household has to enroll as patients or we con't take any or them (I've done this for 34 years- it works well).  It also means they'll be paying enrollment fees for multiple persons.

To make this process smoother, we have a member management platform company that allows online enrollment for Neighborly Family Medicine.  Patients can read about Direct Family Medicine and our philosophy of care and various practice policies on the site at and apply with their information and credit card number.  Yes they apply and we review their information to clarify that they actually qualify for our Direct Family Medicine path.  It detracts slightly from the beauty of this process when we have to review their information before accepting them.

We're a hybrid practice with about 2500 "traditional" patients from all sorts of insurances and government plans that preclude us offering this path to them so we have our original Family Health Connections, Inc. practice that houses them (but with the same tax ID number as Neighborly Family Medicine).  Insurance rules and contracts combined with our current confusion about Direct Primary Care type payment strategies make it challenging to do something that enhances healthcare and the patient- physician relationship.

So, there you have a bit of information about one DPC hybrid practice: Family Health Connections, Inc. and Neighborly Family Medicine and our enrollment process.

What do you think?

Friday, October 31, 2014

Direct Primary Care = Direct Family Medicine, Direct Pediatrics & Direct Internal Medicine

Direct Primary Care is a business model for medical practice that is gathering momentum with a boost from the American Academy of Family Physicians (AAFP) through the "Health is Primary" Campaign. See it here Find definitions of Direct Primary Care at

My practice, Neighborly Family Medicine in Beavercreek, OH, uses the DPC business model to practice Direct Family Medicine (DFM).  Notice that I'm differentiating the business model from the specialty practice.  The semantics are important, but take a while to understand.  Direct Family Medicine helps me to understand what I'm offering to patients.  I assume that a pediatrician would deliver Direct Pediatrics, while an internist would offer Direct Internal Medicine.  A Med- Peds physician would do Direct Med-Peds. Clarifying how the DPC business model is applied can be very helpful for patients and doctors.  The term Direct Primary Care comes up short of adequate clarification when patients seek care.  I love doing Direct Family Medicine (and saying it, too).

Direct Internal Medicine and Direct Pediatrics are needed.  The physicians in those specialties deserve to have the fun and freedom of using DPC to support their specialty.  We need a lot more internists and pediatricians in a DPC business model.  Join the movement, Folks.  We need you.  There are not enough Family Physicians to meet the care needs for America at the primary care level.  Let's team up and shift the cost curve together.

Patients:  Introduce DPC to your pediatricians and internists.  They'll love Direct Pediatrics and Direct Internal Medicine.

Tuesday, October 28, 2014

Teaching Direct Primary Care: Here We Go!

Direct Primary Care is all the rage.  It's been anointed in the "Health is Primary" initiative as a key business model for success by the AAFP (American Academy of Family Physicians).  The initiative was launched by the AAFP last week in Washington, DC.

A keynote presentation by Erika Bliss, MD CEO of Qliance at the Family Medicine Education Consortium (FMEC) in Arlington, VA two days after the AAFP announcement wowed the students, residents and even some faculty at the FMEC meeting. One big question from the students and residents:  Where can I get DPC training?  One big question from the faculty types:  How do you teach it?

Personal reflection as a DPC innovator, DPC Hybrid private practice owner and Family Medicine educator: Direct Primary Care is the only element in all of medicine that is moving ahead on the offensive.  The rest of medicine is otherwise on the defensive, hunkered down waiting for the next mis-directed initiative.  The AAFP is willing to take the risk of helping Family Physicians and their patients by going against the status quo and endorsing the DPC business model.  The "Health is Primary" Initiative allows Family Physicians to get some reassurance about the Future of Family Medicine.

How do we teach DPC along the entire Family Medicine workforce pipeline?
1.  Define our Dream (and help each individual to define theirs)
2.  Have a burning desire to achieve it (and cheer for each other as we get "fired up")
3.  Believe we can do it (and validate/reaffirm the belief of each other)

Dialog will be one of our powerful resources for spreading the word about DPC.  We are good at it.

The DPC pioneers have paved the way for the model to be accepted, proven and recommended.
The "Health is Primary"  initiative will add energy, deliver AAFP introductory workshops during the next year, and facilitate the DPC Member Interest Group which will help interested members to learn more.

Departments of Family Medicine can be pivotal in promoting DPC by updating faculty on the Health is Primary Initiative and the DPC elements in it.  DPC oriented faculty and clinical faculty and preceptors should be asked to orient faculty and departmental staff to DPC.  A Champion for DPC should be identified by interested Departments.

State Chapters of AAFP should be contacted for information or assistance with DPC resources and contacts.  The state chapter web site should connect with the AAFP "Health is Primary" initiative and its DPC elements.

Family Medicine Interest Groups (FMIG's) should get DPC speakers to introduce DPC elements to the student members at FMIG meetings.  FMIG advisors should find the online DPC info which is plentiful.  Pre-doctoral directors in Departments of Family Medicine should identify their DPC resources such as preceptors, clinical faculty and full time faculty, and social media resources for medical student use.

Students could introduce the DPC business model to preceptors for discussion during their clinical rotations. A list of online resources explaining DPC and its variations should be available on FM Department and FM Residency web sites.  Medical students could refer preceptors who are naive to DPC to these sites.

Residencies that identify how they will teach DPC should quickly add a DPC section to their web site and promotional materials.  Similar to the sports medicine, geriatric, perinatal, genomic initiatives across the last couple decades, the DPC aspect of practice management could be in place within two months for aggressive programs.

A champion for DPC should be identified for each section of the "Family Medicine Pipeline" and connected via social media.

Objectives for practice management training should be quickly modified to add a DPC component.  One key aspect of DPC in practice management is the learners attitude about business, money, commerce, ethics (business and medical), and the patient-physician relationship.

The Family Practice Model Units should explore a DPC track for patients and employers, which is doable (FYI-I was Medical Director of a University and a Community FM training practice- multiple payment models fit nicely.  None of them are inherently evil, but some faculty wondered if something they were unfamiliar with was dishonest--like capitation or fee for service.)

Residencies:  Students are hungry for this model.

All of us:  We're part of the problem as a citizen of the Medical-Industrial Complex.  Let's re-direct the ship around the iceberg with "Heallth is Primary", including DPC and what we learn as a result of having to teach about it.  How will it fit with "The Dream".

What do you think?