Tuesday, June 26, 2012

Direct Family Medicine (DFM): More Details about DFM and Direct Primary Care

We've been reviewing information about Direct Primary Care and Direct Family Medicine for a couple months now.  Tonight on the Dr Synonymous Show, we'll review more numbers and information relative to DPC and DFM.  The charts and forms below are the work of Sonia Bennett, MPH a Wright State University second year medical student, with some input from Dr Jonas.  This is information for discussion and not perfectly organized or totally factual, but darn close.

Direct Family Medicine & WSU Sonia Bennett, MPH Interview 06/26 by Dr Synonymous | Blog Talk Radio  9PM ET

Family Health Connections, Inc in Beavercreek, OH intends to add Direct Family Medicine to their practice offerings in July, 2012.

v  What is Direct Family Medicine?
Direct Family Medicine (DFM), a Family Medicine version of Direct Primary Care (http://www.dpcare.org/difference) refers to care that is directly offered to patients without involvement of traditional insurance.  It is not health or medical insurance.  It allows people who do not have insurance to have access to medical care.  It is a way for patients to have a regular source of medical care, develop a relationship with their family physician, and work together to maintain their health and manage acute illness and chronic conditions.  The physician-patient relationship is the foundation of family medicine and DFM allows those without insurance to have access to such a relationship and medical care.

v  Who is Direct Family Medicine for and how does it work?
DFM is for people without insurance or people in career-transition who may temporarily be out of insurance to be able to receive medical care through monthly payments.  It is also for persons with a high deductable health savings account (HSA) in some states.  After enrolling in DFM, patients can have access to family medical care.  People with insurance or Medicare are not eligible for DFM.

Type of fees- Example
Infant (0 to 1yr)
Child (1yr to 17 yrs)
Adult (18 yrs and over)
Monthly fee
$60 ($720/yr)
Co-payment per visit

v  Do I need insurance to enroll in DFM?
No.  DFM is for uninsured patients or patients such as those with a high deductable health savings account (HSA) or who may be in between jobs.  Many who wish to cover their catastrophic medical costs with insurance, but keep their family medical care out of it will enjoy DFM
v  What services are included with Direct Family Medicine?
Preventive services, sick visits, chronic disease management (asthma, diabetes, high cholesterol, hypertension, hypothyroidism, depression, etc.), Saturday appointments, after-hours on-call physician access and other services listed in the Summary of Services are covered by the monthly fee.

Services that are covered by the monthly fee
Services not covered by the monthly fee
Visits for general wellness and preventive care from infancy to maturity
Infant, child, adolescent health (well-child checkups, school physicals, sports physicals)
Specialist care
Women’s health (annual checkups, pap smears, family planning discussion, menstrual issues, menopause, sports injuries )
Outside laboratory procedures such as pathologic exams, X-rays, heart monitors, etc.
Men’s health (sports injuries, prostate problems, erectile dysfunction)
Some immunizations and injections (vitamin B12 shot)
Acute sick care for all ages including routine office tests (urinalysis, strep test, pregnancy test)
Prescription medications. Blood tests
Chronic disease diagnoses and management (hypertension, diabetes, heart disease, high cholesterol, depression, thyroid diseases, asthma)
Surgeries and surgical procedures
Flu shot and injections for some infections
Obstetric procedures
Dermatological health (acne, rashes, skin cancer screenings)

Ear, nose, and throat health (ear irrigation, strep test)

Musculoskeletal problems (arthritis, joint pain/stiffness, back pain)

Gastrointestinal problems (GERD, diarrhea, vomiting, Irritable Bowel Syndrome)

Stress and psychological problems (anxiety, grief, situational reactions, depression)

Brain related problems (dizziness, headaches, numbness)

Weekdays and Saturday morning office hours

After-hours emergency telephone access

v  Is there a co-payment?
Yes.  Co-payment for every visit is $20.

v  Is there a registration fee?
Yes.  The registration fee is $80 for adults and $40 for children (0-17 yrs) and establishes care with a family physician.

v  What are the monthly fees?
Monthly fees are $60 for adults, $60 for infants (0-1yr), and $50 for children (1-17 yrs).

v  How do I pay the monthly fees?
You can pay by direct deduction from checking account, credit card, or debit card on the 25th day of the month
v  How do I cancel membership?
You can cancel anytime with, written notice, effective at the end of the month.
v  Can I re-enroll in the program at a later time if I cancel?
Yes.  You may re-enroll after a 6-month wait for up to 2 times but you will have to pay the registration fee each time you re-enroll.  Re-enrollment will also depend on whether we are accepting new DFM enrollees at the time.

v  Do I pay the monthly fees even if I don’t need to see the doctor every month?
Yes.  The monthly fee allows access to medical care and covers 24 hour on call physician coverage, preventive services and appointments for sick visits as well as chronic disease management.
v  What about the cost of prescription medications?
The cost of prescription medications is the patient’s responsibility.
v  What if I need to see a specialist? 
Referrals to specialists for further evaluation can be discussed with your physician and together you can decide the course of action.

v  What about other services such as specialist care, x-rays, and hospitalizations?
In-office lab work such as urinalysis, strep test, and pregnancy tests will not incur any charges, labs sent out of the office will incur a separate charge.  However, services such as x-rays and some vaccinations can be obtained from outside laboratories and will not be covered by the monthly fee.  Prescriptions, services provided by specialists, and hospitalization expenses will not be covered.
v  Will the physician see my family?
Yes.  At Family Health Connections, we believe in taking care of the family/ household and all members of the family are seen by our physicians and nurse practitioner.

Superficial Comparison of Direct Primary Care Sites

Health Access RI
Physician Care Direct
Family Health Connections, Inc. NEW
Level 1: $59-89/mo
Level 2: $ 54-129/mo
Level 3: $ 60-169/mo
Registration: $ 99
Copay: $0
Exam: $0-10
Sick: $0-10
Adult: $59/mo
Seniors: $39/mo
Child: $19/mo
Visit: $ 10
Copay: $20
Adults: $ 49/mo
Adult: $60/mo
Child: $50/mo
Infant: $60/mo
Enrollment: $40-80
Copay: $20
What/ outside services
On-site dispensary for prescription medication
Affiliation with labs, radiology, women’s care,  drug discount card
Partners with labs, imaging, and specialists
Partners with medical supply and labs.
Lab relationship
Massage therapy
Behavioral Therapy
Anyone with or without insurance, no Medicaid/ Medicare patients
Differs by practice, no Medicaid/ Medicare patients
Anyone with or without insurance, no Medicaid/ Medicare patients
Anyone with or without insurance, no Medicaid/ Medicare patients
People without insurance, no Medicaid/ Medicare patients
Seattle, WA
Various in CA, WA, FL, OR
Dayton, OH
Weekdays and weekends
Differs by practice
Depends on practice
Depends on practice
Weekdays and Saturdays
Shorter wait times, longer appointments, lower cost
Direct access to care
Because everyone deserves healthcare
Spend quality time with physician
Offer affordable medical care to the uninsured
Appointments, phone consultation, email
Contact participating practice for specifics
Contact participating practice for specifics
Access card plan, bundled services for primary care available through participating practices
Appointments, physician on-call 24/7 (as with other family medicine practices)

Sunday, June 17, 2012

Have a Meaningful Father's Day!

Father's Day is here again.  How will it be for you?  OK, it all depends on the health status and location of your father and your health status and location.  If your father is deceased at an old age after a joyous life, you may intend to honor and remember his life forever.  If deceased prematurely, you may still be mourning from the intense sense of loss.  Either way you may be called fatherless.

If your father is living and you're having a huge outing with happiness and celebration and piles of unique family specially prepared foods from the family cookbook, you may be pretty content.  If your father is serving a life sentence in prison for a brutal murder which he confessed to and for which he shows nor has any remorse, Father's Day may be annoying and disheartening.

We all have a father.  Not so fast, you may say, be mindful that there are many types of father, "My step-father is the only one I've ever known." or "My parents were divorced when I was very young, both my biological father and my step father have been great dads and role models for life." or "My biological father was a total loser who drank and beat my mother to death.  My adoptive father is the most loving man on earth."  So "father" has a lot of variations  which may be expanding as our society gets more creative.

God helped us out with understanding the meaning of Father at the highest level.  The Bible is also replete with father figures, many of whom abounded with flaws, freeing modern fathers from expectations of perfection.   Moses and Joseph had special father situations among others, validating the variability of father-child configurations and relationships over the centuries.

 God sets the standard for the relationship starting with:  "Honor thy Father and thy Mother."

How might we enjoy Father's Day as we allow ourselves to reflect on the meaning of father in our lives.  How do we honor our earthly father or the "concept" of father for those who quest for a fatherly anchor in their lives?  How do we spread the word about fathers to others who need to know?  How do we tell the stories that allow the honoring and spreading of the word?

One act at a time.  One honor at a time.  One father at a time.  One story at a time.  Fathers teach others about the meaning and value of fathers.  Many others will do likewise.  Spread the word, folks.  Fathers matter.

Saturday, June 16, 2012

Personal Health: ER Trip of a Family Doctor

Aching all over with nasal congestion and malaise (I love that word- like an acceptable separation between one and others due to illness, warning the affected one while promoting the protection of others, a precursor to infection partly brought on by heroic white blood cells bursting and spilling interferon into the blood stream. This gives muscle aches, fatigue, mental fog, droopy mood, desire to remove oneself from social engagement and is pretty helpful in diminishing contagion) I thought: "I'm getting an infection- respiratory and annoying." Not to worry.  It was late Friday afternoon, so soon I was home taking two acetaminophen, fluids,  two 81 mg. aspirin and resting in my recliner.  By Saturday noon I felt better.  Monday at 4 AM, I awoke a little shaky with a hint of cough, so I figured the Friday infection was continuing, but lower in the respiratory system.  Adding two acetaminophen to my usual load of vitamins and supplements, I seemed alright Monday but had the muscle aches and malaise on awaking Tuesday with a minimal cough.  Continuing the acetaminophen strategy, I went to my office where my body announced at 11:30 that the medicine had worn off but was still needed.  I took two and at 3 PM or so felt the "upgrade" of interferon effects come on very strongly.  I considered the respiratory system and looked at my right leg where I had cellulitis in 2009.  It was red from ankle to below the knee in the front and swollen.  I knew I had the cellulitis again caused by cracks in the dry skin of my foot.

I saw the last two patients and had my wife drive me to the ER since I had an admittable problem and needed professional help.  Since the cough was becoming intense, I knew that physicians would consider whether it was caused by a blood clot in the swollen, red leg or other sources.

My wife said words to the effect, "Why aren't we going to the ER in the new hospital right next door to our office?"  I answered that I am a member of the medical staff here and knew the doctors and staff in the ER where we are headed and I'm more confident in the care and caring there if admitted.  That's where we went for the kidney stones and found a neighborly, caring effective group of health care professionals in Dec. 2009 and New Year's Day, 2010.  They are like family.

In the parking lot, a general surgeon and friend saw me and walked in with me (the squad entrance since I'm on the staff, I know the code and I had called ahead to let them know I was coming- my doctor's office was closed and I knew what type tests had to be done and might be done which were needing an ER).  The ER staff directed me to a room where the surgeon glanced at the right leg and notified me of a need for vascular testing to rule out a blood clot (DVT) which I agreed with and she went to call the vascular lab which was closed for the weekend.  This means the cough has more significance since DVT can't be ruled out, the chance of a blood clot or clots to the lungs still has to be considered in the treating doctors differential diagnosis.

The ER doctor who was part of the team who treated me when I had my kidney stone, walked in after the nurse got my vital signs and into a gown which allowed better visualization of the legs, skin and other areas if indicated.  He asked a couple questions, listened to the story mentioned above politely, asked a couple more questions while he looked at the leg.  He quickly pronounced that in-patient care was the recommended way to care for this since the hot, red and pink rash now entirely circled the leg.  My friendly general surgeon agreed and echoed the criteria.  Both looked at me and I agreed, essentially to be admitted to the hospital with Cellulitis of the right lower extremity.

I was relieved.   I was in need of medical care and caring, especially nursing caring (which still exists, Thank God).   I could relax while an assembly line of phenomena were unrolling to help me, bill me and keep all involved safe and sustainable in the eyes of any and all authorities and certifying entities.  More later.

Friday, June 15, 2012

Personal Health: Blogging from My Hospital Bed

Well, I'm in a hospital bed as a patient.  I love hospitals and oops, I'm being discharged.  More later

Saturday, June 9, 2012

Direct Family Medicine: Basic Package and Fees

 Considerations in establishing Direct Family Medicine charges pile up as one considers the business model versus patient need.  We reflect on, "What is Family Medicine?"  What is a basic package of FM services in the context of the patient-physician relationship?  What  is beyond the basic package but within the purview of generalist physician training that would be included in a list of services for separate payment?  What complementary and/or alternative practices might be included in the fee list for non-FM services on site?

First, the enrollment fee: These vary from $25 to greater than $100 per person.  Family rates seem to expect the full enrollment fee from the adults and a lower fee (like half the adult fee), such as $75 for each adult and $40 for each child.

Monthly membership charges vary depending on the scope of services in the basic package.  $50-60 is a common range for adults, while children may be charged (at the end of the month is when this happens to avoid being considered to be an insurance plan) $30-60 monthly depending on the inclusion or exclusion of immunizations in the basic package.  Imaging with X-Rays in the office usually is not include except for Qliance.  Hospital rounds and admissions are included in the more expensive Qliance package.

Administrative, scheduling or co-pay fees per visit are widely variable with a few plans having no per visit fee and many having a $10 to $20 fee.  For "complete" details about several Direct Primary Care programs click on these links:
Qliance      Health Access Rhode Island     Medlion    Forrest Direct Pay     Physician Care Direct

What aspects of each plan appeal to you?  Which elements don't seem to apply to you and your family?

A Family Physician planning to start Direct Family Medicine must carefully consider the above variables and make a decision.  What will be my basic services and non-basic services?

What basic fees will I start with and what variables will I monitor to know how we're doing for our patients and ourselves?

What do you think?