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?

1 comment:

  1. Hi Dr. A. Patrick Jonas;

    I'm a 4th year med student, pursuing a family medicine residency. I attended FMEC but missed your presentation on Direct Pay.

    When I came back home to New York, I suggested the Direct Pay model to a physician who was frustrated with HMOs. She did some quick calculations in her head and figured she couldn't afford it.

    Did you provide any financial illustrations ? is there anything financial illustrations that you might be able to share or a powerpoint that I could show her ?