Transition to Hybrid Direct Primary Care: Challenges and Pitfalls

I've started four Family Medicine offices from scratch, starting in 1980 through 1999.  I've directed a campus health center, started and directed a Family Medicine training center for a community hospital and directed a University Family Medicine center.  Now, I've helped to start a weekly free clinic for the uninsured and underinsured in my community.  I've learned a lot and had a lot of fun.  Patients in all these setting were great.  The challenge of Direct Primary Care (DPC) is next. It's one of the solutions to the disastrous mess coming to health care (or already here).

Direct Primary Care, the business model, connects well with Direct Family Medicine, my practice model for applying DPC.  I have a fifteen year old, two physician family medicine office which takes "families only".  It's a niche practice now converting to a DPC hybrid, practicing traditional Family Medicine with Direct Family Medicine.  We started formally in July 2012.  See my blog posts about DPC in June, July and August of that year.

Challenges:  My office staff attitude about health care was pretty "normal", with a strong belief that insurance, funded by business or government, paid for health care.  "People need insurance", I had taught them.  With DPC, the challenge is to believe that some people don't need insurance for primary care. With a hybrid practice, all of us had to shift our belief to both- insurance is good for our existing patients and insurance isn't needed for our new Direct Family Medicine patients.

All new patients had to sign into our Direct Family Medicine "track".  How could we explain it to potential new patients calling during busy office hours?  Not Well.
What should we say?  Not much before the phone rang or another patient was signing in or checking out.
How many people were fired up about signing up after our phone explanations?  None
How many people liked the idea as I explained it at the end of their office visit, giving them a one page description of DFM?  About one a day.

The traditional patients with insurance had gradually increasing amounts of administrivia, detracting from our DFM track.  A couple who operate a Christian coffee house that I frequent had a sudden gap in their health care support.  I gave them a year of DFM to speed up the learning and practice curve for us. They helped me to better understand what we were doing.

More later.

Family Medicine: Celebrating the Uniqueness of Each Patient

Sixty trillion cells, each of which has 100,000 chemical reactions per minute (who counts these things?) are the basic material in humans.  As a Family Physician, I am ever mindful of the complexity of such a system. Unique is a word that comes to mind as I think of each patient.  Amazing is another one.

Each patient makes about five billion new cells daily.

Along comes the electronic medical record and "Bonus Based Medicine" and the patient is pushed aside into a "Payment Centered Medical Home" or stumbles into a hospital where nurses greet them with a barcode reader to bill them multiple times daily.  We have guidelines such as, "All humans should be on a statin drug unless they have died".  "All patients should be on a low fat diet"  (known to make people fat).

Wait a minute!  What about the "Meaning of the illness" to help the patient with their evolving humanity?  What about helping them to find the meaning of the illness in their life?  What about the Human Genome Project which gives us the potential for massive differential diagnoses for each symptom or sign?  Are we to ignore over 20,000 single gene disorders that are beautifully documented on the OMIM site?

I love the uniqueness of each patient.  I love their quest for meaning.  I believe they value their evolving humanity and its meaning in their lives.  Let's celebrate it.

Let's allow the EMR or EHR to align with the uniqueness of each patient.  Let's redefine quality so it's connected to mutually agreed to goals between patient and personal physician.  Let's allow physicians to use our "mutant brains" to think about helping the patient to align with their values, goals and dreams.

OK, you might say- they eventually all die.  True, even with the best medical care on earth- they all die.  We can help them to define their end of life goals and enhance the meaning of their life or its end resulting in end of life "quality".

Let's back off on the phony quality initiatives and excessive use of nurses and physicians as billing agents. Let's dive back into the amazing complexity of human life and human biology and celebrate the uniqueness of each patient.  It's fun.

At the same time, let's celebrate the education and training of our physicians and allow them to redefine quality- one patient at a time.  We're unique, too.

What do you think?

Family Medicine: Insurance and/ or Direct Primary Care- Changing Times in Health Care

I'm getting excited at the way patients are discerning their role change in health care.  They are getting to know how the high deductible health insurance works.  It's like a discount card, not real insurance.  They're expected to pay up front for their medication and their visits until they meet the deductible amount, often $3000.

They don't yet know what they have to pay for labs with their discount.  They're surprised when they see the price of their medications.  After they get the first sticker shock, they shift into consumer mode, often rejecting one of the prescriptions at the pharmacy and seeking a less expensive medication.  If they have asthma and bronchitis, they are out of luck since the inhalers are really expensive.  If they have COPD and bronchitis, they may have a $6oo medication charge each month.

They pay their co-pay of $20-35 to us, but three to four weeks later, get the discounted bill for the rest of their physician and office procedure charges.  They may not pay this until they see it for the third time, "I thought I had insurance."

After two or three visits, they have it figured out.  We're all set until next January when it starts all over again.

Many people just decide to get a Direct Primary Care doctor in addition to having the insurance.  They get more time with the doctor, generally don't have as many outside of office charges or go to ER's as much. They have a higher chance of not reaching their deductible. They spend $750-900 for their membership, monthly and any visit fees plus labs for their Direct Primary Care physician.  (Half that for their children, but more for infants).           

What do you think about your insurance or Direct Primary Care?

Learn more about DPC at the DPC Ohio Unsummit II May 17 at the Garden Inn in Beavercreek, OH.  Unsummit

Direct Primary Care: Legislative Example for States to Consider

REFERENCE TITLE: direct care plans; insurance; exemption

State of Arizona Senate Fifty-first Legislature Second Regular Session 2014

SB 1404

Introduced by Senator Ward

AN ACT

AMENDING TITLE 20, CHAPTER 1, ARTICLE 1, ARIZONA REVISED STATUTES, BY ADDING SECTION 20‑123; RELATING TO DIRECT PRIMARY CARE PROVIDER PLANS.

(TEXT OF BILL BEGINS ON NEXT PAGE)

Be it enacted by the Legislature of the State of Arizona:

Section 1.  Title 20, chapter 1, article 1, Arizona Revised Statutes, is amended by adding section 20-123, to read:

20-123.  Direct primary care provider; exemption from regulation; notice; definitions

A.  A DIRECT PRIMARY CARE PROVIDER PLAN DOES NOT CONSTITUTE THE TRANSACTION OF INSURANCE BUSINESS OR A HEALTH CARE SERVICES ORGANIZATION IN THIS STATE FOR THE PURPOSES OF REGULATION UNDER THIS TITLE.

B.  A DIRECT PRIMARY CARE PROVIDER PLAN MAY ARRANGE FOR PRIMARY HEALTH CARE FOR ENROLLEES IN THIS STATE.

C.  A DIRECT PRIMARY CARE PROVIDER PLAN MUST PROVIDE A WRITTEN DISCLAIMER ON OR ACCOMPANYING ALL APPLICATION AND GUIDELINE MATERIALS DISTRIBUTED BY OR ON BEHALF OF THE DIRECT PRIMARY CARE PROVIDER PLAN THAT READS, IN SUBSTANCE:

NOTICE:  THE ORGANIZATION FACILITATING THE DIRECT PRIMARY CARE PROVIDER PLAN IS NOT AN INSURANCE COMPANY AND THE DIRECT PRIMARY CARE COMPANY GUIDELINES AND PLAN OPERATION ARE NOT AN INSURANCE POLICY.  PARTICIPATION IN THE DIRECT PRIMARY CARE PROVIDER PLAN OR A SUBSCRIPTION TO ANY OF ITS DOCUMENTS SHOULD NOT BE CONSIDERED TO BE INSURANCE.  REGARDLESS OF WHETHER YOU RECEIVE TREATMENT FOR MEDICAL ISSUES THROUGH THE DIRECT PRIMARY CARE PROVIDER PLAN, YOU ARE ALWAYS PERSONALLY RESPONSIBLE FOR THE PAYMENT OF ANY ADDITIONAL MEDICAL EXPENSES YOU MAY INCUR.

D.  FOR THE PURPOSES OF THIS SECTION:

1.  "DIRECT PRIMARY CARE PROVIDER PLAN" MEANS A PRIMARY CARE PROVIDER THAT COLLECTS ON A PREPAID BASIS FEES TO CONDUCT PRIMARY HEALTH CARE FOR ENROLLEES.

2.  "ENROLLEE" MEANS AN INDIVIDUAL, FAMILY OR GROUP THAT HAS ENROLLED IN A DIRECT PRIMARY CARE PROVIDER PLAN.

3.  "PRIMARY CARE PROVIDER" MEANS A PHYSICIAN WHO IS LICENSED PURSUANT TO TITLE 32, CHAPTER 13 OR 17 AND WHO SPECIALIZES OR IS BOARD CERTIFIED IN GENERAL PRACTICE, FAMILY MEDICINE, INTERNAL MEDICINE OR PEDIATRICS.

4.  "PRIMARY HEALTH CARE" MEANS CONDUCTING ALL COMPONENTS OF PRIMARY CARE THAT IS ORDERED AND SUPERVISED BY A PRIMARY CARE PROVIDER, INCLUDING MEDICAL VISITS, LABORATORY TESTING, IMAGING, PATHOLOGY TESTING, PRESCRIBING AND ADMINISTERING MEDICATION AND OTHER MEDICAL PROCEDURES THAT MAY BE PERFORMED OR SUPERVISED BY A PRIMARY CARE PROVIDER WITH TRAINING AND EXPERIENCE IN THAT PROCEDURE.

Measuring Quality in Direct Primary Care: Let Patients and Physicians Define it Together

One challenge with the DPC "solution" is the freedom enjoyed by the early adopters of the concept as they frame the potential for a dominant design.  There is still some radical innovation at the edges that should be allowed to play out before nailing down the center of DPC.  Honoring the sacred nature of the patient-physician relationship anchors the potential for personalized quality parameters that exceed some of the phony, but measurable, drivel currently being forced on family physicians and their patients (e.g.,statins for everyone who ever stayed at a Holiday Inn Express). 

While others, such as Harold Sox commented on the need for dyadic defined quality parameters in JAMA a couple years ago, complemented by more recent JAMA comments from Mayo Clinic echoing the same need,  Family Medicine has fallen behind in our responsibility to measure quality through dyad driven parameters, sometimes drooling over A1C's as Godly annointed quality truths while ignoring the beauty of the ongoing patient-physician relationship which has quality defining potential of radical proportions. 

Which is to say we should encourage presentation of DPC quality parameters that show the uniqueness of the model and its fans/ practitioners.  Human values manifested through pt-phys relationships into human outcomes could refresh some of the dullness of the EHR as well as patients and physicians.  This is what we do daily in Family Medicine and it's extremely satisfying.  With the time allowed in most DPC settings, it can continue, and improve.  Onward.