Direct primary care – the answer or the problem?


Category : Medical Rants

Long time readers know of my fascination with the affect heuristic.  Simple stated, we overvalue the benefits of a concept that we like, and underestimate the problems 0r vice versa.

This article about direct primary care induces conflicting analyses – Here is the PCP crisis solution and it’s simple

I like the idea based on this reasoning.  Primary care in 2017 has several problems.  Both physicians and patients have dissatisfaction with direct face time.  Primary care physicians suffer high levels of burnout because the financial model requires them to see patients to quickly to do their job properly.  These quick visits likely induce physicians to order more tests and consultations than they would if they could spend more time on history and physical examination.

Direct primary care allows physicians to spend more time with patients, because they decrease their “panel size” from greater than 2000 to 800 or less.  These physicians have more time to communicate with their patients – using telephone and email.

But the panel size decrease waves a red flag for opponents of this movement.  They always ask – who will care for the patients?

When primary care physicians burnout they often totally leave their practice, often becoming hospitalists or urgent care physicians or subspecialists or retirees.  If direct primary care keeps them practicing, even with fewer patients, at least they are providing important primary care.

Currently, medical students and residents often find primary care unappealing because of the work conditions.  I often argue that direct primary care may induce students and residents to choose primary care and work with a reasonable number of patients.

This debate has no solution.  My arguments are not based on data, but rather on anecdotal observation.  I worry about primary care, because the current model often leads to more expensive substandard care.  You cannot rush visits and provide the highest quality primary care.  You must take shortcuts to shrink your visit times.

This debate is philosophically interesting and, in my opinion, a great example of that affect heuristic.  We cannot resolve this question with data, because the factors are multiple and too often you really do not understand the underlying motivations for doing primary care, or leaving primary care or moving to direct primary care.  So we will likely continue debating this issue to no clear conclusion.

But of course, I am correct.

Direct primary care – understand the appeal before your criticize


Category : Medical Rants

ACP has an excellent position paper on direct primary care – Assessing the Patient Care Implications of “Concierge” and Other Direct Patient Contracting Practices: A Policy Position Paper From the American College of Physicians

Martin Donohoe, MD in a letter criticizing the paper Academic Medicine and Concierge Practice makes what I consider the tired, holier than thou, ethical argument that such practices are in fact not ethical.  He writes,

For such institutions to teach students to treat all patients equally, combat inequalities in health care access and outcomes, and practice evidence-based medicine while at the same time supporting clinics that do the antithesis is troubling. At the least, trainees should not be allowed to work in such clinics.

Bob Doherty, writing for ACP writes a very thoughtful rebuttal – Academic Medicine and Concierge Practice.  His discussion is very worthwhile.

I believe that it is important that, as we research and consider the policy and ethical implications of DPCPs, we also consider the external factors that are driving many physicians toward them—including excessive paperwork associated with insurance interactions, electronic health records that are designed to meet the needs of payers and regulators and not the clinical needs of physicians and their patients, and productivity-based payments that penalize physicians for spending more time with their patients. I have met many physicians who have gone into concierge and direct primary care practices precisely because they want to get back to doing what they love most, which is spending time with patients. Many say that they charge low monthly fees so that they can be accessible to moderate- and low-income patients at less out-of-pocket cost to patients than many high-deductible insurance plans offer. I caution against painting with too broad a stroke in assessing the motivations of physicians in practices that charge retainer fees or limit the numbers of patients they see and about the effect that such features have on poorer patients. Rather, we need more unbiased research and evidence—while strongly reminding physicians, as we do in our paper, of their ethical obligations to provide care that is nondiscriminatory based on a patient’s income, gender and gender identity, sexual orientation, race, or ethnicity, regardless of the type of practice—concierge or not.

As I have often written and espoused, physicians often adopt direct primary care (whether the retainer model or cash only practices) because the insurance system (private and CMS) has failed them.  They are often the burned out dedicated internists and family physicians who want to connect with patients rather than paperwork (hence the ACP Patients before Paperwork movement).  Knowing the reasons behind viral movements can help identify causes and understanding.  Self-righteous criticism without such understanding bothers me (obviously).  As Covey said, seek first to understand then to be understood.

Full disclosure, my colleague Dr. Tom Huddle and I wrote this paper 5 years ago – Retainer Medicine: An Ethically Legitimate Form of Practice That Can Improve Primary Care


One physician’s journey to direct primary care – a burnout tale


Category : Medical Rants

Donald Ross (an obvious pseudonym) has practiced in a medium sized town for around 20 years.  I count him as a protege as we worked together during his residency.  As a clinician educator, we work with many interns and residents and sometimes we develop lifelong relationships.  Donald Ross and I share a love of golf, ACC basketball (although we root for rival teams), and internal medicine.  We periodically communicate through Facebook.

Recently, he posted on Facebook that he was leaving his current group practice to start a retainer practice.  I have visited him as a guest lecturer in the past, and we either talk or exchange messages periodically.  This announcement piqued my interest so I arranged to call him and learn more.  He has given me permission to tell his story.

Donald proceed to tell me a classic burnout story.  I suspect all my readers know that Physician Burnout Is An Epidemic.  Donald’s story is classic.  As family physicians and internists increasingly become employees, the practice leadership defines rules and expectations.  Most such practices embrace electronic records.

How did that impact Donald?  His schedule included 20 minute increments.  Between patients he would try to write his notes and handle electronic tasks.  He noticed that he was becoming increasingly unhappy with medical practice.

With the growth of hospital medicine, he (like many internists) quit following his own patients in the hospital.

His tipping point came when a patient’s daughter fired him because he no longer spent enough time interacting with her mother and her.  She opined that he had changed from the enthusiastic young internist they once knew.

With great soul searching he decided that he needed a different style of practice – one that allowed him to rediscover his joy of medicine.  The article linked above said it well:

Physicians are getting tired of the “turnstyle” medicine they are being forced to practice – seeing more patients in less time – rather than building the relationships that inspired them to enter the profession. Increasingly, however, the physician-patient relationship is being supplanted by the economic demands of a medical machine.

So Donald spent 4 months saying goodbye to some patients, arranging a new physician to see them, and recruiting some patients.  He told me that many patients were more than willingly to pay the retainer fee to follow him, but that others chose not.  He did not think that personal wealth was the deciding factor.

He now works in a free clinic 1/2 day each week and is planning to do some mission work with his church.  He wrote about a recent day:

By the way, went to the hospital to see two patients today after my 7:00 am Pharmacy and Therapeutics meeting (required to keep my privileges)..met with the rounding Hospitalist and gave them background info who seemed surprised and pleased to have some help…saw my patients (who were appreciative) and went back to my office to see my 9 patients today….who says I am not busy!

My colleague, Tom Huddle and I, wrote about the ethics of retainer practice in 2011.  In response to numerous letter we responded and included this concluding paragraph:

Although medicine is not just a job, it is, contrary to Dr. Webster’s view, business as well as service. We should welcome retainer medicine, integrated health care systems like Kaiser Permanente, and other attempts to combine high-quality health care with physician and patient satisfaction. And we should permit physicians to make their own decisions in regard to political participation and the importance of societal health compared with other societal goods. Physicians who form retainer practices should offer some free care; if they otherwise conduct their medical practice in conformity with the ideals of professional ethics (excluding any putative bearing of professional ethics on politics), they are exhibiting anything but “a rather thin view of moral responsibility”. In performing exemplary professional work, they are providing society exactly what it asks of them and, in so doing, giving the medical profession everything that our profession should demand of us.

Donald’s story speaks loudly.  He is a very dedicated primary care internist.  As we talked I could tell how making this decision involved great self reflection.  We talked about the joy of being a physician and how the many administrative burdens and payment requirements had sucked the joy out of his career.  He told me how happy he is spending adequate time with his patients.  His patients all have his cell phone number.  He calls them to discuss their test results.  He has returned to practicing the medicine we trained him to practice.  He sounded relieved and very happy, looking forward to many productive years.

My friend and colleague, Yul Ejnes recently wrote about the quadruple aim.  The fourth aim involves health care workers health, especially mental health.  As he writes:

Improving the care of individual patients, bettering the health of populations, and lowering health care expenses — that covers everything, right? Not so, according to Drs. Thomas Bodenheimer and Christine Sinsky. In 2014, they published a paper in the Annals of Family Medicine titled “From Triple to Quadruple Aim: Care of the Patient Requires Care of the Provider.” In it, they very effectively made the case that our ability to achieve the triple aim is jeopardized by the burnout of physicians and other health care providers. They proposed adding a fourth dimension to the three in the triple aim: “the goal of improving the work life of health care providers, including clinicians and staff.”

A TV series from the late 50s and early 60s featured this line in closing – “There are eight million stories in the naked city. This has been one of them.”

We do not have 8 million physicians, but we have many.  This rant tells the story of one physician.  He is not alone.

Initial reporting of direct primary care impact


Category : Medical Rants

While these data might have bias, they are still important.  I have argued that spending time with a good outpatient doc could save money.  This report supports that hypothesis.

Direct Primary Care Practice Model Eyed to Trim Health Care Spending

For example, the affiliated medical practice, Qliance Medical Group, analyzed internal data from 2009 and found that its direct primary care model lowered emergency department visits by 62% and hospital days by 26% for patients on its plan, when compared with regional averages for the same year, Dr. Bliss said. The group also cut specialist referrals by 55% and advanced radiology services by 48%, compared with regional averages.

“Insurance really doesn’t work for primary care; it’s meant to protect you from catastrophic events. It just adds a whole lot of administrative cost, not only on the doctors’ office side but also on the insurance side,” Dr. Bliss said in an interview. “Primary care is 90% of what people need, and we can provide that.”

The direct primary care practice model resembles the concierge medical practice model, but – unlike concierge practices – direct primary care practices cater to a lower-income demographic and attempt to provide almost all necessary care for a flat monthly fee. Many concierge practices charge a monthly or annual retainer, but also bill for services provided to the patient.

The direct primary care practice model also follows some of the same principles as the patient-centered medical home model. However, the direct primary care model does not team physicians with other health care professionals, such as social workers and pharmacists.

“One of the things that really strikes me with the move to the patient-centered medical home is, there’s an assumption that in order to take better care of patients, you need to put together a multidisciplinary team,” said Dr. Bliss. “We assume you need a pharmacist, a nutritionist, and a social worker, but while it’s nice to have those people around, they’re not really necessary, and they also add a lot of cost. When you spend time with someone, you can solve their problems without them seeing a nutritionist.”

At Qliance, patients pay monthly fees of $44-$129, depending on their age and service preferences, for unrestricted access to physicians and nurse practitioners. The three Qliance clinics, with their nine physicians and three nurse practitioners, provide all routine care including vaccinations, routine blood tests, women’s health services, pediatric care, broken bone setting, and ongoing management of chronic diseases like diabetes and obesity, Dr. Bliss said.

This movement will likely pick up steam.  We need to examine it carefully and understand what is happening here. As the Buffalo Springfield said,

"There's something happening here
What it is ain't exactly clear"

Direct primary care – an interview


Category : Medical Rants

Yesterday I had the pleasure of talking with Norm Wu, President and CEO of Qliance. Qliance is a start-up primary care concept in Seattle. I learned of them through twitter, and began communicating with Norm. We had a 30 minute conversation yesterday. These are my reflections. If I get anything wrong, Norm will let me know and I will correct my entry.

Direct primary care provide less costly retainer medicine. They charge around $50-$60 per month for primary care and full access. They do not accept any insurance; they do not bill any insurance; their members cannot bill insurance for repayment.

The physicians practice an average of 40 hours per week and follow 500-800 patients each. The office is open from 7 am to 7 pm Monday through Friday and 4 hours each on Saturday and Sunday. Obviously, if you need to see a physician outside their hours, you will see a partner. Each partner covers their fair share of weekends.

What do patients get for their monthly fee? First, they have easy access to their physician and their visits are not rushed. They can schedule telephone consultations. They have email access.

Three types of patients come to Qliance. First, working patients who choose Qliance along with high deductible catastrophic insurance. While we did not get into the details, my impression suggests that most patients save money with this combination. Medicare patients are willing to pay a fee for primary care access, even though Medicare does cover outpatient visits. Finding a physician who accepts Medicare is becoming increasingly difficult in this country, so patients are often willing to pay a monthly fee to have excellent access. It’s of course more than access – it’s about unhurried care and coordination of specialists and hospitals, the full medical home concept. Finally, Qliance reduces ~ 10% of their revenues with a combination who truly cannot afford the fees and those who receive discounts. They have provisions for temporary or permanent waving of fees.

Some of the physicians also coordinate hospital care and make hospital visits – that adds approximately $20 to the monthly fee. Otherwise, hospital care is coordinated through faxes and phone calls with the hospitalists.

Quoting from their web site:

Your monthly care fee covers the primary and preventive care services described on the Patient Services page of our website. However, at times your care may require durable medical supplies or third-party services that are not included. You may be asked to pay additional fees for items such as prescription medications, laboratory tests and outside services such as x-ray interpretation if needed. In all cases, incidental items are charged at or near our cost and their prices and relevance to your care are fully discussed with you in advance of being incurred.

If you have health insurance, you may choose to have your laboratory tests billed to your carrier as well as have prescriptions written to a pharmacy that accepts your plan.

I hope that I have described the program succinctly and clearly. I like the concept and now will give my impressions.

Since beginning this blog in 2002 I have expressed interest in alternate ways of funding primary care. The retainer movement has fascinated me, but for many patients the price made this option unrealistic. I like the cash only practices, because once you eschew insurance companies, your overhead and documentation requirements decrease dramatically. Qliance seems to combine the two concepts and provides a reasonable monthly fee (approximately $2 per day) for excellent access. The business model works because all the attention goes to patient care rather than billing and documentation. Thus the overhead decreases dramatically.

I like that Qliance does not bill insurance at all. When retainer practices also bill insurance I get the impression of greed. This model has conceptual purity – you pay for access and receive access.

I suspect that what Qliance has done is to create a financially viable patient centered medical home. The difference here is that with a smaller patient panel, the physician spends more time with patients – both in person and using phone and email contacts.

We should follow this experiment. Having enough time to devote to all ones patients improves physician satisfaction and patient satisfaction.

Direct pay primary care – removing the insurance company burden


Category : Medical Rants

I highly recommend these two blog posts:

Guest Post: Why the Direct Primary Care Model would benefit poor patients (1 of 2)

Guest Post: Why the Direct Primary Care Model would benefit poor patients (2 of 2)

I have written often about “retainer medicine” and direct pay. These articles describe an innovative, exciting implementation of the ideas for poorer patients.

For years I have written that we should study these alternative models carefully. While they started for the wealthy, the underlying concepts were intriguing. What I like is a return to the patient and physician having a direct relationship, the physician decreasing overhead because the business model does not depend on paperwork with insurance companies, and the honesty of the charges.

Direct primary care can be first class, business class, or economy class. We should carefully consider these models as a potential solution to retaining primary care physicians. I would bet that the physicians in such programs are much happier. I also would be that they write more informative and shorter notes.

Ban the term productivity from medical care


Category : Medical Rants

According to Wikepedia:

Productivity describes various measures of the efficiency of production. A productivity measure is expressed as the ratio of output to inputs used in a production process, i.e. output per unit of input. Productivity is a crucial factor in production performance of firms and nations.

Please tell me how this relates to being a physician or a patient.  We do not produce anything.  Rather we work with individuals to diagnosis, prevent, treat, and hopefully improve both longevity and quality of life.

Physicians work with individual patients.  We should strive to tailor care with our patient.

Productivity implies that we can count patient units.  That idea really disrupts the essential Why question?

If you are unfamiliar with Why I highly recommend Simon Sinek’s book Start with Why. Why did we become physicians?  I think the answer for most physicians includes helping individual patients.  We strive to do our best for each patient.

Where did productivity enter our profession?  Most experts believe that Hsaio’s NEJM article – Estimating Physicians’ Work for a Resource-Based Relative-Value Scale led to RVUs (relative value units) which many practice administrators use to measure “productivity”.  Hsaio, a noted economist, wrote in the abstract of that article:

We found that physicians can rate the relative amount of work of the services within their specialty directly, taking into account all the dimensions of work. Moreover, these ratings are highly reproducible, consistent, and therefore probably valid.

However, this model has led to gaming the system, and equating RVUs with hard work or productivity.  But many physicians believe that the RVU system provides many wrong incentives, the most important being that shortening visit time leads to more patients per day and thus more money.

I wish physicians could just ignore RVUs and spend appropriate time with each patient.  When physicians try to do this, practice administrators work to get physicians to see patients faster.

This leads to great stress for many physicians, and often unhappy patients.  Many physicians believe that shorter visits (especially with primary care physicians) lead to more testing and consultations.

Productivity implies that seeing more patients each day is a good thing.  But likely most patients and physicians will agree that we need to optimize the time with each patient.  How many patients can we comfortably see in one day and deliver high quality care?  High quality care does not refer to performance measures, but rather complex multi-dimensional factors that improve the patient experience.  For many patients, talking is both therapeutic and diagnostic.  We shorten our conversation time at the risk of diagnostic errors, higher health care costs and dissatisfied, confused patients.

So please join the movement to ban productivity from medicine.  We are not producing anything.  We are caring for patients who need our full attention.

Retainer medicine as a potential primary care solution


Category : Medical Rants

Today’s NY Times includes a rather sensationalist article about high end concierge medicine – Enhanced Medical Care for an Annual Fee Writing stories about $25k per year concierge medical service provides great sensationalism, but in many ways detracts from an alternative payment model that we should take seriously. I believe that the ACA does allow for retainer medicine with catastrophic type insurance.

I believe the concierge, high cost practices, detract from an interesting primary care model. Many experts have written about the problems of our current payment system, that devalues time spent with patients. My personal interviews with some retainer based physicians suggest that their main goal is to deliver the highest quality care to their patients. Obviously, if the patients do not believe that they are getting their money’s worth, they can just leave the practice.

What is the essence of excellent primary care? One could argue, and obviously I will argue, that spending adequate time with patients and using that time to carefully address the patient’s issues and their diseases allows for the best primary care. The best primary care limits unnecessary testing and unnecessary consults through careful history, physical and thinking!

My acquaintances often describe physician excellence through comments like “she really listened”, “he spent time talking with me”, “she returned my calls promptly”. Retainer medicine, sometimes called direct primary care, places the patient and the physician into a mutual relationship. The physician provides transparent fees and the patient gets access – visits as needed, telephone consultations and usually text or email access.

Patients deserve this brand of high touch, high quality care. If one takes the insurance companies and their induced overhead out of the physician’s office, the costs can be relatively modest. Qliance in Washington State gives such an example.

We ignore the retainer medicine model at our peril. Perhaps this is a much healthier model for both patients and physicians.

Internal medicine interest increasing, not so primary care


Category : Medical Rants

Med Students Like Internal Medicine OK. Primary Care? Not So Much.

As I write repeatedly, what outpatient internists do is not what most physicians consider primary care.  Internal medicine program directors and primary care champions keep insisting on using an antiquated term. has these two definitions:

  1. :  health care provided by a medical professional (as a general practitioner or a pediatrician) with whom a patient has initial contact and by whom the patient may be referred to a specialist for further treatment
  2. The medical care a patient receives upon first contact with the health care system, before referral elsewhere within the system.

These definitions are not appealing to most students who become enamored with internal medicine.  These definitions are not the same definitions we understood in the 1980s.

This semantic drift (see the Wikipedia entry on semantic change):

Semantic change, also known as semantic shift or semantic progression describes the evolution of word usage — usually to the point that the modern meaning is radically different from the original usage. In diachronic (or historical) linguistics, semantic change is a change in one of the meanings of a word.

Many things have happened since the 1980s.  The field of hospital medicine now captures many who love internal medicine and avoid subspecialization.  Before the turn of the century, internists (note the lack of adjective) did both inpatient and outpatient care.  Their patients had complex problems.  Their pay fit the complexity of their practice.  But that wonderful job, which oldtimers often call primary care, is difficult to find in 2011.

I do not think that medical students have changed.  I think medicine has changed because of Medicare and insurance companies.  Payment problems and the growth of hospital medicine have made the idea of internal medicine primary care relatively less appealing.

Our terminology is a major part of the problem.  But then if you read this blog over the years, my message is an old one.  But apparently, I am not convincing many people about that message.

Palliative care extends life – and improves quality of life


Category : Medical Rants

Surprise, or maybe not – Palliative Care Extends Life, Study Finds

In a study that sheds new light on the effects of end-of-life care, doctors have found that patients with terminal lung cancer who began receiving palliative care immediately upon diagnosis not only were happier, more mobile and in less pain as the end neared — but they also lived nearly three months longer.

The findings, published online Wednesday by The New England Journal of Medicine, confirmed what palliative care specialists had long suspected. The study also, experts said, cast doubt on the decision to strike end-of-life provisions from the health care overhaul passed last year.

“It shows that palliative care is the opposite of all that rhetoric about ‘death panels,’ ” said Dr. Diane E. Meier, director of the Center to Advance Palliative Care at Mount Sinai School of Medicine and co-author of an editorial in the journal accompanying the study. “It’s not about killing Granny; it’s about keeping Granny alive as long as possible — with the best quality of life.”

Actually i am not surprised.  One of my favorite quotes, attributed to Osler, goes, ""The good physician treats the disease; the great physician treats the patient who has the disease"

I fear that to often sub-specialists focus on the disease more than the patient.  They do not do this because they do not care, rather they live reading and talking about disease.  They are, almost by definition, disease-focused.

We had a situation during my father's illness where a medication, prescribed to slow his metastatic cancer, caused significant side effects which greatly hampered my father's quality of life.  He decided (and as a physician son I concurred) that he should stop the medication.  Fortunately my father had no symptoms from the cancer; unfortunately he had symptoms from a medication.

According to my father, the oncologist did not understand his decision to discontinue the medication and appeared angry about that decision.

Now perhaps I am exaggerating, and I do not really know the interchange.  But I have seen too many patients with physicians who focus on slowing the disease "at all costs". 

Having a good primary care physician involved can work.  Having excellent palliative care can work. 

Palliative care works because it is patient focused.  And after all, our job is to treat patients.

Bravo to the group who did this study.