Direct Primary Care, a New Paradigm
Our medical system is good at treating chronic conditions and damn good at treating acute concerns. Survival rates for cancer, heart disease, stroke, heart attacks and trauma from accidents have risen dramatically over the past 50 years. That’s good.
Here’s what’s not good. Despite our ever improving ability to treat things we aren’t improving at preventing them. This graphic comes from the CDC:
Many reasons are cited for the increasing prevalence of chronic diseases:
Growth of processed foods as a percentage of total calorie consumption
Increasing rates of people living with obesity
Decreasing rates of physical activity
Increasing life expectancy (more time to get sick, see chart below)
In this post we’re going to talk about the problems with the current paradigm of delivering primary care (fee for service). Then we’re going to contrast that with what we believe is the most impactful solution: Direct Primary Care (DPC).
What Direct Primary Care Isn’t
Let us stress, the problem we’re about to describe is not the fault of physicians. Rather, it is the fault of a broken system that is incentivized to treat patients as quickly as possible, prescribe as many drugs as possible, order as many tests as possible…you get the picture.
Almost 70% of primary care doctors work for corporations or entities like private equity firms, insurance companies and hospitals. These organizations are profit motivated and the executive management is beholden to a board and shareholders whose sole objective is to increase profits. This is one of the two primary reasons that doctors visits are so short and inadequate for addressing chronic conditions: more visits = more money.
There are 480 minutes in an 8-hour work day. 30 visits per day equates to 16 minutes per visit.
But here’s the second reasons doctor visits are so short. Most doctors spend enormous amounts of time interacting with electronic health record systems. According to a study published in 2017 in the Annals of Family Medicine, which was co-written by researchers from the American Medical Association (AMA) and the University of Wisconsin, physicians spent an average of 5.9 hours out of an 11.4-hour work day in the EHR. 4.5 hours during clinic and 1.4 hours after work.
That time was broken down as follows:
44 percent on documentation, order entry, billing and coding and system security
About 1/3 on medical care tasks such as chart reviews and problem lists
24 percent on inbox management
The linked article quotes doctor Christine Sinsky, MD on some of the causes:
“Work previously done by other team members has been shifted to the physician in the EHR. Tasks that may have earlier required a matter of second, now may each take one to two minutes. Add this up over the thousands of individual tasks each day and it wasn’t surprising that I and other physicians began to wonder if we were spending more time caring for the computer than caring for the patient.”
If a practice needs to be reimbursed by an insurance company for the work they perform then the work has to be documented perfectly according to a very complicated and labor intensive coding system. If the T’s aren’t crossed then dealing with rejections and resubmission requests can take longer than the initial process itself.
Anecdotally, just yesterday Matt had to open a chart 5 times and add addendums to get home health physical therapy to see a Medicare patient.
In many cases physician visits are 10 minutes or less. Sometimes 10 minutes is all you need. The diagnosis is straight forward. The solution is antibiotics. Easy. Done. But consider the case of someone who is having their first visit after being diagnosed with Type Two Diabetes (T2DM).
When they arrive the physician either says: “I’m going to start you on insulin, here’s how to take it”, or, maybe, they spend a completely inadequate few minutes talking about a new prescription pill, making sure to list off the 7 side effects and potential interactions with other prescriptions you’re taking. What is a patient supposed to do with that? The honest answer is: hope for the best.
If you are a person living with T2DM then you have probably experienced how inadequate this response is and how it makes you feel to hear it. It’s dismissive and borders on being outright inconsiderate. Even if you haven’t lived with T2DM you can probably imagine…
What Direct Primary Care Is
Direct Primary Care (DPC) is almost the exact opposite of the experience above in every way. Here’s how it works.
You pay your doctor a flat fee every month. That’s it. There are no co-pays and no charges for any procedures done in the office.
In return, you are able to call, text or email your physician at any time. If you have an issue that needs immediate attention you will get through (for example, a rash has just broken out and you are trying to determine whether you need to go to urgent care).
Visits whether in person or via telehealth are free of charge, no matter how many you need.
What if you need to get lab work done?
DPC doctors operate in a “cash-only” world. This allows them to negotiate favorable rates for tests, prescriptions, imaging (x-rays), and even visits with specialists like dermatologists. Remember, if you are not seeking reimbursement from an insurance company then you don’t have to pay for staff to handle claims, and enormous amounts of doctors’ very valuable time is freed up by not having to spend so much time in the EHR. Test and drug prices can be negotiated at discounts up to 90% compared to insurance reimbursement averages, which makes paying out of pocket feasible. If you have a high deductible health plan (or if you are a “self-funded” employer covering your employees’ costs) then you are paying out of pocket anyway. What’s more, many necessary preventive measures will not be covered by insurance. A perfect example we see regularly is CT scans. A copay might be $900 (with far more reimbursed by insurance or paid by employer) but the cash pay through a DPC could be only $200. Yes this sounds crazy - welcome to our healthcare system.
Let’s revisit the example of our patient with T2DM.
This may be shocking to hear, but MOST T2DM cases can be put into remission with a normal A1c and off of ALL medications. That’s right. The disease the causes 130,000 amputations annually in the United States alone can be put into perpetual remission.
A typical first encounter with someone who has been diagnosed with T2DM should be 45 minutes to 1 hour. Here’s why.
First, most patients are receptive to the idea of lifestyle changes as long as they aren’t suggested in two minute platitudes. Over the course of 45 minutes a doctor can hear a patient’s story and learn about:
Their daily schedule
Experiences (successful or otherwise) dieting
Cultural eating habits
Spouse and children’s favorite foods
Ability to wear a continuous glucose monitor
Ability to exercise
Once this information has been gathered a doctor and patient can enter into a collaborative relationship to create an individualized lifestyle modification plan that actually has a chance of being adhered to.
In addition to regularly getting patients off of insulin and other diabetes medications, we have seen patients de-prescribed cholesterol and blood pressure medications, benzodiazepines, anti-depressants and anti-anxiety meds, among others.
The DPC model removes conflicts of interest. You pay your doctor and your doctor works for and with you, not a private equity company or a hospital who will have angry shareholders if they don’t make enough money off the time they spend with you.
To the business executives out there, a recent study which will be released shortly shows that self-funded employers can actually save money on their healthcare costs by paying for DPC style medical weight loss programs, at the same time as keeping their employees healthier and happier.
To summarize:
DPC doctors have no conflicts of interest
A DPC doctor works for you not a corporation
DPC doctors have more time to spend with patients because they aren’t dealing with middlemen, red tape and EHR systems
You get to pick up the phone and call or text any time, and can usually get an appointment scheduled within 24 hours (and often times have your question answered immediately if the doctor is available)
Your doctor is a mentor there to help you craft a personalized strategy for optimizing your health
If you don’t like your DPC doctor you can fire them immediately! You can’t (easily) fire your insurance company and hand pick “in-network” providers
If you like what you see on Aging Successfully and would like to become a patient, or if you know someone who you think would benefit from becoming a patient of Laura’s, please don’t hesitate to reach out! Laura has just joined Dr .Tro’s Medical Weight Loss and Direct Primary Care practice, based in New York but licensed to practice in all 50 states through telemedicine.
Check out the website by clicking here!
