Four Months as a DPC Doc

At the end of my fourth month as a DPC doc, my total patient enrollment is 145, still exceeding my expected pace of enrollment.  My Medicare opt-out was approved effective October 1, and I enrolled 40 prior Medicare patients of mine in the first month as an opted-out doc.  For those considering DPC, the opt-out is essential and can only be done on the first day of each quarter; it also must be repeated every 2 years. You also need to plan ahead and have all necessary paperwork submitted at least 30 days prior to your opt-out date. Finally, and this is very important, you need to ensure that you are still registered under PECOS to be able to refer medicare beneficiaries for labs, X-rays, therapy services and DME. I am happy to assist anyone with the opt-out process.

So, after just four months, my monthly cash flow is enough to cover all my expenses and pay myself a small monthly salary.  Within the year I will no longer need my business line of credit for capital contributions. For those seriously considering DPC I'd be happy to share the numbers to show where the expenses go and how my monthly fees break down. 

I am ready to launch a full-scale marketing effort, rolled out throughout 2015, to target small business owners and small companies in order to provide direct primary care to their employees. I am on track with my plan to be able to offer employment to fellow family docs who would like to practice DPC in the Tampa Bay Area starting in the Fall 2015. I would like to know of any interested third-year residents or practicing physicians so I can stay in touch with you directly throughout 2015. 

On Jan 1, the CMS carrot turns into a stick for those tracking PQRS data, or those enrolled in Medicare shared savings ACOs. I'm sure physicians will be dissatisfied in unparalleled numbers beginning this year. Also, record numbers of patients will be sporting high deductible plans this year, increasing the strain on fee-for-service primary care physicians. The time has never been better to join the DPC movement. My early experience suggests anyone can do it. You don't need the backing of any company -- just a mentor and a small business loan. Or let's talk about coming to Tampa Bay with a guarantee until you reach profitability. 

DPC/HDHP Combo Attracts Attention of Small Business Owners

I am celebrating my first month as a DPC doc.  I am celebrating the fact that I enrolled 50 patients, doubling my expectations for the first month.  All but four are former patients of mine, but this is still cause for celebration.  I am truly celebrating the fact that I have filed my affidavit to opt-out of Medicare and will begin enrolling Medicare beneficiaries under a private contract on October 1, so I expect a second influx of former patients at that time.  And I am celebrating the fact that my practice has garnered the interest of local small business owners sooner than I expected; this gives me the potential for growth at a much faster rate than expected.  For example, this week I am making a presentation to a local title company with 23 employees who begin open enrollment for 2015 this month.  Their family premium has risen to $1600 per  month.  I explained to the owner that my maximum monthly fee for a family is $150 per month, and this can complement the high deductible plan that carries a premium that costs $7000 a year less.  After the $1800 annual premium for my direct primary care, they save more than $5000 per year in premium.  The bottom line is that, due to the accessibility to care that they will get from me at no added cost, they are likely to save thousands; but even if someone in the family has a catastrophic event, and they reach the $6350 individual out of pocket max, the family will still spend $900 less than if they pay the higher premium for the comprehensive plan all year, with its $2000 individual out-of-pocket max.  In the absence of the DPC option, many of these employees will be forced to choose the HD option anyway, just to save on premium; but they will not have access to affordable care, so they will defer care, making it more likely that they will reach their out-of-pocket max anyway.  This is the scenario that leads to "coverage without care," a harsh reality of the present system.

I would like to invite 3rd year family medicine residents who might be interested in having a DPC practice in the Tampa/St. Petersburg/Clearwater area, and never have to file a claim to a third party ever, and have a great quality of life with a salary equal to that which would be offered to join a busy fee-for service practice -- follow this blog throughout your third year.  I will hire a physician for every 400-600 employees for whom I can contract to deliver care.  My goal is to be able to do this by Fall 2015.  I welcome your inquiries throughout the year.  I also welcome the inquiries of established physicians who have had enough of fee-for-service medicine.  Lets build a DPC network in the Tampa area that saves businesses millions while providing great, accessible care to their employees.  We can disrupt the prevailing business model of our healthcare system one region at a time.  

Doing More With Less

When I tell people that I am leaving a group practice to start a fixed monthly cost membership practice that will only cost them $50 per month, and they will never have any other costs for my services no matter how often I see them, their brow invariably tightens.  "How can you afford to do that?" they always ask, either genuinely concerned for my well-being or worried about my sanity.   "How can I afford not to?" I always reply. And after I explain it, they are usually left concluding the same.

Direct patient care practices come in various shapes and sizes, but they do lend themselves nicely to the micro practice model.  The overhead expenses in a DPC practice are inherently so low that the provider can run the practice with few staff and in small spaces.  In the fee-for-service model the provider collects about 70 cents on the dollar after contractual adjustments, then after overhead expenses of 50-60%  (often 70% with increasing requirements for extra staff and care coordinators), the net reimbursement can be as low as 25-30 cents on the dollar.  Contrast that with a DPC practice where 97 cents on the dollar can be collected, and with overhead of  20-25%, the net collection is in the range of 75 cents on the dollar.  So yes, I can afford to have a DPC micro practice, with 1/4 to 1/3 of the patient panel that I have currently.  What really matters, however, is the quality, access and affordability to which my patients will have access.  I will be able to do much more for my patients with much less. 

My direct patient care practice, River Jordan Direct Family Medicine (rjdirectfammed.md), will open its doors on July 28, 2014.  I am subleasing space from a specialist in an agreement that allows for low rent initially, and it will increase as my practice grows.  I will have just one staff member until I enroll my first 100 or 200 patients; only then will I need a full time medical assistant. My electronic medical record is free. I am not paying anyone else to "manage" the monthly payments, although there are several companies who cater to DPC docs by offering low cost solutions using gym membership software that has been modified for medical practices. I am going to use Quickbooks for this initially. I am using a medical supply company that caters to DPC docs by giving group purchasing power among all docs around the country who are in the micro practice model. So you can see that an entire industry is developing to support physicians who are going into business by themselves in a micro practice model.  For my part, I am catering to patients who have high deductible plans by compiling a list of low cost options for labs and radiology services, as well as cash pricing from specialists. "Consumer-driven" healthcare is a great idea, but unless patients have the ability to know what they are getting with their healthcare dollar, savings will not occur. We can't wait for the system to cater to cash pricing options; it is going to ride the fee-for-service wave as long as it can with little motivation to change quickly. So DPC docs offering low cost primary care, and helping patients find lower cost options for their additional care, will disrupt the system from the bottom up. The evolving support for the micro practice model allows physicians to do just that, and pass the saving to our patients. Once we bring employers into the model in larger proportions, we will be successful in disrupting the system.

I start July 28 with a member count of zero. Please check back regularly for a status update!

The Access Conundrum

There are many factors which clearly predict that we are facing a catastrophic access problem in the US healthcare system.  The Affordable Care Act has provided coverage for millions already, with millions more expected to follow.  Baby boomer physicians, who were prepared to retire 5 yrs ago, but whose retirement plans were delayed by the collapse of the economy, will likely be exiting the workforce in the near future.  In addition, many mid-to-late career physicians are leaving the practice of medicine to pursue other medicine related activities such as consulting, legal reviews, or chart reviews for insurance companies, providing them with the same or increased incomes without all the hassles that are inherent to working mainly for third party payors. The shortage of physicians by 2025 is predicted to be greater than 100,000.  The physician shortage that under-served areas have felt for years will become a reality for populated areas as well.   So "coverage without access", a term first coined by Dr Marcia Angell, former executive editor of the NEJM, will not be just a prediction for the post-ACA era, but a reality.

There are so many powerful stakeholders in the status quo that waiting for the healthcare system to reform its delivery model "from the top down" will not take place quickly enough to match demand.  The supply of new physicians to fill the gaps in access is likely to be inadequate when the dissatisfaction of physicians with current and evolving delivery models is so evident. I believe, and many others, including leaders within family medicine believe, that the direct patient care model is the best solution to the access problem in the long-term. The image of the family physician of the past, practicing personalized care to all members in multiple generations of families, will be further eroded in a model of care in which larger teams coordinate care "more efficiently" for larger panels of patients.  It is very difficult to practice truly patient-centered medicine in large teams, no matter how efficiently they function. So innovative delivery models like direct patient care need to quickly disrupt the healthcare system from the bottom up.  This can be done by demonstrating to employers, starting with the 50-200 employee companies and progressing to larger ones, that they can get significantly more value from their healthcare dollar by paying directly for their primary care.  Physicians will quickly realize that they can practice the type of medicine they always intended to practice when they spend the majority of their time directly in the care of their patients, and there will be a surge of medical students and residents interested in primary, direct care medicine.  Once there is a large enough “network” of direct care providers around the country that the largest of corporations in America can purchase care directly for their employees in all regions of the country, the direct care business model will no longer be a “movement” but the prevailing business model.
 

Clearly the movement towards smaller patient panels only benefits that small number of patients who are fortunate enough to receive care from the early adopters of DPC. The access to the system as a whole could be severely compromised in the short-term. There is only 1 rational conclusion to solving the access conundrum--solving the problem in the long-term without paralyzing the system in the short-term--and that is for primary care physicians and their peers with advanced nursing degrees to collaborate in meeting the primary health needs of ALL our citizens in unprecedented fashion.  The Federal Trade Commision recently issued a report that, in keeping with its mission, urged states to consider that scope of practice limitations may be detrimental to public safety, and anti-competitive in a way that prevents costs from declining.  The issue of public safety is key in this discussion because the purpose of professional licensure requirements and state scope of practice regulations are generally to protect the consumer. The Institute of Medicine, in its 2011 report on NP scope of practice, argued that easing limitations on scope of practice has no detrimental effect on consumer safety, and tighter limitations do not prevent harm.  When you consider the fact that NPs have been effectively caring for the primary health needs of the under-served in the country, it is hard to refute.  The FTC report also noted that requiring supervision of NPs by a physician inhibits the development of innovative delivery models that are so desperately needed to meet the rising demand for access. 

Many physicians experience fear and trepidation when the issue of NP scope of practice is even mentioned. More on this in a moment.  First, I am reminded of the climate in the late 1960s when Dr. Nicholas Pisacano established the American Board of Family Practice, a move which was controversial among his family practice colleagues.  The need for such stringent licensing requirements and certification, as well as examinations of competency every 7 years, was questioned. Dr. Pisacano moved forward and enacted these requirements against the popular opinion of his colleagues because it was "good for the health of the American people."  Today we are in a similar situation where the popular opinion of physicians must take the back seat to what is best for the health of the American people.  No one has more "skin in the game" than do our citizens.  But not to worry -- there is no reason whatsoever for providers of primary care services to fear competition in a direct patient care business model.  The fears of competition are rooted in the fee-for-service model in which the best negotiated rate for services is the primary focus. In the DPC model there is more turf than all the primary care providers in the world could hope to cultivate.  We are all on the same team and there will always be more patients than any of us could handle, especially when the new deal is for each of us to do a better job with fewer patients. 

So step back and view the access conundrum in the context of the DPC model.  All of us working together for a low, fixed monthly fee for our 600-800 patients (or 1200-1500 depending on personal preference) have no reason to do anything but collaborate. DPC physicians need to help NPs to adopt this business model for themselves.  Some NPs will be comfortable practicing on their own; others will still feel more comfortable collaborating directly with DPC physicians; but all should be free to practice within the scope of their training without unnecessary limitations on the scope of their practice.  Within each region of the country, DPC providers need to position themselves in clusters that can negotiate collaboratively with employers to provide direct care to their employees (as Qliance is doing effectively in Seattle, for example). Showing these businesses how well DPC providers meet quality measures with fewer ER visits, less missed days work, fewer high cost imaging studies, fewer referrals to subspecialists, fewer workman's compensation claims, and greater satisfaction for their employees, then the model will spread to larger companies. The health of the American people depends on it -- urgently. 

Finding the Joy in Medicine

I have decided to get off the treadmill of fee-for-service medicine. I didn't go to medical school to spend less than half of my time on the direct care of patients, and the greater portion of it on checking boxes and documenting why each visit is complex enough to warrant the reimbursement for which I submit. I am convinced that one of the greatest contributing factors to spiraling costs in our wealthcare system is that we pay for our primary health needs with insurance. The purpose of insurance is to insure against low probability, high cost events. We don't use insurance to pay for auto maintenance, utility bills, or groceries; if we did, that insurance would rapidly become unaffordable due to the overhead involved in processing claims and collecting payments. We would demand a change in the system and start paying for those things within our monthly budget.  So it should be with primary care medicine!  We should pay for our everyday healthcare needs with cash as a budgeted monthly expense. But the prevailing business models are not set up for this. Employers have resorted with greater frequency to the use of health care spending accounts, which is a great idea if the consumer has the ability to shop for the greatest value for their healthcare dollar.  But we don't know what services cost so we can't shop where the value is -- at least for now.

One of my favorite prayers, The Serenity Prayer, pleads:

God, grant me the serenity to accept the things I cannot change; The courage to change the things I can; And wisdom to know the difference. 

The one thing I can change is the business model under which I practice, and I choose a low-cost, transparent, direct payment model that can deliver on the promise of accessible, high-quality care.  It is truly the wise thing to do. It just makes so much sense that courage is optional. 

Some will say that this is a selfish move, but my mission is two-fold.  I want to (1) deliver on the "quadruple aim" of healthcare delivery reform (high-quality, low, transparent cost that is accessible) for my small panel of patients, while (2) promoting a hopeful model for the future that will spawn incredible interest in the pursuit of primary care medicine, which will do a superior job of fixing the access problem in the system by 2025 than will the prevailing model for reform. Merging practices into "integrated delivery networks (IDNs)" or "accountable care organizations (ACOs)" makes very good sense for the large systems that are creating them, and is a decent answer for the access problem in the short-term. If you give primary care docs 4-5000 patients to whom they deliver care, rather then the current base of 2-3000 patients, and put them in teams to make them more efficient, that model may work for providing care to the millions of people who will be entering the system. It does work for the healthcare systems themselves by aligning with the planned changes in reimbursement by 2015.  But increasing panel sizes will further erode the joy in practicing primary care medicine  and the workforce will likely suffer as fewer students choose medicine as a career.  And will it work for employers and patients?  Can that system really deliver on access?  Affordability?  Transparency? We will still have what healthcare strategist David Steinman calls the "I don't know and I don't care" problem -- consumers don't know what services actually cost and don't care because they are not directly paying for them.  So the ability of employers and individuals to lower their healthcare costs will likely be hindered, as well as the ability to access the care they need.  We are headed to a systemic problem of "coverage without access".  

My purpose in writing this is to stimulate interest in the direct patient care model among my fellow family medicine colleagues, medical students, family medicine residents, and all those with a stake in the successful reform of our healthcare system.  The status quo becomes less tolerable when a viable, attractive alternative exists.  I am not an innovator in DPC; many have practiced this way in clusters around the country since the 1990s.  I am merely an early adopter in this movement.  As our numbers increase around the country, and more employers realize the cost savings and improved quality that can simultaneously be achieved in a network with direct primary care at its base, the care delivery model in the healthcare system can be disrupted.  By chronicling my practice transformation I hope to show how the joy can be restored to the practice of medicine so that others will jump off the treadmill to join me.