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Monday, April 21, 2014

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. 

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