By Todd Hixon, Contributor
APRIL 4, 2014 – Many proposals for improving cost/effectiveness of U.S. medicine are contending for resources and attention. These proposals span personalized medicine, big-data technology to find patterns and coordinate care, tightly-managed accountable healthcare systems, and marketplace incentives. Listening to a panel prepare for a conference this week brought that home to me: each panelist has a different view, often based on his/her skills and role in the system. I don’t doubt that each approach holds promise. However, they tend to be complex and sophisticated, and they will need many years to develop. For example, connecting most patient and provider information to the cloud and finding ways to manage and analyze it there, with appropriate privacy and security, is a huge project. If healthcare.gov was a moon-shot, this will be colonization of Mars.
A simple and low-tech change to U.S. healthcare holds great promise and offers a fast pay-back. It’s re-investment in primary care coupled with giving primary care providers the right role in the healthcare system and incentives.
The logic is easy to follow. It’s built on three principles:
- Primary care providers can help people avoid illness and identify problems earlier, particularly if they can truly get to know their patients and build a relationship of trust. All that is required is making the provider accessible, spending more time with the patient, and providing resources to ensure that patients are following through on behaviors, meds, and treatments. Providers will tell you that it is difficult/impossible to build trust, get patients to be honest, and change behavior during a ten-minute visit (e.g.).
- Primary care providers can treat at least 80% of medical conditions in a venue that is fundamentally lower-cost and less stressful for patients than advanced-care venues. Today’s primary care business model loads each provider with about 2,500 patients which means visits last 10-12 minutes. The provider is forced to refer anything complex to a specialist doctor, resulting in a second appointment that costs more. If primary care doctors had more time for more complex problems, they could solve many of them, saving both money and suffering. This link provides a poignant example.
- Primary care doctors can help patients manage the rest of the medical system: decide what treatment they need, choose the best providers, avoid overpaying, and recover after acute care. This works best if they are financially independent from advanced care providers [which is the opposite of the current trend towards hospital systems owning primary care practices].
Several start-up companies and many primary care practices are pushing in this direction. The movement is called “Direct Primary Care (DPC).” These providers employ a different business model, which enables a much better care model:
- Direct Primary Care (DPC) providers receive a fixed monthly fee paid by the patient and/or the health plan; many DPC practices do not bill insurance at all. This is not expensive: about $60 per month for most patients (and $100 for the least healthy) enables the provider to earn a competitive salary. Eliminating the overhead created by insurance billing and high patient volume, which typically eats up 30%-40% of revenue, helps greatly.
- Reducing the panel size from about 2,500 to around 1,200 results in twice as much time per patient. Hence, DPC providers can understand patients better and manage more complex problems.
- DPC practices make themselves much more accessible to patients. They typically offer Saturday hours, 24×7 phone access, and appointments within 24 hours. Easy access is a powerful tool to surface health problems early and head-off ER visits, many of which occur only because the primary care provider is not available.
- Because DPC providers are paid for care, not for procedures, they can use phone consults, email, video, and other technology much more extensively. This enables more contacts with patients and faster response. Today many providers resist phone and email consults with patients partly because insurance reimbursement for these encounters is much less than for an office visit, and often $0.
It just makes sense that more intensive primary care will improve health, reduce downstream healthcare costs, and improve patient experience. Data coming forth from diverse sources shows that it works. WeCare Clinics, Iora Health, Qliance Medical Management, MDVIP, and OneMedical have all reported reductions in total healthcare costs for their patients of 15% or more versus population norms*. Most of these programs are only a few years old; there is reason to expect that results will improve as their providers have a chance to deepen patient relationships and see the cumulative benefit of preventive work that they have done in the past.
There are a couple of knocks on direct primary care. Some equate it to “concierge medicine”, which is a high-priced service for the affluent. The idea did start with affluent customers, as many new products do, but it has become thoroughly mainstream: leading DPC providers now serve unions and Medicaid patients as well as large corporations with a broad spectrum of employees. The health and cost benefits tend to be greatest with down-scale patient groups because many of these people are chronically ill and have never had a real primary care relationship.
The other knock comes from a policy perspective: how can you reduce panel sizes when there is a shortage of primary care doctors and it takes ten years to train new doctors? DPC practices are increasing primary care capacity by hiring nurse-practitioners and physician assistants to work along MDs and by using technology to leverage provider time: e.g., a five-minute call or email can often substitute for a 20 minute office visit. Today there are about 280,000 MDs in the U.S. and about 80,000 NPs and PAs working in primary care; moving that ratio to 1:1 is a dramatic expansion of primary care capacity**.
Moreover, a major cause of the primary care doctor shortage is the low pay and status that primary care MDs have been afforded by the U.S. medical establishment. They earn about half what the average MD earns and often burn out from the 25-patients-per-day treadmill; it’s no surprise that the percent of medical school graduates choosing primary care has dropped from ~50% in the 1990s to less than 20% recently. Letting this happen was a huge policy error. Improving pay, status, and working conditions for primary care MDs is fundamental to a long term solution to the supply/demand problem.
Sometime the best answer is the simplest: go back to the basics, in this case primary care, and do it right.
MDVIP and OneMedical can be considered “concierge medicine” practices (see discussion in following paragraph), but their care model is similar to Direct Primary Care, and hence their results are meaningful.