Everyday, we hear about significant changes that may be coming to the Affordable Care Act (ACA). There’s a ferocious debate going on over what should be done. Unfortunately, and as far as I’m concerned, far too much of the discussion focuses on insurance access rather than on how we reduce overall cost.
Healthcare is a $3.4 trillion system, one-third of which (according to many researchers) may be wasteful, not adding value and even causing harm. To me, that’s where the greatest opportunity for improvement lies.
As consumers, a complaint for many of us as we access care is that administrative barriers get in our way. Often, systems are set up to meet the needs of the provider, not the patient. Ironically, I hear the same complaints from primary care physicians themselves, one of whom described the system she works in as, “an environment where I lose a piece of my soul every day.”
In practice, the long-term relationship that must be cultivated and nurtured for a physician to influence a patient to make the changes necessary to impact his/her health, is one that is impossible to foster in today’s transactional-based environment. Instead it requires a culture of “relationship building.”
Fortunately, many physicians are taking it on themselves to move in this direction. A recent Wall Street Journal article titled, With Direct Primary Care, It’s Just Doctor and Patient, describes how some physicians are attempting to do things differently, not only with care delivery but with alternative payment models.
Direct Primary Care Model
Direct Primary Care is one in which a direct relationship exists between the physician and the patient. It bypasses insurance by charging the patient a monthly membership fee. This fee covers things like office visits and some basic laboratory tests and ranges in price from $25 to $85 per month.
A Direct Primary Care arrangement with a practice does not eliminate the need for insurance to cover more costly items, such as diagnostic testing, outpatient procedures and hospitalization. But it may be attractive to people who find themselves in low premium, high deductible health insurance plans in which they must pay the first $5,000 – $10,000 of health care costs before the plan kicks in.
Some of these practices are small and independent and appeal to individual patients, while others are multi-state networks that work with large employers, insurers or unions offering unlimited primary care as part of an employee benefit package. Still others are focused on the Medicare Advantage Plan market and/or insurance for those using Medicaid products.
A major advantage of the Direct Primary Care approaches is that the culture of the practice is different – it is less focused on individual transactions (for which a provider will be paid) and more on what it takes for that provider to influence a patient to make the necessary changes in lifestyle to achieve good health and/or manage chronic disease. Overall, the atmosphere is “relationship based” – more compassionate and less hurried.
These models are often team-based and involve multiple means of communication beyond the in-person visit. Technology is leveraged so that email, texting, video conferencing and group visits are all incorporated into a patient’s experience, thus ensuring that the most appropriate professional, trained at the most appropriate level, is interacting with patients as needed. These teams are led by physicians, and also include nurses, social workers, physical therapists, health coaches, exercise trainers, etc.
Overall, Direct Primary Care practices are considerably less hierarchical than traditional environments. Here, all opinions about healthcare management – including those of the patient – are valued and incorporated into a plan of care.
The success of these practices has been demonstrated in improved patient satisfaction, physician satisfaction, medical outcomes and, lastly, decreased overall cost. And yes, in case you are wondering, I am a fan!
While Direct Primary Care Practices often attract lower socioeconomic populations, concierge practices tend to attract more affluent folks (monthly fees range between $100.00 and $250.00).
In concierge practices, physicians limit their patient case load from the usual number of 2,500 – 3,000 patients down to less than 1,000. They also offer visits that are 60-90 minutes long rather than the more typical 20-minute encounter with a traditional practice.
As with Direct Primary Care, participation in these concierge practices also does not eliminate the need for insurance for costlier items, such as hospitalization, etc. However, the fee may include additional services such as the development of a personalized wellness plan and some advanced testing.
Personally, and based on the experience of some of my clients, I’m not sure the higher fees of concierge practices are justified.
What really matters in choosing a practice
We have clients who participate in all manner of practices, including the ones described above, Patient Centered Medical Homes and, of course, more typical primary care practices. Overall, it’s not the structure that determines whether or not patients have a satisfying experience. Rather, it comes down to the following three factors:
- Ease of access. Every healthcare consumer wants the ability to interact with his/her physician and/or an appropriate healthcare professional when needed. At one time, this was the major advantage of concierge practices. Today, however, and again thanks in no small part to available technology, I’m happy to say that it doesn’t require an additional monthly fee for this to be achieved. The culture and commitment of a given practice in making this a reality is what matters.
- Coordination of Care. With older adults in particular, coordination of care becomes much more important. One of my patients, an elderly gentleman who at the time was paying nearly $25,000 a year for a concierge practice, needed this as he approached the end of his life. At this point, his physician was totally uninvolved in his care. Instead, and as a result of frequent hospitalizations and the need to transition to a long-term care facility, what his family needed most was assistance with coordination of care across a number of dimensions.
- Relationship. This may be the most important factor of all. At the heart of things, what we all want is a positive and collaborative relationship with someone we trust, whether that’s our primary care physician, a specialist, or any other healthcare professional with whom we come in contact. And while that should certainty be the foundation for a profession focused on healing people, our current volume-based transactional system often undermines the process.
Alternative delivery models emerge because of multiple factors, including frustrated patients and physicians, as well as (more recently) a desire to provide quality care more efficiently and at less cost. I fully support the innovation that is going on today and applaud those who know things need to change and who are willing to stand up and take action.
And remember, whether you participate in one of these newer models or not, focusing on your relationship with your physician will always hold the key to success.