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Monday, August 24, 2015

The impending revolution

This weekend I attended (and spoke at) the Concierge Medicine Assembly in Atlanta. My role was to give the perspective of a “successful” direct primary care (DPC) practice. This being the second such conference in 3 weeks, I've learned that my panel of 600+ patients and survival for 2.5 years puts me in the higher ranks of solo DPC practices. The Atlanta conference was actually a combination conference, catering to both the more recent “direct care” style of practices like mine, and the more traditional “concierge” practices, with their higher fees and smaller panels, both grouped together under the blanket term of “membership medicine.”

Technically, the difference between DPC and “concierge” care is not the cost or panel size, but the fact that DPC practices do not accept insurance for payment, while the concierge practices have a membership fee on top of what they can bill to third-party payors. But in my eyes the main difference is the overall movements each of the practice types represent as defined by their patient demographics, and panel sizes. Concierge practices, in general, are focused on giving high-quality care by limiting panel size and giving significantly increased access to their members. In essence, they see fee-for-service medicine as something which gives inadequate care to a large number of people (which it does), and so choose to reduce panel size and give adequate care to a few.

While I see nothing wrong with this approach in the smaller picture, it clearly has limitations when generalized to the larger healthcare system. Doctors in this type of practice choose to not address the greater impact their practice model would have on healthcare. I don't criticize this approach, as it is probably more honorable than the current fee-for-service system which encourages doctors to wantonly spend money in a way that the system cannot bear and to short-change patients by giving them substandard care. But it was this limitation (along with the fact that most people can't afford to be members) that will keep the impact of this type of practice relatively small. It is also the reason I chose the alternative type of “membership” practice: DPC.

DPC is the new kid on the block, and has more energy in its camp. When meeting with other DPC docs, it almost feels like I'm part of the covert meetings of the Sons of Liberty before the revolutionary war; it feels like we are doing something that is raises a fist to the status-quo in a way that improves the lives of Americans. DPC relies on the simplicity of the care model to give enough efficiency to keep overhead low, cost to patients down, and to allow for larger patient panels. Right now I have 600 patients and am able to easily give care with only 2 medical assistants. While this is still a far cry from the thousands of patients on my panel in my old practice, it is significantly larger than most concierge practices.

I am often asked what is my ultimate goal for patient panel size. That's a tough question and I usually obfuscate by saying that I want to have the largest panel possible in which I can continue to give high quality care. I know that's a cop-out answer, but when we started the practice in February of 2013 we had very little idea what my practice would look like, and so just made things up as we went along. So I'd be lying if claimed to know where exactly we are going at this point. Why start pretending I know where we are going now, when following the course set by the needs of our patients and available technology has led me to this position of relative success?

My idealistic ultimate goal, as is the case with many in the “DPC movement” is to make my practice large enough to be a viable alternative for other primary care doctors to adopt without causing the system to implode through a dramatic reduction in panel size (and hence PCP availability). If I can grow to 1,200, 1,500, or even 2,000 patients and still give excellent care, the game would indeed change.

The limitation of patient panel size is what relegates membership medicine practices to being a niche practice model instead of becoming the game-changing disruptive force many of us believe it can become. So how can practices like mine improve efficiency enough without falling prey to the forces that drove fee-for-service practices to severely limit access and ultimately to give expensive and substandard care? In other words, how can I grow my practice size without either limiting patient access to me (which is my main differentiating product) or decreasing care quality? I see 2 ways to approach this problem: diversifying my staff and improving my use of technology.

The idea of growing my staff doesn't refer to simply adding front desk and nursing staff (although that will certainly happen); it focuses on specialization within the practice to meet various needs of my patients. A dietician, for example, could handle the problems my patients face due to poor nutrition or lack of knowledge in that area (and do so far better than me). Similarly, a trainer or exercise specialist could come up with ways to improve their physical fitness, a pharmacist could maximize the effectiveness and minimize the cost of medications, and a counselor could help people deal with the emotional aspects (both cause and effect) of my patients' lives.

This is what I have previously referred to this type of growth as the “organic medical home”, which would meet the needs of my patients through offering holistic care that was shaped around their actual needs (as opposed to a government-designed program telling us what we need to offer). The downside to this approach is that it requires a larger staff, increasing my cost and moving away from the simplicity of my current practice. But such growth will definitely be necessary for the DPC model to move from niche to mainstream.

The second key to growth is technology (which should come as a shock to no one who knows me). When I started using electronic records in 1996, there was a feeling of excitement and revolution among the early adopters as there is now in the DPC movement. We really felt that technology, which had dramatically streamlined many industries (destroying immovable monoliths in the process), would improve the quality and efficiency of care.

Unfortunately, instead of increasing efficiency, technology allowed for increased inefficiency by allowing massive over-documentation and codification that would never have been possible in a paper universe. The third-party payor system was the reason EMR's turned out to be a wolf in sheep's clothing. Commercial and government payors controlled the money, and so demanded more and more control of care. They are, after all, the true customers in fee-for-service medicine. So electronic records, instead of improving the quality of care, became a tool to wrest control from healthcare providers and put it in the hands of insurance companies and government regulators. The result is what we have now: care that is not patient-centered and of lower quality, and medical records that focus on billing rather than clinical issues.

But these forces are not at work in membership medicine practices, where the patients are actually the customers. So the technology that develops alongside practices like mine will only be accepted if they improve care quality or access. I saw the consequence of this at both meetings, as I saw the various technology solutions sponsoring the meetings, including:
• EMR's that focused on patient care rather than coding and billing
• Simplified billing systems that allow practices to manage large numbers of subscriptions efficiently
• Care management tools which increase between-visit contact with patients and significantly improved outcomes (one of them advertised that they could “cut office visits by 2/3 - a claim that would result in decreased revenue for fee-for-service practices)
• Communication tools that increased simplified and improved patient contact with care
• Educational tools which give physicians the ability to give only the care patients need.

As these technologies grow, the size and number of membership practices will increase. This will, in turn, increase the number of businesses interested in creating technology for those practices, making adoption of this practice model much less risky. This has clearly happened in the 2+ years I've been in this practice, and only seems to be accelerating. The next conference I will be attending (and speaking at) will actually be a technology-centered “hack-a-thon” with a healthcare track. Pair a disruptive business idea with a bunch of geeks with a chance to solve one of our biggest problems and there is a real chance of getting amazing results. I am really excited to be a part of it.

Like my practice, membership medicine is still in its early phases. Like my practice, the future of membership medicine depends on a lot of things beyond our control. But the excitement I hear regularly from physicians, residents, medical students, patients, business owners, and even politicians about its potential is quite remarkable. Both of these conferences were full of something that I once thought no longer existed: doctors who were excited about medicine and cautiously optimistic about the future.

Don't tread on me, CMS and Blue Cross. Give me liberty from “meaningful use” or give me death!

Load your muskets. The revolution has started.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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