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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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.
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