Friday, October 7, 2016

My answer to direct primary care evangelists

One thing I’ve  learned is that physicians who have gone into direct primary care (DPC) practices are passionate about their decision: they not only believe that DPC is better for their patients and their own professional and career satisfaction; many  assert it is the answer to just about everything ailing primary care.  There is an evangelical fervor among some DPC advocates to spread the word and convert other primary care physicians to their cause.

It’s no surprise to me, then, that many of them have expressed frustration—to put it mildly—that ACP has decided not to endorse or promote DPCs. Instead, our 2015 position paper, for which I was the lead author on behalf of the College’s Medical Practice and Quality Committee, aims to provide a balanced and evidence-based assessment of the potential impact on patients of practices that have one or more of the following 3 features:

They charge monthly per patient retainer or subscription fees.

They do not participate in insurance contracts.

They have reduced their patient panel sizes well below the norm. 

The American Academy of Family Physicians says that “Generally, DPC physicians have a panel of between 600 and 800 patients. In typical FFS settings, the patient panels tend to range from between 2,000 and 2,500 per family physician.”

One of the challenges ACP found in assessing the impact of direct primary care is that it is only one variation of practices that charge retainer fees, do not participate in insurance, and/or have smaller patient panels.  For example, practices often described as “concierge” practices often charge much higher monthly per patient retainer fees than most DPCs say they charge.  (Many DPC proponents fiercely object to being labeled as concierge practices). 

Yet ACP found little in the literature that defines the accepted range of monthly fees charged by DPC compared to “concierge” practices—Medical Economics magazine says they typically range from $50 t0 $150 per month, citing AAFP.   A study in the Journal of the Board of Family Medicine (JBFM), which was published after ACP had completed the literature search for our paper, reported that “Practices that used the phrase DPC on average charged a lower fee than practices that used the term concierge to describe their model: $77.38 compared with $182.76, respectively. Of 116 practices with available price information, 28 (24%) charged a per-visit fee, and the average per visit charge among this group was $15.59 (range, $5 to $35). Thirty-six of these 116 practices charged a one-time initial enrollment fee, and the average enrollment fee among this group was $78.39 (range, $29 to $300).” 

The wide variations in the monthly fees charged begs the question:  at what point, does the monthly fees charged by DPC practices make them concierge? 

Our paper found examples of DPCs that provide low cost and accessible services to all types of patients, including Medicaid patients.  Yet we also observed that there is a potential that less well-off patients, who can’t afford to go without insurance or pay a monthly fee, might be disadvantaged.  Guided by our Committee on Ethics and Professionalism, we accordingly urged physicians who are considering DPC, concierge or other practice arrangements that have one or more of the features described above to consider steps, like waiving or lowering monthly fees for patients who can’t afford them, to mitigate any potential impact on undeserved patients.  Perhaps most importantly, we called for more research on the potential impacts of such models. 

This reasoned position, neither endorsing nor opposing DPCs,  instead calling for more research and consideration by physicians who enter into such practices of steps that could mitigate any adverse impact on poorer patients, has been misinterpreted by some DPC advocates as ACP being opposed to  DPCs.  This is not the case.  Our paper clearly states that physicians should have a choice of entering into practice arrangements that provide ethical and accessible care to their patients, which can include DPCs that meet the ethical considerations laid out in paper.

In a recent letter published in the Annals of Internal Medicine, I responded to a letter from Dr. Martin Donahoe that was highly critical of what he called “luxury care clinics,” especially in academic medicine.  I cautioned against painting too broad a brush in characterizing the motivations of physicians who charge monthly retainer fees and have downsized their patient panels:

“I have met many physicians who have gone into concierge and direct primary care practices precisely because they want to get back to doing what they love most, which is spending time with patients.  Many say that they charge low monthly fees so that they can be accessible to moderate- and low-income patients at less out-of-pocket cost to patients than many high-deductible insurance plans offer. I caution against painting with too broad a stroke in assessing the motivations of physicians in practices that charge retainer fees or limit the numbers of patients they see and about the effect that such features have on poorer patients. Rather, we need more unbiased research and evidence—while strongly reminding physicians, as we do in our paper, of their ethical obligations to provide care that is nondiscriminatory based on a patient's income, gender and gender identity, sexual orientation, race, or ethnicity, regardless of the type of practice—concierge or not.” 

I am heartened that Dr. Bob Centor, chair-emeriti of the ACP Board of Regents and a long-standing proponent of direct primary care, blogged that my Annals letter was “a very thoughtful rebuttal” to Dr. Donahoe’s broad condemnation, noting that “ACP has an excellent position paper on direct primary care,” referring to our 2015 paper.

Yet some DPC evangelists remain unsatisfied with the College’s position that we need more research on the impact of DPCs  on quality, access and cost, especially for underserved populations.  One DPC evangelist—a DPC physician himself, and one of the co-authors of the AJFM study cited above—called the analysis by ACP, our Medical Practice and Quality Committee and our Ethics, Professionalism and Human Rights Committee “ignorant”—even though his own ABFM study concluded that “Most DPC practices are young and small and thus lack sufficient quality and cost data to assess outcomes thus lack sufficient quality and cost data to assess outcomes.”  Calling one’s colleagues in another primary care field “ignorant” is a sure fire way to win people over!

Finally, it needs to be acknowledged that there is a significant crossover between DPC advocates and anti-Obamacare physicians.  Just do a Google search of “direct primary care as an alternative to Obamacare” and you’ll find dozens of commentary about why DPC is a “free market” alternative to the Affordable Care Act’s insurance regulations, alternative payment models, and other features.  ACP, which strongly supports the ACA’s benefit requirements, subsidies, and consumer protections, would have difficulty embracing a movement that many of its own advocates assert is intentionally designed to subvert the ACA.  DPC, on the other hand, could be a reasonable option that exists as already permitted by the ACA, as long as it doesn’t weaken the law’s consumer protections.

So this is how I see things.  It is fine for DPC advocates to promote the benefits of this model.  It is fine that many physicians are considering going into a DPC, motivated by their desire to  desire to spend more time with their patients, although I would encourage them to consider the steps recommended in our paper to mitigate any adverse impact on poorer patients.   It is fine—in fact, imperative—that there be more research on the impact of DPCs on quality, cost, and access.  However, the evangelical strain of the DCP movement that seeks to convert ACP, and everyone else, to endorsing the movement—you're either for or against them—is not going to result in the respectful, evidence-based dialogue that is needed. 


Today’s question: what is your opinion of Direct Primary Care?

10 comments :

happy internist said...

After almost 14 years in a traditional insurance-based internal medicine practice, I was burned out and exhausted. I had a panel of almost 2000 patients, about 45% Medicare. I loved my patients, but was I drowning in work - working longer hours each year and unable to keep up with the steadily rising regulatory burdens. I suffered, my family suffered, and increasingly I felt I was not giving my patients the attention and care they deserved. I watched two of my colleagues in our smallish mid-Atlantic town closed their practices this summer for similar reasons. Perhaps in contrast to some of my fellow DPCers, ideologically I support single-payer care. I even went to DC on the 50th anniversary of Medicare with other like-minded health professionals to rally and lobby our lawmakers. The only thing that has shaken my stance on this issue is my firsthand experience with the disaster that was Meaningful Use. Last week I opened my new practice - a direct primary care practice - and I feel sane again. I am not 'evangelical' about DPC, but it has saved my career, and probably my life. I absolutely agree that we need to match this practice model to the communities we serve. To that end, I continue to accept Medicaid (I do not ask those patients to pay a membership fee). I also have a financial hardship policy through which I enroll low income patients at steep discounts, and I have several patients whom I see for free. I think in addition to ongoing research looking at the outcomes of DPC practices as you suggest (I am participating in a Medicare study to that end), there are two important questions to ask: 1) How and why did we decide that a patient panel should be 2000-3000 patients? Is that realistic given the complexity of modern-day healthcare? Or is it based more on our dismal recruitment of doctors to primary care? And, 2) Why can't insurers, including Medicare, work to encompass DPC practices, perhaps setting and paying baseline membership fees, letting us deliver primary care and focusing more on the bigger picture of healthcare and delivery? Clearly, the over-regulatory stance of recent years is not working for primary care doctors or their patients. I think DPC has a lot to offer both patients and physicians and I am excited to see how it evolves.

Jay Larson MD said...

Once the American healthcare system became commercialized, the ethics train left the station, and that was a long time ago. You really have to look at why DPC's even became a reality. If the system was working the way it should, no one would leave it. The RVU system and penny pinching insurance companies have crushed primary care. PCP's are seeing way too many patients to provide good care. The "norm" is the problem. The key factor in providing good medical care is time. Because DPC's have smaller patient panels, they have the time to build relationships with their patients as well as do a more thorough history and physical. You don't need to do a "cost and quality" study to know that "outcomes" will be better. DPC's also allow the providers to take care of their own health. A burned out physician makes bad decisions, which harm patients.

Our primary responsibility as a physician is to our patients. It is not to a faceless population. That's society's and society leaders' responsibility. This tread towards "population management" and defining quality by how many colonoscopies a physician orders
draws physicians away from their first priority. Is a primary care provider ethically responsible to see everyone in society when there is a national shortage in primary care? Should the ACP even comment on how much a primary care provider charges for their services when it has mentioned multiple times that primary care is undervalued? In the big picture the fees DPC's charge is peanuts. $800 for a 5 minute skin biopsy? Give me a break.

The ACA did nothing to improve the US healthcare system. When the ACA became enacted, it only resulted in more money being dumped into a greedy dysfunctional system. Much like chum being dumped into a shark tank. The pharmaceutical companies jumped at the chance to improve their profit margin and drug costs just went up and up. Some people want single payer, thinking that it would solve all our woes. It is unlikely to change anything because those taking the biggest bite of the healthcare system would do everything possible to keep their piece of the pie the same or even bigger.

If we want a better healthcare system, money has to be taken out of the equation. Make every part of the system non-profit. That way CEO's responsibilities will no longer be to their share holders but to the patients they serve. Plus all their tax forms would be available to the public for scrutiny. Capping salaries (especially of CEO's) should also happen. Yes, I know that is a pie in the sky fantasy.

If primary care providers want to do DPC, all the power to them. Do what you must do to survive. I know of anesthesia groups that do not participate in any insurance companies, that way they can charge what ever they want to the patient. Who would be willing to undergo surgery without anesthesia? Where is the ethics in that?

Rob Lamberts said...

As an ACP member, a contributor to this blog, and a DPC doctor, here is my perspective on this.
1. While DPC is not clearly defined, the best distinction between DPC and 'Concierge' that I've found is that concierge medicine continues accepting/billing insurance in addition to their monthly fees, while DPC eschews all insurance money. Hence "direct care."
2. ACP's support of doctors moving to DPC has been, at best, minimal. I don't understand why it is not possible for the college to support multiple models embraced by their members, perhaps allowing them to better serve their patients in the model they have chosen. It seems as if ACP is fearful of endorsing DPC as a viable option (supporting meetings, hosting forums, etc) for some of their members. Why not see DCP as an R&D project that could possibly morph into the transformational and disruptive model that many of us believe it could be? I see DPC as a lifeboat from a sinking ship, as I am now able to give excellent care to my 800+ patients instead of giving ever-worsening care to the 2000+ in my old practice, yet ACP seems to want to study more the ethics of saving those 800 people? Research it! Yes! But that doesn't mean resources cannot be devoted to improving the model to maximize its outreach and quality.
3. The argument about ACA is straw man, as a vocal minority has labeled DPC as an ACA-bypass, while many of us are not against the legislation. Given the rising deductibles for most Americans, the idea of paying someone to "play defense" against unnecessary care/cost is more and more rational. Additionally, the rising cost of plans on the marketplace make a distressingly increasing number of people once again uninsured. DPC (in my practice) helps folks in financial need to get care they otherwise could not get. Please don't paint us all with one political brush.
4. With its emphasis on "Choosing Wisely," it would seem that ACP should embrace a model that does not benefit from over-testing and over-treating. Since changing to DPC, I have much more success avoiding antibiotics, removing unneeded (and potentially dangerous) medications, and re-educating my patients off of the "more care is better" approach encouraged by the fee-for-service model. I have found most DPC docs are far less prone to order "executive profiles" and label it "better care." I have been very impressed by the focus on education, which we never had time for in the FFS 30 patients/day model.
5. What do you think the reason is for the "evangelical" nature of DPC physicians? It is life-changing. It is life-changing for the physicians, who actually get to care for patients and not the payors. It is life-changing for our patients, who frequently say how much better our care is than anything they've ever gotten. I earn less than I did before, but I left a system that was forcing me to give up more and more of my patient time and devote it to data collection and documentation. I left a system that was leaving me empty at the end of each day. I left a system that made me choose between my patients and my business: either I gave good care and made less money, OR I checked my soul at the door and ran the business. My partners chose the latter. You seem to be annoyed at how excited we are about making this change, rather than have that enthusiasm remind you of just how broken medicine is right now and to make you (the ACP) aggressively look at alternatives to the doomed system we have been smitten by.

I don't think the ACP should take sides with DPC. I do think more research is needed. But I think the incredibly tepid, if not negative stance the college has taken is woefully short-sighted and seems to ignore the looming burn-out crisis.

Sorry for going so long. I guess I should write a post about this, but you got me going.

TriToy said...

I have a hybrid practice (a model you conveniently leave out) meaning I take Medicare/Medicaid and SOME commercial insurance, and enroll the remaining patients in DPC. It is an answer to the vast number of uninsured where I am (our governor elected NOT to expand Medicaid and in fact kicked many off 2 years ago). I will likely have the size practice I did in a traditional FFS setting. - One size does not fit all - so please, check the attitude.

Thanks

Cathleen London, MD

Dr. Ryan Neuhofel said...

Serious questions for you Dr. Doherty . . .

1) My local non-profit hospital bills $2300 for an MRI (radiologist fee billed separately). I know several independent radiology centers that bill $500-600 TOTAL (including radiologist fee) for an MRI. So, by your "too expensive" definition of "concierge", would you define my local non-profit hospital as concierge?

2) Do you suggest or demand that standard FFS insurance-based based practices lower their billed fees for lower income patients? Perhaps you or your organization has done so in the past, but I couldn't find such a statement from ACP.

3) What is a sufficiently large panel size to be in ethical good standing? You mention the "average" (not backed up by good studies, by the way) as 2000-2500, but I know some PCPs to claim panel sizes of 3000-4000. Do you think physician who accept insurance with a smaller panel size of 1500-ish -- the norm for "micro" practices -- are also not living up to their societal obligations?

Michel Accad said...

Dr Dougherty,

You mention that the "ACP...strongly supports the ACA’s benefit requirements, subsidies, and consumer protections."

Is there any evidence that the "benefit requirements, subsidies, and consumer protections" have had a positive benefit for all Americans? If not, why is ACP endorsing such measures?

Does the ACP deny that premiums and out-of-pocket costs have increased enormously under the ACA? If the ACP recognizes that increases in premiums have been large, does the ACP feel that the increase is justified by fact that more Americans are now insured thanks to the ACA? If so, does the ACP believe that it is OK for some Americans to benefit at the expense of other Americans?

Yours sincerely,

Michel Accad

Dr. G said...

Dr. Doherty,

Thank you for this perspective on progressing toward a balanced dialogue about direct primary care. I am what you would call one of the DPC evangelists. I am also a board certified family physician, a fellow of the AAFP and a very passionate family physician who has worked in the trenches for my entire career taking care of wealthy, poor, healthy and challenging.

Many DPC doctors have taken on tremendous personal and financial risk, left 'normal' jobs and risked leaving medicine all together out of our desperation for change and to be the physicians we set out to be. Perhaps that is why we come across so passionate or evangelical. I would contend- just as you ask for a dialogue of respect and call out being called 'ignorant', 'evangelical', in many contexts is also an accusatory (and not all that positive) type of name-calling.

So let us all get to a balanced dialogue. What is peculiar about our profession is that 'we eat our own'. We are unkind, overly-analytical, critical and un-supportive. In fact, we physicians are often down-right UNcollegial. This is particularly odd for a profession built on the esteem of our fore-physicians.

We can debate 500, 1000, 3000 patients. We can debate who's responsibility it is to take care of the uninsured, the difficult, the privileged. We can debate who 'carries more weight'. But NONE of this dialogue advances our profession. What does advance our profession are physicians staying in the trenches, taking care of patients, FIGHTING for accessible and affordable care and supporting each other in what is truly a very difficult time for everyone in healthcare.

Let's have that dialogue. DPC is a solution. A small solution. But a solution. I left a panel of 2500 patients who I could not care for properly for a panel of 600 who have access when they want it, medications at cost (to a savings of $100s/month for many) and I get to be the kind of doctor I set out to be. I did not set out to be rich. I set out to care for people across their life-span, through thick and thin in a sustainable way. We need more of that. And we need more physicians to know that they can do just what they set out to do. DPC or no DPC, the present 'path' doesn't work for many. So let's talk about what does work.

Harrison Robinson said...

Wait. How do they not charge insurance? Or Medicare? Do they simply leave that money on the table?
I get the math. If you decide on a panel of 1000, and you charge them each $100 per month, then that is $100,000 per month coming into the practice as cash. And even with overhead, that is a lot of money for one physician.
So I can get it that you might not need to charge anything additionally.

But if that is an enrollment fee, then the per visit charges are there for billing.

Are the patients uninsured?
They are fined for this under the ACA, are they not?

I am not interested in this for myself.
I'm happy with our practice model.
Which includes a lot of HMO, PPO, Medicare Advantage, and Medicare -- and no cash payment patients.

But I always thought that the enrollment fee was in addition to billing insurances.
And of course it would have to be either waived for capitated patients in HMO's or Medicare Advantage Plans, or those patients could not be part of the practice.

As far as the good vs bad debate -- I claim no moral high ground. I think we all take care of patients and we do it because we find it rewarding, and if we are interested in the business aspects, then we find our ways into the ownership of practices or into administrative positions. And that is needed too.



Harrison

B Doherty said...

Dr. Neuhofel,

1) My local non-profit hospital bills $2300 for an MRI (radiologist fee billed separately). I know several independent radiology centers that bill $500-600 TOTAL (including radiologist fee) for an MRI. So, by your "too expensive" definition of "concierge", would you define my local non-profit hospital as concierge?

Answer: Nowhere in ACP's paper, or in my blog post, do we define "concierge" as "too expensive" nor do we attempt to define what range of fees are affordable or not. (Affordability for any given patients is a function of the fee charged by the facility, a patient's insurance coverage, the patient's out-of-pocket cost after insurance payment, whether the facility has policies to discount or waive fees for poorer patients, etc). Some concierge, DPC, or cash-only practices may be quite affordable, others may not be; the same would be true of traditional FFS practices. We observe that the literature suggests that concierge and other practice arrangements that do not accept insurance, and/or charge retainer fees, have the potential of creating barriers to poorer patients who can't afford to pay the retainer or pay for services out-of-pocket at the time rendered, and that physicians in such practices should consider steps to mitigate any such impact, such as lowering or waiving the retainer fee or the requirement that payment be made at the time of service.

However, our concern about providing non-discriminatory and affordable care is not limited to concierge, DPC, or cash only practices. See this statement from our policy paper:

"The ethics policies of ACP, as embodied in the College's Ethics Manual, Sixth Edition (12), state that physicians have both individual and collective responsibilities to care for all. Such ethical considerations must guide physicians in considering the types of practices they choose to participate in and what they must do to ensure their practices provide accessible care to patients in a nondiscriminatory manner."

The above would be true whether you are in a concierge, DPC, cash-only, traditional FFS, or academic practice.

2) Do you suggest or demand that standard FFS insurance-based based practices lower their billed fees for lower income patients? Perhaps you or your organization has done so in the past, but I couldn't find such a statement from ACP.

Answer: ACP has extensive policy on reforming FFS, including independent review of RVUs that are overpriced/overvalued; increasing RVUs for evaluation and management (cognitive services) while lowering payments for overvalued procedures; eliminating hospital "facility-fee" charges, bringing down excessive prices charged for prescription drugs, and transitioning away from FFS to value-based payment models, including risk-adjusted primary care capitation, blended payments, and patient-centered medical homes supported by prospective per beneficiary per month payments (risk-adjusted) plus FFS (hybrid FFS+Capitation). No matter what payment model you are in, we remind physicians of their responsibility to provide accessible and affordable care to all patients, especially poorer patients. See statement from our paper (above) on physicians' ethical responsibilities "to ensure their practices provide accessible care to patients in a nondiscriminatory manner"--this guidance applies to FFS practices, as well those in concierge, or direct primary care.

B Doherty said...

3) What is a sufficiently large panel size to be in ethical good standing? You mention the "average" (not backed up by good studies, by the way) as 2000-2500, but I know some PCPs to claim panel sizes of 3000-4000. Do you think physician who accept insurance with a smaller panel size of 1500-ish -- the norm for "micro" practices -- are also not living up to their societal obligations?

Answer: Our paper in no way says that physicians have an ethical obligation to see a certain fixed number of patients, whether in traditional FFS practices, DPC, concierge, or any other type of practice. Rather, we recommend that when a physician "downsizes" his or her patient panel for any reason (not limited to concierge or DPC; physicians in traditional practices may choose to begin seeing fewer patients for any number reasons), there needs to consideration of what the impact will be on patients that no longer will have access to the practice and would have to get care elsewhere, the impact on the large community, and especially, the impact on access for poorer patients. (Does the downsizing, for instance, when combined in other changes in the practice, result in poorer patients being disproportionately being the ones who are left behind?, even if they would prefer to remain in the practice?) Downsizing also creates legal and ethical issues associated with patient abandonment that physicians need to be aware of. Here is the relevant statement from our policy paper:

"Physicians in practices that choose to downsize their patient panel for any reason should consider the effect these changes have on the local community, including patients' access to care from other sources in the community, and help patients who do not stay in the practice find other physicians."

In sum, ACP’s policies recommend ways that physicians can honor their obligation to “provide accessible care to patients in a nondiscriminatory manner”—in all models of practice—as well as reforms to FFS to ensure that the prices charged are reasonable and affordable and aligned with value to the patient.