Family Medicine / Direct Primary Care / Walk-Ins

The sometimes incoherent
ramblings and rants of an
ordinary family doctor...
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The well-dressed VIPs slowly walked into the dimly lit upscale restaurant's conference room for meeting over a rich meal at the invitation of a consultant and his three colleagues.  The topic of discussion was a revolutionary new approach to delivering primary care, one that had shown considerable cost savings for a self-insured employer. The VIPs were important hospital administrators, people with considerable clout and control over the finances and decisions of a large community health system.  

The busy hospital administrator

The consultant began by passing out binders with confidential information including data, graphs, and charts explaining how a seemingly insignificant movement known as direct primary care could have such a dramatic effect on reducing costs upstream for a large employer. He explained that he discovered this new approach quite by accident, observing that anywhere a direct primary care practice was available, the costs of the employer's health plan dropped by 18% or even more.  It seemed that DPC doctors' habit of spending significantly more time with patients (on the average 30 minutes vs 8 minutes), providing better access, and building a strong trusting doctor-patient relationship perfectly balanced the healthcare quality/cost equation. After briefly presenting these amazing facts, the consultant introduced a new direct primary care doctor who had only been practicing DPC a couple of months. One of the hospital administrators asked the physician how many patients he was seeing a day, to which he replied, "About 8 or so."  With that revelation, the tone of the meeting changed abruptly. All but one of the hospital administrators completely disengaged from the conversation. The others started laughing and giggling, talking about personal matters and recreation, sharing pictures on their phones, all while the consultant attempted to share the profound evidence that could potentially have saved them millions of dollars a year in excess healthcare expenditures. Alas, the critical information fell on deaf ears. The VIPs scarfed down their meals and after finishing, one by one departed from the meeting failing to appreciate the hidden treasure that was placed right under their noses.  In the end after they had all left, the consultant's colleagues sat there in shock and amazement at what had just happened. But the consultant was by no means deterred. In fact, he acknowledged that their behavior was more the norm rather than the exception. He noted that highly paid hospital administrators, well atop the pyramid and food chain of their respective organizations, rarely grasped what he was trying to show them. They are typically more risk-averse and rarely depart from the formula that they have always used for prior success, he confided to them. As a rule (although there is the occasional rare exception), they typically dismiss his approach despite the mountain of evidence supporting it because it just doesn't fit their paradigm.

Currently, direct primary care is a tiny niche of the healthcare landscape.  It has been overwhelmingly lauded by early adopters who marvel how this approach brings back the good old days of the Norman Rockwell-portrayed general practitioner who knew and loved his patients.  But it's not only just for concierge practices. DPC has demonstrated significant cost savings for government, insurance companies, and self-insured employers. In a world of hospital readmission penalties and expensive emergency department care for patients who would get the best care in a family doctor's office, you would think that hospital administrators would be tripping over themselves to develop and expand their own network of direct primary care physicians.  They have the resources at their disposal to make that happen. Unfortunately, it hasn't.

For now despite all of its advantages, direct primary care will remain a slow-growing, tiny fraction of the total primary care market.  But why? First, large health systems don't see the value of investing in an approach that provides little in the way of downstream revenue.  Downstream revenue is the amount of money generated by primary care physician volume and referrals, including those for radiology studies and procedures performed by specialists. According to a 2016 Merritt-Hawkins report, family physicians generate 7.5 times their salary in downstream revenue, the highest of all medical specialties.  In the financial world of hospital administrators, that is where the money is made... or at least that's where the money WAS made (past-tense emphasized).

Employers, who foot the lion's share of healthcare costs besides the government, are realizing that they cannot absorb continued exponential growth in their premiums.  Our consultant was attempting to show the VIPs that although DPC may appear to be small change in terms of downstream revenue, it could actually generate dramatic savings that become exponentially amplified upstream.  In a new market paradigm that rewards healthcare systems for improving quality while simultaneously lowering costs, a DPC doctor could potentially be worth his weight in gold. Unfortunately, it is hard to teach an old dog new tricks.  As one of the administrators summed it up best, "There's just nothing in it for us."

The best ally for expanding direct primary care right now to a larger audience would be a healthcare system.  However, because so few have the long-term outlook and foresight to support DPC, who else will step in to expand the movement?  

Here the crickets chirping?

 

Basically, we are left with primary care physicians themselves to eschew the safety net and apparent convenience of employment to start their own direct primary care practices, basically reversing the trend over the past 20 years of physicians seeking employment as opposed to entrepreneurship.  And why not expect the trend to reverse? After all, physicians are burning out in record numbers in the traditional, volume-focused systems that place primary care physicians and their patients on a conveyor belt in order to maximize referrals, imaging studies, and downstream procedures.

Burned out physician

Not only are they burning out, more and more are choosing to kill themselves. A little known fact is that male physicians are 1.41 times more likely to commit suicide than the general male population.  And among female physicians, the risk is even higher: 2.27 times greater than the general female population! Physician, heal thyself! How can we physicians promote good health in the community when we are so unhealthy and unbalanced ourselves? With these statistics, you would think that direct primary care, which brings back the joy of practicing medicine all over again, would be growing by leaps and bounds. But it isn't, and it won't for this simple fact. Doctors are coming out of training with a quarter million or more debt, and they are required to start paying off this debt immediately upon finishing their training.  Direct primary care pays off in the long run, but initially, it is lean and slow going until the practice builds. But that can take up to 2 years or so and these doctors simply are not afforded that luxury. Even worse, banks are not loaning to doctors like they used to in this difficult economic climate, so in some cases, primary care physicians may find it very difficult or even impossible to secure the necessary funding to start a clinic.  Finally, even the government makes it more difficult. To see Medicare patients in a direct primary care practice, a doctor must "opt-out" of Medicare, which is a minimum two-year commitment. You see, it is nearly impossible to achieve the goals of DPC while attempting to comply with all of the burdens of Medicare's bureaucracy and countless regulations. But once a doctor opts out, he or she may find it nearly impossible to moonlight part-time in hospitals or emergency departments to supplement their income while their DPC practice grows.  

My point is this:  Don't be looking for a DPC practice on every street corner anytime soon in the near future.  The deck is stacked squarely against this movement. Its meager growth will continue to be from physicians such as myself who have experienced the horrors of the current system first-hand and have made it our life’s mission to fight healthcare’s current downward spiral into the abyss.  I have been fortunate that I could self-fund my clinic but I am realistic about the future growth of this movement. Without a major partner to provide the capital, the structure, and the division of labor to establish a wider footprint for direct primary care in the community, I'm afraid we will only witness tepid growth for the foreseeable future.  It will take a major shock to the healthcare market that rocks the status quo before we will see positive, lasting change. Until then, embrace that DPC clinic that just opened in your neighborhood. It's an opportunity that may not present itself again for a long time.  By the time you realize the tremendous value of DPC and muster up the courage to act, that clinic may be completely full...with no new clinics forthcoming.  

Face Value Health DPC is located in Ridgeland, Mississippi and is accepting new patients right now.  Come experience a different, better approach to primary care.

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