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Improving Patient Care: Back to Basics

By Heather Hogstrom

Direct primary care, or concierge medicine, provides a higher quality of care while controlling the costs of tests and treatment.

Insurance companies can make it difficult for physicians to provide quality care by denying medications and treatments because of cost, for example, rather than covering the cost of treatment that’s in the patient’s best interest. To avoid such frustrations, some physicians are choosing not to accept insurance and instead provide fee-for-service practices called direct primary care, or concierge medicine, which enables physicians to practice patient-centered medicine.

Physicians who engage in similar practices deliberately limit their patient load to provide timely, high-quality care. While some primary care physicians in traditional practices may be required to see as many as 40 to 60 patients per day followed by several more hours of documentation, the direct primary care model allows physicians to work more efficiently, improving their work/life balance.

Cost Considerations
Rather than relying on insurance to reimburse treatment costs, physicians practicing direct primary care charge patients a monthly membership fee, which is determined differently among practices. For example, the membership fee could be based on rates that increase according to patient age range or could be based on the number of family members, with an additional fee for elderly patients. However, physicians recommend that patients carry some type of insurance to cover hospitalization, referral to a specialist, or labs and prescriptions not provided by the physician’s office.

Atlas MD, a concierge family practice in Wichita, Kansas, works with several local specialists who work with insurance and offer cash discounts to patients without insurance. “One of the things we have been able to do is custom-tailor insurance to the needs of the patient, and sometimes that includes specialist visits built right into their policy,” says Doug Nunamaker, MD, chief medical officer at Atlas MD.

When a patient has insurance and needs to use it, a discussion may be required to help the insurance company personnel and other entities understand what the direct primary care practice is doing regarding patient care and why it’s beneficial. It can be a struggle to get insurance companies on board with the concept, and Nunamaker says one of the few disadvantages of direct primary care is trying to help people understand that “this is one of the things that needs to happen to help save the [health care] system.”

The direct primary care model enables physicians to make decisions based on what’s best for the patient and then discuss the costs associated with testing and treatment rather than simply passing along costs to insurance companies. Nunamaker says having a practical discussion of cost vs. benefit with a patient can impact overall health care costs. When patients are paying out of pocket, they may opt for a less expensive therapy. “If insurance is paying for it, then you want the brand name medicine, but when you’re paying for it, more often than not, you’ll get the generic from us,” he says. Few people will pay more for a medicine that’s essentially equivalent to the brand, so the patients make choices based on cost vs. benefit.

The direct fee-for-service allows Atlas MD to offer wholesale prices on lab tests, imaging, and medication, and their patients appreciate the opportunity to access medications from the in-house pharmacy. “I can utilize the free market to find inexpensive medicines, lab work, imaging, procedures, etc,” Nunamaker says. “I can tell the patient what things will cost without having to wait to see if something is preapproved or find out months later that it was denied, leaving the patient to foot a large bill.”

Two-Way Street
The direct primary care model can be financially beneficial for both patients and physicians. Nunamaker says his income under this model surpasses what he would earn if working with insurance reimbursement. “I can base my income on the number of patients that are enrolled with me and not have to worry about keeping my clinic full by double-booking patients every 10 to15 minutes. I see fewer patients per day and I’m much happier,” he says. In turn, patients are healthier and typically save a lot of money in the process. In fact, he says, “Some patients actually make money ... after we offer savings on medications, labs, and insurance.”

He continues: “Basically, if we can offer [patients] more in savings on medications and labs than they are already paying, including our membership fee, then they are essentially making money by being a member. For example, we had a mother who was paying $90 per month for each of her two daughters for a medicine for their migraines. We get that same medicine for $6. So the mother and the two daughters signed up [for direct primary care] for a total of $70. The medicine added another $12. She was paying $180 for just the medicine, and now she is paying $82 for the medicine and a month of 24/7 access to her own physician. She gets to keep $98 of what she was spending; her daughters have the exact same medicine; and they can get all the care they want/need. She essentially makes $98 by being a member.”  

Atlas MD has received calls from patients who were pleasantly surprised to learn that products and services they thought the practice had forgotten to charge them for simply are not as expensive as they thought. “It’s rewarding to get calls like that because it shows that you really are making a difference in people’s lives,” Nunamaker says.

Patients find the appeal in many other aspects of direct primary care as well. At Atlas MD, patients can call, text, or e-mail their physicians and have access at all hours, even during weekends or after regular business hours. Patients also appreciate the ability to schedule an appointment on the same day or even in the same hour they call since the limited number of patients means prompt care usually is available. Patients generally can be seen without waiting and can expect visits that allow ample time to address multiple concerns without feeling rushed. Some direct primary care practices also offer home visits, sometimes without an additional charge.

What’s the Catch?
This many positive aspects of patient participation may sound too good to be true, creating one of the challenges Atlas MD encountered in setting up its practice. “One of the first things that we hear from people in our meetings is that it’s too good to be true or that there’s a catch,” Nunamaker says. “We spent over a decade of market research on concierge medicine and insurance-free practices to see what worked and what didn’t.” Atlas MD physicians took advantage of lessons learned from others’ unsuccessful practices and unfortunate mistakes and then pioneered a model addressing myriad issues they had observed as potential stumbling blocks.

“The main challenge that we faced was having to try to dispel the myth that [direct primary care] is unaffordable or just for the wealthy,” he says. “If you target the 1%, then you can only hope to get 1% of the market. This isn’t nearly as ideal as trying to be affordable to the masses. Once we get over that hurdle, then trying to find other valuable solutions via the free market becomes important.

“Talking with national labs about getting discounts or finding prescription medications at fairly radical discounts came next,” he explains. After carefully assembling all the elements, Atlas MD could demonstrate that direct primary care really is different and comes without catches or strings attached. “Advertising was also a bit of an issue because it didn’t seem to matter how we did it [print, radio, etc]; many people couldn’t get past the nagging thought that there was a catch,” Nunamaker says. The practice received support from a local radio morning show host who believed in the model and whose listeners called to find out more about how direct primary care operates.

Once the practice gathers patients’ attention, Nunamaker says it’s fairly simple to attract patients by showing them the value of the model for them personally. His practice has used social media to help attract new patients, and current patients show their support on their own Twitter or Facebook accounts. Word of mouth is the greatest asset, and Atlas MD personnel spread the word by remaining active in the community and speaking at various meetings and events.

Final Thoughts
Many similar practices are being launched around the country, providing care that is convenient and meaningful for both patients and physicians. “The main advantage to direct primary care is allowing the patient to interact in a meaningful way with their physicians again,” Nunamaker says. “We have allowed our system to push physicians to the brink of early retirement and, at the same time, we’ve permitted the perception of the quality in primary care to be far lower than it can and should be. [Direct primary care] allows primary care physicians to do what they always wanted to do: care for patients, to be part of their lives and to feel like they’re part of something special. Unfortunately, that’s been lost in our current system.”

He adds, “With high-deductible policies coupled with [direct primary care], you can start to see the kind of transformative change needed to bring primary care back to what it always should have been.”

— Heather Hogstrom is an editorial assistant for Today’s Geriatric Medicine.