Tag Archives: DPC

Why Overpay for Healthcare?

I firmly believe that family medicine is rooted in communities. It is the only way the physician can develop an understanding of the local culture, industry, and lifestyle to “get it” from the patient’s perspective.

Live, work and serve in the community was a principle articulated by Ian McWhinney in his Introduction to Family Medicine in 1981. Cost shifting, that is using your revenue from paying patients to care for those who could not afford care, was a time-tested method of paying for healthcare for decades. This was a tacit understanding between paying patient and physician which exists no longer. Although it is not a direct part of the physician-patient relationship, it has always been part of the landscape and responsibility that a physician embedded in a community would be expected to live up to. It is also part of the responsibility of a community in taking care of their own.

What about people who don’t need “therapy?”

Well the longer you’ve been around, the more you realize everyone needs therapy. But for those where the posture is too much, realize that life coaches approach therapy from a really practical perspective, rather than the stereotype of a navel gazing, pipe smoking “shrink.” Also for those whose counselling needs are not very acute, we can always stand to improve ourselves, be more effective in relationships, health habits and goal achievement.

 

The impact on the uninsured and uninsured

Low income individuals are often uninsured or under-insured, on medicaid or bouncing on-and-off. Generational poverty, substance abuse, environmental deprivation are all contributors to a profound psychosocial malfunctioning.

These bad decisions we see and urge people to take responsibility for are often beyond the capacity of the more unfortunate. Teaching adaptive behaviors goes a long way to enabling personal responsibility. Combining medical care, prevention, care coordination, behavioral counselling and connecting to the rest of the community as a hub connects to the spokes of community services is a fantastic way to lift people out of generational dysfunction… one person at a time.

Is it Tax Deductible?

DPC fees are not tax deductible or applicable to health savings accounts (HSA’s) due to an IRS regulation that views DPC as insurance, although it is clearly not. Several state legislatures ahve passed enabling legislation that specifically states DPC is not insurance, nor is to be treated as such. Currently, Senate Bill 1989 at the Capitol will make this the law of the land and open the possibility of allowing Medicare money to be directed by patients to primary care physicians who are willing to accept such payments.

 

 

Objections to DPC

The taint of concierge care for the elite sticks to DPC, although it is an inherently advantageous way to provide primary care and is ideal for people who cannot afford going to the doctor or taking care of themselves.

There is so much more to the stubborn misunderstanding of the role of DPC in the health system, but this is why we have blogs and record brief videos.

What is Direct Primary Care?

This is my version of a definition, but the best legal definition of direct primary care is here:

FOR THE PRACTICE TO QUALIFY AS A DIRECT PRIMARY CARE PRACTICE THE PRACTICE MUST:

1) CHARGE A PERIODIC FEE

2) NOT BILL ANY THIRD PARTIES ON A FEE FOR SERVICE BASIS, AND

3) ANY PER VISIT CHARGE MUST BE LESS THAN THE MONTHLY EQUIVALENT OF THE PERIODIC FEE

Thank you Dr. Eskew.

Addressing Primary Care Gaps

I recently met Diane Lund-Muzikant, publisher, editor, organizer and all ’round charm for The Lund Report.

Every state should have such a publication focused on the local health system. And a fireplug to match Diane’s energy. She said I could write an editorial whenever I would like to highlight primary care issues.

Here is my first effort published September 22, 2015.

The greatest success of Obamacare, is the reduction in the number of uninsured. Most of this improvement has come in lower income groups, who disproportionately suffer the burden of illness and the most difficult social circumstances, including poor employment prospects. So it is unsurprising that Medicaid expansion accounts for over 2/3 of the newly insured, according to the Heritage Foundation. The political partisans use this as a weapon arguing that Obamacare resulted in little more than the expansion of the Medicaid entitlement. The other side feels that more has to be done to cover the remaining 10 million uninsured.

What about the social value of medical coverage to vulnerable populations, the economic benefits of health care to this group and a questioning of the cost relative to the benefits? Sometimes it is OK to spend tax money if there is value and accountability. If our nation is to spend public money on healthcare, it is incumbent on policy-makers to ensure the greatest value for the effort.

The greatest public value derived from modern medicine is derived from immunizations, maternal-child health and primary care. When the newly insured report that they do not have access, they mean primary care docs who understand their situation and listen to their concerns. Unfortunately, the healthcare system as it stands commoditizes primary care and works against the functions of primary care, especially continuity. Each time someone looks for new primary care provider, the system has failed.

Because healthcare in the US is purchased through employers, their entire family would change provider when jobs turn over. As health plans move to narrow networks, odds are increasing that their doctor will not be in the network offered by the next employer. This interferes with continuity of care over time and erodes outcomes.

The situation is worse for low income individuals and the Medicaid population. Some in this population suffer from mental health problems and are easily overwhelmed by the normal demands of life. They find it difficult to hold onto jobs for a long periods of time. Unstable insurance source from a Medicaid provider to a narrow network and back, repeatedly forcing them into new primary care relationships.

Long term relationships between doctors and their patients build trust. It is the trust built on years of knowing the person embedded within the context of family and community which improves outcomes and reduces costs. The lower the income level, the greater the vulnerability, the greater the risk of bouncing on and off Medicaid, with lapses and fluctuating access determined by deductibles and coinsurance.

Erika Bliss, the CEO of QLiance, a Direct Primary Care company in Seattle, suggested to me a few months ago an idea that could help bolster how primary care improves health system performance. Perhaps it is time to consider a primary care benefit that is portable from employer to employer and continuous with Medicaid. It is easy to carve primary care out of traditional insurance, where it should always represent the top dollar of healthcare spending. This is the idea behind the growing Direct Primary Care movement where high impact primary care is paid for on a monthly subscription basis. First, this helps maintain continuity between a doctor and their patient, a foundation stone of primary care. Second, it serves to create a sustainable business model for medical students to do what they idealistically entered medicine to accomplish and attract more smart people to primary care specialties. Third, primary care increases the efficiency of healthcare systems around the world, which seems to be the fundamental motivation behind the notion of value-based purchasing. If you want to buy value, invest in primary care not MRIs and pay as much as you reasonably can.

Media Mentions for EverMed and DPC, Another Grant Request for PanZoe

We got a couple of media mentions a couple of weeks ago for EverMed’s DPC efforts. They were brief, one more or less accurate and the other word-for-word the way we would have like the issues framed.

From Elizabeth Hayes of The Portland Business Journal comes the following:

A Vancouver-area company is launching a new model of delivering primary care services in the Portland area, one designed to give patients direct access, regardless of their insurance plan.

EverMed Direct Primary Care of Camas isn’t itself insurance, but layers on top of a patient’s existing plan. A member pays a set monthly fee and receives comprehensive primary care services.

While most Director Primary Care companies employ doctors directly, EverMed is seeking established, independent primary care clinics. About 30 clinicians at eight clinics have signed up in Clark County and about half a dozen clinics are in various stages of the contracting process in Portland, said Seth Sjostrom, director of business development.

EverMed charges patients $45 to $85 a month for unlimited access to a primary care doctor for wellness exams, basic diagnostics and other non-emergency needs.

“The principle of DPC is that you don’t need insurance for day-to-day care. It’s for catastrophic illnesses,” said Dr. Dino Ramzi, EverMed’s chief medical officer and a physician with Lacamas Medical Group in Camas.

Members can enroll directly, though many have come through self-funded employer medical plans. Ultimately, EverMed would like to partner with an insurer who would devise a plan that doesn’t include primary care, Ramzi said.
So far, EverMed has signed up 75 members and five corporate clients. Sjostrom said the company is now promoting itself with insurance brokers in hopes of attracting more business during the 2015-16 enrollment season this fall.

More and more patients have gravitated to “bronze” plans, with high deductibles. Faced with copays or an unmet deductible, these patients may defer care, which ends up costing more in the long run when a patient ends up at an urgent care clinic or the ER. Highly effective primary care could save the health system a third of its costs, Ramzi said.

This upset Seth, as noted above, our Director of Business Development. It turns out I misrepresented our pricing structure, essentially because it has undergone several changes. My momoery is not what it used to be. In fact, as we prepare to enter the employer market more profoundly, there are signals we may have to make further changes. Pricing is an important component. We want to make sure providers get good value, but it is telling that employers are falling over themselves, given the price of assured primary care is remarkably low from tehir perspective.

The Direct Primary Care Journal did a perfect job representing our efforts. (Duh, it was a press release.)

Direct Primary Care clinics have been popping up all over the country, it was only a matter of time before the Portland marketplace became a part of the revolution in healthcare.

Born from the concierge clinic concept, Direct Primary Care (DPC) is the iteration for the masses. As one of EverMed DPC’s marketing tag lines states, DPC is “genuinely affordable health care”.

Direct Primary Care is a healthcare benefit option where members pay a set, low monthly fee to receive comprehensive primary care services. DPC is not itself insurance, it is an affordable option to access primary care needs for the member and their family.

EverMed DPC is a new spin on the growing Direct Primary Care marketplace. While most DPC offerings are staff model enterprises (the physicians work for the DPC business), EverMed DPC seeks out independent primary care clinics that are already established in the communities they serve.

“One of our key objectives as EverMed DPC is preserving the viability of the independent primary care practice. We see Direct Primary Care as a way for clinics to not only survive, but thrive,” says founder and clinician Scott Jonason, PA-C.

EverMed DPC makes accepting direct primary care patients a turn-key proposition for clinics. “We handle nearly everything for clinics – marketing, contracting, payroll and bank withdrawals, enrollments – all the clinics we serve really have to do, is see their patients,” Director of Business Development, Seth Sjostrom states.

With their network in southwest Washington established, growing northward into Seattle and across the river into Oregon were natural next steps. “If anything, we were overwhelmed by the positive response we received. We quickly realized growing slowly was not an option,” Sjostrom says.

EverMed DPC’s plan? Having enough clinics spread throughout the Portland metro in time to have homes for primary care patients opting for DPC membership during the 2015-2016 healthcare enrollment season.

“Our second objective is to truly remove finances as a barrier to primary care,” Jonason explains, “Working with the healthcare broker community and employers, we provide an affordable way to provide quality care while at the same time, driving down costs.”

EverMed DPC aims to add value to employers and individuals by minimizing the number of urgent care and emergency room visits, thereby reducing the overall total healthcare spend. “When patients are concerned about paying copays or worried about unknown costs of seeking care, they tend to avoid seeking treatment until it is too late and then they end up in the ER. With DPC, if they have a concern or even unsure if they need to come in, they can call, visit or even use secure email or text depending on the clinic,” Jonason adds.

“We believe when physicians have genuine relationships with their patients, quality of care improves. Timely care that values the relationship and is focused on the whole patient means that doctors are in the position to respond quickly and guide the patient to the right diagnosis, coordination or medical management as efficiently as possible. The hallmark of quality primary care is taking care of the individual, not the visit,” Dr. Dino Ramzi, EverMed DPC’s Chief Medical Officer states.

With healthcare reform, many individuals and even businesses opted for plans with higher deductibles in order to secure lower premiums. Direct primary care serves those with high deductible plans to manage their day to day health, knowing their insurance is in place should they require more extensive care. The trend across the country is to increase individual out-of-pocket expenses. This trend is unlikely to reverse, but DPC makes those expenses more budget-friendly.

“We have had a number of members who purchased a Bronze plan through the exchange but signed up for DPC to take care of their more common needs, assuming they wouldn’t hit their deductible. We have had several taking part in Christian medical share programs that also saw DPC as a way to bridge the gap,” Sjostrom shares.

“Our most common membership, though, has been through employers with self-funded medical plans. They see DPC as a fixed variable in their annual medical cost plan while serving as a way to manage costly medical interactions by avoiding unnecessary Urgent Care an Emergency Department visits.”

How do businesses and individuals enroll in EverMed DPC? “Members can enroll directly through our website or 800 number, but we strongly encourage prospective members to learn more about DPC through their licensed insurance broker. Healthcare can be complex, we want to be part of a package that really meets our members’ needs,” Sjostrom says.

Direct primary care programs on their own do not meet the obligations required in the Affordable Care Act, though they can be a complement that makes sense for a lot of people and companies seeking for a solution that provides real healthcare value.

“No copays, no deductibles, the smallest administrative burden…with EverMed DPC, we return the focus of healthcare to the patient,” Sjostrom adds.

Meanwhile PanZoe‘s efforts to raise funds for a national giving effort for DPC is going strong as we apply again to the Community Foundation of Southwest Washington.

Direct Primary Care and the Working Poor

This post was written for PanZoe‘s blog on May 21, 2015, here.

 

One of the easiest vulnerabilities to spot in healthcare after the Accountable care Act are those individuals who simply cannot afford their deductibles. The insurance mandate in Obamacare leads those who work low wage jobs without benefits to buy the cheapest policies.

These policies have huge deductibles, so even with great subsidies, these individuals simply can’t afford to see a doctor. In fact, they are often exposed to the full “rack rate” for health services and have inflated out of pocket costs 2 to 3 times as high as insurance companies pay providers.

A 40 year old man sat at home with a cold, or so he thought. When his fever did not get better after three weeks and he started getting so short of breath that he couldn’t work, he finally came to see me. His cold was really a pneumonia and could have been treated weeks earlier by someone who recognized the red flags early enough. Instead, he ended up in hospital and his $8000 deductible got charged pretty fast.

Low wage workers are the productive members of society trying to transition out of multi-generational cycle of poverty, and succeeding to some extent. Such shocks can throw them back on the public rolls. One of the major advantages of Direct Primary Care for low income individuals just above the Medicaid threshold is unlimited access to high-impact primary care. They can get minor illnesses treated quickly, before suffering serious illness requiring hospitalization. In addition they have access to prevention, care coordination and chronic disease. The technology that goes with Direct Primary Care, like secure video and texting is of particular importance to people whose trips to the doctor often impact their income. In jobs without benefits, if you don’t work, you don’t get paid.

In policy circles Direct Primary care suffers from an image of care for the elites. But the low price point makes it most appropriate for low and middle income individuals. These are the people most likely to benefit from a close relationship with a primary care provider.