A primary care direct pay model that works

in Physician | 40 responses

by Brian Forrest, MD

When I started a cash-only, direct-pay practice nine years ago, my reasons were simple: spend more time with my patients, provide better care, and live a better life.

I was uncomfortable signing insurance contracts that limited my ability to care for my patients. I was unwilling to sign an employment contract that required me to see a patient every 7.5 minutes, or lose a productivity bonus.

Nine years later, my practice Access Health Care in Apex, North Carolina is living proof that primary care physicians can provide better care to more patients more economically while making significantly more income if we start answering to our patients instead of answering to insurance companies or government bureaucrats.

Our model attracts a lot of interest:

Interested in low cost? How about a patient reducing her expenses managing her diabetes from $5,000 per year to less than $500?
Interested in improved outcomes? How about 91% of patients achieving their target blood pressure within 6 months? How about being named one of only four Cardiovascular Centers of Excellence in our state?
Interested in quality of life? How about only scheduling eight patients per day, leaving ample time for walk-ins and same day appointments, and never seeing more than 16 patients per day?
Interested in reducing professional liability? How about your malpractice premium being cut in half, and having zero risk of Medicare recovery audits?

As word about my practice began to spread, I began answering questions from other physicians looking to start or transition their own practices following our Direct Pay model. Over the past five years, those questions evolved into a consulting practice helping over 75 physicians across the country, in specialties ranging from family medicine to ophthalmology.

In the wake of health care reform, and with physicians facing financial stress from reduced reimbursements and increasing Medicare recovery audits, interest in alternative practice models is surging.

It is time to get off the treadmill of factory medicine, and return medicine to doctors and patients.

Brian Forrest is a family physician and is the founder of Forrest Direct Pay.

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Comments

The 50 Best Health Blogs
If this model became widespread, replacing traditional insurance, what would happen to patients who developed expensive illnesses beyond their immediate ability to pay? Would they just die, or become financial burdens on hospitals through their emergency rooms?

Edward Stevenson
traditional insurance isn’t insurance, it is prepaid healthcare. when people pay for basic services then insurance will be affordable for catastrophic care

http://www.conciergemedicinetoday.com Michael Tetreault
I agree. When we stop pre-paying to insurance companies, save those dollars or put them into an HSA (or the like), couple this with a catastrophic plan…we can save families, individuals and seniors a lot of money.

FamDoc
@50Best – We need health insurance for the exact situation you described: the unexpected accident or catastrophic expensive illness.
Primary care, however, is not expensive to administer. It’s a physician spending time with patients, focused on maximizing wellness and preventing or managing expensive long-term chronic illnesses.
Primary care becomes expensive, unaffordable, and offers low quality for patients and doctors, however, when we try to “insure” it — because the insurance is simply a middleman that stands between the doctor and the patients.
The cost of “insuring” primary care is astronomical, because physicians are forced to adopt overhead of up to $250,000 per year per physician to cover the cost of submitting claims and trying to get paid by Medicare, Medicaid, and private insurers. All of that staff and technology is completely unnecessary for patient care — it is overhead and expense forced on the physician by the third-party payers, and raises the cost for everyone.
If Dr. Forrest’s model became widespread, high-quality primary care would be widely available and affordable to every American — you could manage chronic illnesses like diabetes and hypertension for less than the annual cost of a cell phone bill, as is the case with his practice.
For folks who are truly indigent, charity care and safety nets would be a possibility since primary care would actually be affordable.
For everyone else, a healthcare savings account for routine primary care, plus the ability to cover the deductible for a high-deductible (true) insurance policy will provide peace of mind, widespread access, and freedom of choice to find the best health care to meet an individual’s needs.

http://www.conciergemedicinetoday.com Michael Tetreault
We absolutely do need catastrophic health insurance plans to become more relevant. To simply the understanding for some readers, we choose not to use our homeowners insurance until there is a catastrophy. We pay the deductible, get whatever is wrong fixed and move on. However, when we need to hire something simple or routine to be maintained or fix, (ie get an annual physicial; blood work or x-ray), we can pay for the service out of an HSA, MSA, or out of pocket.
Not having to pay expensive insurance premiums is a huge savings for people. Did you know that over 60% of concierge-style programs cost less than $136/mo. or less than $1,632 per year!? That’s huge savings when you compare that to what we pay now to be “in-network” with a doctor who has to look at a chart to know my name and assess my symptom is about 6 minutes.
Sited Source: http://www.AskTheCollective.org; July 2010

Dr Synonymous
Dr Forrest, You are Spot On! You’ll be the ReTweet of the week. Keep preaching, the choir is waking up. The congregation might get the message sooner or later. Congratulations!

http://www.conciergemedicinetoday.com Michael Tetreault
You might find this article interesting. “The Difference Between Direct Primary Care and Concierge Medicine” – http://www.conciergemedicinetoday.com/diff.html

stargirl65
I like the theory of what you are talking about but my area has a strong HMO presence (closed HMOs) and these people want to use their already prepaid expensive health insurance. In fact a close friend transferred out of my practice when her employer switched to a health plan that I do not participate in. She has a high deductible and will probably never meet it so the issue is moot.
How do you convince people to pay cash when they already have health insurance?

http://www.conciergemedicinetoday.com Michael Tetreault
Most direct pay or as they are more commonly referred to, “concierge” doctors business models accept insurance, including Medicare (approx. 80%; July 2010; http://www.ConciergeMedicineToday.com and http://www.AskTheCollective.org). This is a fact that not a lot of patients understand.
Yes, most HMOs do frown on this type of business model and most of these types of physicians decide not to participate in HMOs but still do participate in the PPO plans.
It’s more about the physician selling his access, features and benefits. By “normalizing” his practice and not running in the hamster wheel of healthcare mandated by insurers, he can emphasize that he/she spends more time with each patient, he/she is more acceptable and can find more time in his/her busy schedule to have a better relationship with you.

in theory
Concierge medicine is usually a great idea for doctors and patients but how did you come up with the patient volume to do so? I’m assuming that you had to accept insurance for several years and then gradually transition to the direct pay model.
How is it possible for a doctor fresh out of residency to practice boutique medicine? Thanks.
http://www.conciergemedicinetoday.com Michael Tetreault
Dear The 50 Best Health Blogs –
In your comment you asked, “If this model became widespread, replacing traditional insurance, what would happen to patients who developed expensive illnesses beyond their immediate ability to pay?”
Most of these types of doctors, whether you call it “direct pay”, retainer-based, membership medicine or even concierge medicine, suggest to their patients that they pay the affordable fee to the doctor each year and have a catastropic health insurance plan that covers them in the event of an emergency, car accident, etc.
As it relates to your question about “Would they just die, or become financial burdens on hospitals through their emergency rooms?”
Answer: No way on earth are the patients of these types of physicians going to be a burden on ERs or hospitals. Reason, the quality of patient care and treatment is much more closely monitored by the physician in these types of medical practice business models. Because the doctor has more time to spend with the patient and can help take more preventive measures to ensure better quality of life and quite possibly, a longer life.
Studies are still being done about this type of care but I can tell you that The Concierge Medicine Research Collective did a survey among these types of physicians across the U.S., and found that on average, these types of physicians improve patient care by spending more time with their patients. Here are a some survey and studies that will help glean more insight:
According to Concierge Medicine Today (www.conciergemedicinetoday.com) and its research arm, The Concierge Medicine Research Collective (www.askthecollective.org), they have been surveying concierge physicians and concierge medicine patients across the U.S. since 2007 and found the following:
78% of concierge or “direct pay” doctors surveyed include home visits as part of their annual fee and at no extra cost;
97% of concierge or “direct pay” doctors surveyed provide at least 10 to 20+ home visits per year with their patients;
83% of in-office, routine visits with each and every patient last no less than 45 minutes.
Sited Sources:
http://www.ConciergeMedicineToday.com
http://www.AskTheCollective.org
HJ
Looking at Dr. Forrest’s website, a office visit costs $49. For $350, you can reduce the cost of that office visit to $20 and get free basic lab tests. The cost of imaging is not included. My last ultrasound cost $500. House calls-$199. This fee also doesn’t include medication costs-mine cost about $3000 a year.
I have multiple chronic health problems-for all I was sent to a specialist-either for diagnosis, treatment or both. Most of them required imaging, diagnostic procedures and non-standard lab work. Perhaps a PCP with more time would have been able to order the tests, it doesn’t reduce the cost of these tests. As for treatment, a PCP is not qualified to do psychotherapy or physical therapy.
While $49 is a reasonabe price to see a PCP, it is not cost effective for me to abandon my comprehensive insurance.

FamDoc
Dr. Forrest has negotiated low “cash discount” rates with a network of outpatient specialists in the area — for example, his patients (who by definition are paying cash up-front) benefit from $19 digital x-rays with a local radiologist (including the interpretation). Specialists also understand the benefits of direct pay, and not having to spend money to collect money.

HJ
Cash only still is thousands of dollars a year more expensive even with the $19 x-rays. It’s better for me to use comprehensive insurance. Why is that so difficult to understand? It seems disingenuos to pretend that this is the solution for everyone. Why don’t you just say it will cost me more instead of trying to convince me I will save money?
I already have a doctor that calls me on the phone with lab results, coordinates my image studies, and makes sure I see the right specialist. I get 80-90% discounts at LabCorp, just like everyone else with insurance. I have a nurse line for late night questions and don’t need a cheerleader to tell me to eat well, exercise and take my medication. I don’t have high blood pressure or diabetes.

KP Internist
Patients who are willing to pay more for access and time are generally the ones who do well regardless of the system they use to get their care. They are generally motivated, educated and activated to maintain their health. They just so happen to have enough disposable income to pay for this luxury. I worry that concierge medicine will bankrupt many primary care doctors while syphoning access to those patients who need to see a primary care doctors the most. I don’t see how concierge medicine will serve the social mission that primary care was supposed to deliver.

CSmith MD
It could be mandated that insurance plans have to set aside $400-500/ year out of the premium into primary care accounts. Patients could use this to purchase retainer or cash pay plans of their choice without network restrictions.

KP Internist
It would still limit access to primary care for the majority of patients who are unable or unwilling to pay a retainer. If you have a primary care doctor carrying a panel of say 500 patients, then that is obviously much less than their capacity. But, it takes quite a bit of time to make housecalls or round on every patient that gets admitted at every hospital. I just question how concierge care will address the primary care shortage. It doesn’t maximize our efficiency, in fact, it encourage more inefficiencies (wasted appointment opportunities, doctors doing the booking, driving to and from, ect…) to justify the extra payments by the patients.

CSmith MD
A panel of 2000 patients where I practice generates about $500,000/year in revenue. For $400/patient I could have a panel of about 1250 patients with significantly lower overhead not having to worry about I&B. I wouldn’t do house calls or have 1 hour appointments, but I could coordinate care, do evisits, email etc. I would have time to perform registry functions ( i.e. search my database for all A1C’s above 7 % or BP > 140/90 etc). I would still admit my own patients.

KP Internist
How is what you are proposing any different than a full service insurance policy at a integrated delivery system like NCAL KP? We do everything that you offer but at much lower costs and way more coordination. The registry functions are all “baked in” to the system and the visit extenders (phone, e-mail, and online pharmacy ordering, labs, appointments). We do handle panels of 2300 patients and access is not a big issue.

jsmith
That social mission is as dead as a doornail. Docs with a social mission have been played for suckers in this country for a long long time, but that time is about over. Just ask the 4th year med students. Nothing to to be happy about really, the pts will suffer most, as always, but facts are facts.

http://brucehopperjrmd@gmail.com Bruce Hopper Jr MD
KP Internist,
Yes, it may bankrupt many primary care doctors, but that is not necessarily a bad thing. Medical students are not entering primary care because of its hamster-wheel image so we are losing doctors anyways. Direct-pay practices open the market and disrupt the current unsustainable care non-system. Furthermore, these practices are armed with technology that improve access and care coordination without having to churn patients through the brick and mortar office. Stop the fear-mongering about access. It’s already a problem, and it’s about to get a lot worse. Your model does not solve the access problem. KP-style practices are a great option, but they certainly cannot be the only option. Not everyone wants to be an employee, and that’s not a bad thing.
ninguem
Here we have a model of healthcare delivery that’s on a reasonable scale, can be expanded if successful, and easily reversed if it didn’t work, in that the underlying matrix of healthcare finance is still in place.
So what do we get?
What if What if What if What if What if What if What if What if What if What if …..so it can’t be done or even tried.
Instead, the current Administration and Congress passes a healthcare monstrosity that they themselves admit, they don’t know what it is, what it will do, and they didn’t even read.
And that’s OK.
And the right is the party of no.
http://brucehopperjrmd@gmail.com Bruce Hopper Jr MD
KP Internist,
I think you are confusing direct-pay with concierge. Yes, typically concierge charges ~ $1500/year and up, which can be pricey for some. Although, I would argue traditional, comprehensive insurance premiums are absurdly high with no value added, and will only increase. In fact, insurance has led to wage stagnation and employers will merely pass the premium increases, deductibles, co-pays, etc. on to employees further. Individuals and small business are already saddled with insane premiums.
My direct-pay micropractice is $35/month and face-to-face visits are based on a $240/hour schedule. You can book 15 minute incremental appointments. If you are a member, you have 24/7 access to me through my web portal, which includes HIPAA-secure videochat, email, instant messaging, electronic prescription, open medical records, scheduling, etc. You also have my cell phone to text and call me. Non-members pay on a fee schedule of $300/month.
Hate to say it but the good old days of both inpatient plus outpatient medicine are dead. Thank the hospitalist movement for that. But, also, not necessarily a bad thing.
Ambulatory outpatient practice must be direct-pay to survive because traditional payers refuse to fund it. Again, KP is a great option for some doctors and patients, but it is not perfect. There needs to be different care models competing with one another to spur innovation.
Lastly, if patients feel my fee schedule is too burdensome, chances are they just don’t value their own health. As you know, 70% of chronic diseases are lifestyle-mediated, preventable, and reversible. We need a care model that engages patients, not one based on entitlement. For some reason we Americans value cable tv, cell phones, car leases, manicures, pedicures, cigarettes, video games, etc. far more than our own health.

KP Internist
Bruce, I would love having more innovation in how we take care of patients. I just don’t know if changing how we do the billing (payments) is what we need. What you are talking about doing is given patients options to pay for access to your services, right? How do you propose that a patient will know how much time they will need for a complaint? I don’t know how many times I have had a visit for “headache” become a 1 hour long discussion about depression and then I am to give them a bill for the overage? Yes, insurance premiums are high. But, as was pointed out earlier, your services are a cost on top of usual premiums.
SmartDoc
This type of common sense, low cost, high quality care is illegal in NY. The bureaucrats there went after a good doctor with a very similar practice, They said (I swear) that he was operating his own insurance company.

FamDoc
This type of Direct Pay care is not illegal, and is not insurance — if the physician is careful about how it is structured, and the way the private contract with the patient is created.
ForrestDirectPay.com has guidance for how physicians can set up a Direct Pay practice that contracts with patients directly, and does not run afoul of insurance or other regulations.

http://mumumed.com/blog Asya
Do you also answer patients’ e-mails? If so, do you charge for that separately or is that part of an annual fee?
Also, I’m interested in how you deal with patients with chronic conditions who require a lot of imaging and lab work like HJ above?
http://www.brucehopperjrmd.com Bruce Hopper Jr MD
Asya, yes, emails are included in the membership fee. Managing chronic illness is the foundation of primary care. I can draw lab work myself. My lab rep will bill patient’s insurance if they have it or give 80-90% discount if you are without. as soon as I get the lab results, I import them into my HelloHealth web portal, you log on, and have them, too. most of the time, results can be discussed through email, thus, avoiding office visits and $$$. Imaging studies can be coordinated as well.
http://www.brucehopperjrmd.com Bruce Hopper Jr MD
KP Internist,
We philosophically disagree on payment, which is fine. I certainly do not want KP to change how it does things. Who is to say that KP’s way is the best? You seem to be saying (in an elitist way, in my opinion) that billing is what it is, so let’s work around it. I cannot disagree more. There is a burgeoning market for people who would rather pay their doctor directly. This model aligns the patients’ needs with the doctors’ needs. your payment model does not. . You payment model will always emphasize quantity.
Dr. J
Health insurance should work like car insurance
Lets say you have a 2006 Ford Escape, it’s a good car, but you have been hearing a ticking noise lately so you bring it to the mechanic. The mechanic does some diagnostics and tells you that the rear differential needs to be replaced, and in addition you are overdue for an oil change and have a head light that is out. He tells you that your brakes will last another 6 months and you will need to see him again then. This is primary care for your car and while none of us like to spend money at the car shop we all recognize that this is not covered by our insurance. We all recognize how crazy our premiums would be if car insurance covered all this, and that this sort of maintenance is uncomfortable but affordable.
The car gets fixed up and on the way home we stop to do some shopping and our car disappears, later that night the local constabulary call and tell you that your car was stolen by a meth head, crashed at high speed and destroyed, it cannot be repaired. We all recognize why insurance is needed to cover this catastrophic and unpredictable expense.
Primary care is predictable and for most people affordable (as affordable as the mechanic anyways). Much hospital care, and advanced diagnosis is catastrophic and makes sense to insure, but insuring primary care is what has lead us to the disaster that our current primary care system is.
KP Internist
But doesn’t the direct pay model still encourage waste. You are still being paid per unit of care delivered. It still sets up a perverse incentive for providers to encourage increased utilization of testing, treatments and visits. Also, don’t you think that insurers will limit payments for procedures, treatments from out of network providers?

Max
I believe it encourages the exact opposite. You can’t run up expensive cash-paying procedures without telling the patient up front the costs associated and let them decide. It’s not like you’re going to spring a $1500 office visit on a cash-paying patient. I don’t think any physician would be that dumb. That to me is the beauty of the cash model. Here are my prices.

http://brucehopperjrmd@gmail.com Bruce Hopper Jr MD
KP Internist, We continue to disagree. Perverse incentive? You clearly misunderstand the philosophy of direct pay practice: aligning the needs of patients and doctors, thus, preserving the patient-doctor relationship. Do you feel threatened by direct-pay practices for some reason? Again, I am not suggesting KP switch to direct-pay. If people or employers choose this brand of insurance, so be it. What do you have against others practicing in a different way other than your own? There are many patients and doctors disillusioned with KP, not to say KP is bad, it’s just not the right match for some.
DrJ is exactly correct.
HJ, I don’t know the details of your condition nor is this the arena to discuss it, but, I still bet, a direct-practice could save you money. At the same time, I would never admonish you for wanting to keep your current insurance.

HJ
“HJ, I don’t know the details of your condition nor is this the arena to discuss it, but, I still bet, a direct-practice could save you money.”
Last year my medical expense totaled over $12,000. So how does paying cash to save me money…? Specifics please.

KP Internist
KP does offer a direct pay option for large payer groups. Many of our contracts are for “self-funded” groups. They prefer to not pay for our comprehensive product and we have to generate a bill for each service we provide. It is very time consuming and it doesn’t add anything to patient care. However, it is something that we have to do to keep our contracts with these companies.
http://www.forrestdirectpay.com Brian Forrest
I wanted to try and answer some of the comments in one succinct reply about my post on Direct Pay.
1. If model becomes widespread how do people pay for things like hospitalization and expensive procedures.
I encourage all of my patients to try and get at least a catastrophic high deductible plan in case they go into the hospital or have some really expensive procedure done. So, my model being universal does not change the need for catastophic “real” insurance. Also, I have convinced a large number of specialists in my area that direct pay will work for them, too. I can get plain digital films with the overread and a burned cd for $19 from a local radiologist for my patients. He does comprehensive mammograms for $89 and I can get some ultrasounds for my patients for $70. I have a cardiology group that will do stress echos for $200 for my patients, even though they charge insurance $1800 for the same thing. So my patients save money on many of these services by using our “network discount” which often makes their out of pocket cost less than what their copay might have been.
2. We are in a high HMO penetrated area and it works fine here. 43% of my patients have traditional managed care and still choose to come here. You asked, why would they pay their premium and pay me too. Well, I have done studies with UNC School of Medicine where they put 4th year medical students in practices all around our area to compare cost and quality. Uninsured patients saved about 85% on average over the “going rate.” Out of pocket costs were 7% less for commercially insured patients. And Medicare patients saved about 12% out of pocket if they had part A and B and no significant supplement. This means when you actually looked at what patients spent out of pocket for copays, noncovered services (like a PSA in a 39 year old) and other costs they actually spent less in our model. Patients also cannot get an hour long, on time, non-rushed visit in practice that “takes their insurance.”
Quality- top 10%ile compared to national standards for things like HGBA1C, average LDL, and percent of patients to JNC goals.
3. Someone said I must have done this by starting with a well established patient population so that I would have enough volume to sustain myself. Well, actually I started with not a single patient and the first week I was open did not see a patient until Thursday. I am NOT volume dependent. I only want to see about 12-15 patients per day. However, I break even with overhead after seeing four. http://www.aafp.org/fpm/2007/0600/p19.html
4. Someone stated that they already get the 80-90% discounts because their insurance does this for them. This is incorrect. Your insurance company does get a discount. Let me give you a typical example: A complete metabolic panel in our area goes for about $175 for cash patients. The insurance companies get a rate of around $85. We charge our patients $36 now (if they are not on an access card plan) and our cost for the test from the same lab company that charges the above prices is only $4.
5. We are not concierge-concierge shares some of the same benefits for patients and physicians but our charge is only $29 per month for the Access Card patients,not thousands of dollars per year. This improves access for the undersinsured rather than making it an elitist practice that only a few can afford. Maybe you could call us concierge -lite. We never bill insurance, unlike many of the concierge practices that still bill your insurance and charge you the concierge fee.
6.Another comment revolved around getting in trouble with insurance regulations in your state by being considered an insurance company. This is a valid point, and if not done correctly this could be considered the case. However, insurance companies have to have capital to cover potential losses. We never have losses because we always charge at least as much as our costs for tests etc. For example, if someone on an access card came in for their HGBA1C and a followup visit, their appointment scheduling fee/overhead fee would be $20 for the visit. The A1C only costs me around $5 and the other overhead for the visit will be well under $20. However, if the patient needed a tetanus shot that day I would charge them a fee based on my cost in addition to their normal $20 fee. Thus, I never will lose money on a visit. It also does not motivate me to “overutilze” tetanus shots- because I will not really profit on them, just cover my cost. I make my profit on the monthly or annual fee, not the per utilization charges.
I hope that helps, if you would like a more recent reference try http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=652945
or
http://www.weeklystandard.com/articles/cash-doctors

HJ
“Someone stated that they already get the 80-90% discounts because their insurance does this for them.”
Let me give you an example…blood work from a physical…charges $267…paid $60.85…percent discount-22% of the charges…
Extensive workup ordered by specialist…charges $1952…paid $223.78…percent discount-11% of the charges…
” I can get some ultrasounds for my patients for $70.”
Mine only cost me $50.
“Uninsured patients saved about 85% on average over the “going rate.”
Of course…if I were uninsured, I’d be all over a direct pay option.
“Out of pocket costs were 7% less for commercially insured patients. ”
Examples please…your fee is twice my co-pay. Why would I pay this? I assume the 7% is saved for those who aren’t educated and don’t keep track of tests. If I had diabetes, how would you save me money?

KP Internist
Bruce, I agree that we have a philosphical disagreement. I suspect that there are some of us who will do great in this payment model. But, I think that most PCPs are more like me. We are horrible businessmen and given the choice of submitting a bill or just letting it go, we would do the latter. I go to work and I do the best that I can for my patients and I want someone else to figure out the details of how much they pay for my services. Doctors, for the most part, are horrible at the things you have to be good at to do well in a direct pay system. So, I see how this direct pay model will spread beyond it’s current establishment.
http://www.brucehopperjrmd.com Bruce Hopper Jr MD
KP Internist, I hear you. Do you think radiologists, ortho, anesthesia, derm, ent, and urology think as you outlined in your post? Of course not, and their specialties are the most in demand. Primary care is dying because of your described philosophy. The worst part of it all is that patients suffer most, and we are letting a phenomenol profession die in front of our eyes. A tremendous number of med students would love primary care as a profession but enter other fields because their elder primary care docs have failed them. All because we “want someone else to figure out the details.” Come on, really now. With all due respect what a pitiful excuse! I support your decision to be an HMO employee, but to suggest primary care should be globally modeled on this makes it an easy decision for med students to choose other fields.
A Real Patient
Interested in real patient view of a concierge doc? I’m 59 yr old male. One year ago I signed up, finding my doc through MDVIP. Fee is $1500 per year – no added charge for physician time (although some docs do bill insurance for office visits. Mine does not.). Doc is 61, practicing locally for 32 yrs (fmr Chief Resident at leading medical center here), only concierge in practice of 4. Although w/o reg doc for about 10 yrs, had no hypertension, etc, and thought in good health. After first physical, dx MDS (subsequently confirmed – IPPS Int Risk that has been stable and req. no rx so far). Long story, doc has given me huge amounts of time, seen me through extended evaluations w/spec nationwide – and kept me out of hosp w/ multiple skin infections. Can’t imagine how typical harried PCP could have handled my care.

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