Technology empowered direct pay primary care

by Anar Mikailov

By now it is common knowledge that primary care is an undesirable field for newly graduating medical students.

Additionally, many current primary care physicians are closing shop and either enter early retirement or seek non-clinical professions. According to the American Academy of Family Physicians, the 2010 Residency Match showed that 1,184 U.S. medical grads chose Family Medicine, less than half of the available positions (aafp.org Match 2010). As the down falls of practicing family medicine continue to mount (e.g. low salary, minimum time per patient, significant paperwork and insurance headaches), residencies in this field become less desirable. Given the lack of medical student demand for primary care careers, I would like to discuss a tangible alternative for practicing primary care: a direct-pay practice utilizing web based technology.

About three years ago I learned of a primary care physician who implemented such practice. Dr. Jay Parkinson had just completed his residency, moved to Brooklyn, New York and realized that one – many of his friends did not have health insurance and two – he did not want to start or join yet another typical practice that most of us visit. So he took an innovative approach by creating a direct-pay clinic managed entirely by web-based technology. In doing so, Dr. Parkinson obviated the need for administrator staff and nurses, ended waiting lines and said goodbye to insurance. More importantly, the patients received dedicated doctor face time, web scheduling, email access, video chat access and a PHR – all on a sleek web portal. Since 2007, the HelloHealth based direct-pay model has been adopted by hundreds of doctors across the country.

In June of this year I met with the first doctor in Philadelphia to implement HelloHealth – Bruce Hopper Jr. MD. He was a physician on the hamster wheel, churning through over 40 patients a day while seeing his annual income decline and burn out set in. Instead of abandoning medicine, he adopted the HelloHealth direct-pay model. Since June I have worked closely with Dr. Hopper learning the ins and outs of his practice and I will continue my work as I begin my clinical rotation with him. The following describes just a few aspects of a HelloHealth managed direct-pay practice.

The office staff includes only a doctor; there are no nurses or administrators, as all organizational aspects of the practice are managed via HelloHealth Portal. Additionally, all scheduling, billing, and medical information also resides on the remotely hosted, HIPAA certified HelloHealth servers. Patients sign up for HelloHealth online, and then add Dr. Hopper as their doctor. As an official member, patients can set up in-person appointments, video chat appointments, send email, and instant message with Dr. Hopper. In addition, all patient medical records (labs, medicines, diagnoses, imaging) are easily accessible, printable and syncable with other PHR (Personal Health Record) providers like GoogleHealth. The HelloHealth practice management portal is intuitive, very web 2.0, and the way medical management should be in 2010. With decreased overhead burdens and flexibility of this model, it is not uncommon to find Dr. Hopper making house or office visits and managing follow-ups by video or email. More importantly the new model allows Dr. Hopper to continue his passion for modern medicine and building meaningful patient relationships.

The big question for many medical students is what the expected annual income is for a doctor who adopts such model.  Based on Bureau of Labor 2009 Statistics, the median wage for a Family Physician was $160,530; based on modest cost and revenue figures, income for a direct-pay model will be at least double that amount.

Instead of waiting for medical reform legislation or other top down intervention the direct-pay practice is a grassroots alternative ready for adoption. And to any medical student that brushed off primary care, I suggest to please reconsider. Our country needs a new wave of medical students interested in front-line positions – and I strongly believe the technology empowered direct-pay approach is a major leap in that direction.

Disclaimer – I am not affiliated with or sponsored by any person or company mentioned.

Anar Mikailov is a medical student and blogs at his self-titled site, Anar Mikailov.

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  • family doc

    Direct pay practice is more likely to save quality primary care than the PCMH and ACO hype we’re getting from CMS and the politicians.

    You don’t need Hello Health to do this. Many of the Ideal Medical Practice Practice providers are doing this already. Very low overhead is the key to having a sustainable practice at an affordable price.

  • everyman

    this is an interesting idea, but am I missing something here, if no one is going to into primary care wont the demand be high and thus making a more desirable career?

    • r watkins

      With primary care docs being the number one target of recruiters for the third or fourth year in a row, one would think so. The problem is that the AMA and CMS, with the tacit agreement of the primary care societies, work to intentionally keep primary care pay low via the RUV system.

      • Anar Mikailov

        Unfortunately current medicine economics are not founded on supply and demand from a free market, rather a third party (CMS) decides reimbursement.

  • Adam Rothschild, M.D., M.A.

    I agree with everything that family doc said above. While Hello Health is a nice platform, and Jay Parkinson is an interesting guy, I believe that the lion’s share of credit for innovating and popularizing the low-overhead, cash-only, technology-enabled practice model is due to L. Gordon Moore. See http://www.impcenter.org/

    • Anar Mikailov

      Gordon Moore is actually working with HelloHealth and you are right he does deserve a lot of credit for these ideas.

  • stargirl65

    Very interesting concept for Hello Health. Did not mention costs associated with using their platform.

  • Susan71

    There is an article that explains the difference between direct pay primary care and retainer based medical practices. This type of technology is actually very good for both. See http://www.conciergemedicinetoday.com/diff.html

  • Anar Mikailov

    Absolutely agree about L. Gordon Moore and Ideal Medical Practice – He deserves a lions share of credit for these ideas.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    I don’t think the platform is the main issue here. The direct pay model is.
    When you “say goodbye to insurance”, you also say goodbye to the sickest and arguably those most in need of primary care. I understand that physicians have needs too, but there must be a better solution than to limit services to those who can afford to pay cash.

    • family doc

      Instead would you trap all physicians in a failing government and commercial third payer model that has been steadily destroying primary care for decades while paying lip service to its importance?

      High quality primary care can cost less than cable TV. It is affordable for the vast majority of the population.

      Set up a safety net for the poor but free primary care from the third party payers.

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        I agree that the current system is perverse when it comes to primary care, both public and private.
        However, I still think that an equitable solution must be found, without creating two tiers of health care: a poor system for the poor and a rich system for the rich.

        As to affordability, you will need to cast a rather large safety net if you include those currently on Medicare with multiple problems and innumerable prescriptions. I guess you could say that those folks need to be seen by specialists, thus limiting primary care to simple ailments or largely healthy populations.
        I guess my question is what is the exact definition of primary care?

  • everyman

    the real issue is hospital care, there is no way for regular people to afford hospital care out of pocket, the nice doc with the pretty website who treats hipsters in williamsburg doesn’t really have any solution if one of them gets hit by a car and needs an ER trauma unit, so direct pay for an outpatient visit is fine but the patient still needs insurance for medicines hospitals and advanced testing, so insurance companies will always be around torturing all of us good doctors. Also how come now one is talking about how patients don’t want to pay for anything, I’ve had 2 page handwritten letters written to me asking for a 10 dollar refund, my staff has been yelled at for asking for 30-40 dollar co-pays, can you really expect them to now pay 60-100 dollars out of pocket especially since these same patients still need to pay for medical insurance?

    • Anar Mikailov

      Everyman,

      You are spot on, every person will still need insurance that covers catastrophic coverage, imaging, and prescription drugs (High Deductible Insurance). Direct-pay practices encourage such insurance. These plans are much more affordable than comprehensive coverage plans.

      In regards to your patients who want refunds – sure that will always happen. Thats fine, those people will seek out non direct-pay docs. On the flip side, there are plenty of people who would rather pay $35/mo and have more personalized care.

  • http://www.FairCareMD.com Alex Fair

    Hey Folks,
    Indeed, Dr. Moore deserves a good deal of credit here too, especially for his direct pay CMEs which are very good. So does Dr. Garrison Bliss who helped write direct pay into the PPACA legislation and has been at the direct pay plate, swinging away for almost three decades (see http://www.qliance.com/pdf/BNA+Health+Care+Policy.pdf).

    You could point to Aaron Blackledge or Sonya Kim, Jay, of course, or dozens of pioneer physicians that are leading the way to direct pay, but this is a supply and demand thing, so the question is not just a supply side one, it is also about demand. You can’t push on a rope and expect to get anywhere.

    So let’s look at supply, specifically the patients and the pipelines that lead them to one particular provider or another. I can best speak about my own site since I have access to the data. Since we opened out doors in June our second most frequent search on the site is for a PCP (see blog post for details: http://blog.faircaremd.com/2010/08/the-first-9653-searches-for-care/. With more patients and employers choosing High Deductible plans, one in every 4 patients has essentially become a “direct pay” or cash patient. So the supply side is there as indicated by the 20,000 searches from patients looking for Physicians in New York we have gotten in the first few months. On average our direct-pay patients pay 25% better than the average insurance company does for the same service. So the demand is there and it is not just the problem patients, they are just people who have to arrange for care on their own and are up to the challenge.

    To Everyman’s valid point – in our system and others, when a patient finds a doctor with good credentials and a fair price they get a contract for care – this clarifies what they are getting and preempts the two page letters for $10. So far so good, but as Anar points out, this will probably still happen even though we do our best to prevent it.

    So without getting too self promotional, my point is that these direct pay contracting systems exist and the demand is there. This is a self-directed, grassroots approach to reforming healthcare. We can poke holes in the model all we want but a good question is are Physicians ready for this?

    “But what about outcomes?” you ask…
    You might imagine that people watching their own costs will get less care. In fact, a few studies have shown that when combined with a care coordinator focused on wellness, consumer directed health plans actually result in a healthier population. I discussed these studies in a recent blog post, which was just a reflection on Joe Flower’s original. (His: http://www.imaginewhatif.com/2010/09/accountable-for-patient-health.html mine: http://blog.faircaremd.com/2010/09/are-people-healthier-when-they-pay-for-their-own-care/) As a result of this work we recently signed up fifteen wellness coaches for our site and they are proactively working on helping getting our users what they need.

    On a financial basis it is a Win-Win-Win-Win. Patients pay less, Doctors get paid better, Payers have less administration costs (and risk), and Employers pay less for coverage when the public and providers deal directly. I guess traditional insurance would be a Lose-Lose-Win-Lose.)

    On sites like ours everyone can be a pioneer in their neighborhood and insurance can become like car insurance, only for catastrophic problems – which is how it used to be.

    Please feel welcome to contact me. I designed our site with Patients and Providers in mind and the feedback of over 100 Physicians including some of the leaders listed above, so I welcome yours too – or just sign up. The patients are there.

    Best Regards,
    Alex Fair
    Founder, FairCareMD

    (Kevin & co – sorry for all the links. Feel free to remove them, I just wanted to give folks access to more info if they wanted)

  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Technology enabled primary care will be far more likely to allow doctors work-life balance. It doesn’t however need to be direct pay. Not all doctors want to be entrepreneurs. Some like to work in a group practice, enabled with advanced IT systems, and who are respected by both patients and colleagues for the work they do.
    Ultimately, primary care will thrive in practices enabled by IT systems either traditional, ideal medical home, or direct pay as well as large integrated groups like Kaiser Permanente (where in Northern California is currently does and where I work and where we continue to hire!).
    Why medical students should choose primary care – http://davisliumd.blogspot.com/2009/12/why-medical-students-should-chose.html
    I don’t believe, however, that IT enabled direct pay alone will stem the flight of medical students away from primary care.

    • http://www.FairCareMD.com Alex Fair

      I could not agree more Dr. Liu. Most MDs just want to focus on the care, not the administrative work or being entrepreneurs. This is a good thing that even ten years ago when I helped run a PPM, we all strove to accomplish – more care, less business from the actual providers of care.

      The intent of automated patient acquisition and payment processing systems is to vastly simplify the business side of care. Automated direct contracting and being paid promptly allows more time per patient and reduces overhead. For example, the ratio of staff to doctors in a direct pay practice is more like 1:1 than 4:1. Secondly, if you can be paid fairly for the most efficient technology-enabled services (email, phone, video chat,…) which are currently not reimbursed for by our artificial and inefficient payment system, it means you can deliver more great care to more people with less time. This is the tech enablement, coupled with more efficient access and capture of clinical data, that we believe has a chance of transforming healthcare. Just putting the EMR in is not the whole answer, we have to hack the payment system too.

      To your other point, I concur there as well. Only when Primary Care no longer has the stigma of being the least rewarded and most harried of paths will the popularity improve. As long as the AMA codes and reimbursement favors specialists, we will suffer PCP shortages. One approach is to throw out the AMA codes like we did when we took Dr. Jeff Rice’s “CFT” or Consumer Friendly Terminology codes as the basis of our system and let them mutate with every Provider who sets up their offers on our site. What is developing is an amorphous, free market approach to getting and giving care. Since the public values Primary Care more than payers do and we all know they lead to the balance of referrals, this approach may treat them like the unsung heros of healthcare that they are. It is too early to tell the outcome, but the potential for vast change is there.

      With Consumer Direct Health Plans (CDHPs) increasing by 27% last year and likely more this year and next, the stream of direct-pay patients is becoming a river.

  • http://www.IMPCenter.org L Gordon Moore MD

    The direct pay model is interesting as it makes it possible for a practice to engage in behaviors punished by the insurance payment model: keep panel size in reasonable approximation of capacity, non-visit care (e.g. phone, video, email), taking the time and/or investing in staff to engage patients in healthy behavior change and provide follow up and outreach.

    While these activities are not strictly prohibited in most cases, spending more than nominal time and effort on them can cause a practice to fail in the current toxic payment environment.

    Putting aside very important discussions about how our country chooses to think about health care, we are definitely facing an exploding population of people with little real benefit from the insurance premiums they pay. More people are uninsured than ever before and tens of millions more have health coverage in name only – they are out of pocket for most services they require.

    It makes sense to explore models like this. There is a lot we can learn about the simplicity, service, quality, experience of care, and outcomes when we shed the immensely costly and distracting work of claims manipulation.

    L Gordon Moore MD
    President
    Ideal Medical Practices a non profit helping those seeking to deliver ideal care