An alternative to the current model of primary care


What does a primary care visit look like from the patient’s point of view? I often wonder this myself, as a resident physician currently seeing patients at an FQHC in Austin, Texas. A brief look at the process reveals an often tumultuous ordeal for patients and providers alike.  Consider the following steps: Finding an available appointment day and time in an overbooked schedule, requesting time off from work in order to fit in the appointment, driving across town to the “in-network” clinic, insurance verification and check-in at the front desk, then the nurse intake, and then the wait begins until finally, your physician arrives to see you for the 15 to 20 minutes he or she is allotted before rushing on to the next appointment. Then, you are off to wait in additional lines for scheduling, lab, imaging, and pharmacy. There are several other barriers to continuity and quality of care, which are also a product of our current model for primary care.

With experience as the physician and patient in this scenario, I can relate to the burden the current health care model places on doctors and patients alike. According to a Journal of the American Medical Informatics Association article, burnout rates are rising as more demand is placed on primary care physicians to see more patients in shorter time-slots, while also completing the electronic medical record, which takes even more time and attention away from the patient’s care. A higher focus on corporate and government-driven measures of “good health” has also placed additional burdens on physicians, shifting their focus from building rapport with their patients to making sure their notes are detailed enough to fulfill these quality measures. If the charting is inadequate, insurance companies and the government can reduce primary care physician reimbursements.

What if we could simplify health care delivery and eliminate a vast majority of barriers to quality care? There is a model that seeks to simplify primary care and eliminate barriers for patients and physicians. It is called direct primary care (DPC).

DPC focuses on the doctor-patient relationship by creating a subscription model of per-visit or periodic payments that cover unlimited appointments, yearly lab work, and clinical services. Shorter wait times from scheduling to appointment, longer appointment time slots, and sometimes home visits are available. The model removes fee-for-service costs negotiated between hospital administrators and insurance companies, along with reducing practice overhead. The model stresses fewer patients per physician, allowing for a significantly closer relationship between patient and physician. Patients often have direct physician access, whether through instant messaging or an extended hours direct line. Often the physician will communicate with patients directly during business hours to avoid unnecessary patient stress or office visits.

Concierge medicine often draws comparisons to DPC. The two differ in that DPC offers a more affordable option that bundles some additional value rather than charging fee-for-service on top of a monthly “retainer” fee, as is often done with concierge practices. Many concierge practices also bill insurance companies for additional reimbursement. Keeping these costs down is essential to the success of the model’s mission to serve as a low-cost option through reducing overhead and eliminating the insurance company’s opportunity to overcharge for services. The argument against DPC is that there are patients unable to afford the average monthly cost. Although a legitimate concern, there are 28.5 million U.S. citizens uninsured under our current insurance-based care delivery model.

What if you need more acute care that requires an emergency department or hospital stay? This is another valid question brought up often during the discussion about the DPC model of care. Currently, it is recommended that patients utilizing DPC carry a high-deductible (HD) wraparound policy to cover catastrophic medical emergencies. If health insurance underwriters are able to incorporate DPC into bundled health coverage with HD wraparound and specialty coverage, the DPC model would become a realistic option for employer health insurance plan offerings. This is already available on a national level through a provision in the Affordable Care Act that allows DPC to be offered in a bundled fashion in the insurance market when bundled with a wraparound policy.

Furthermore, physician burnout is well documented across primary care specialties. On a national scale, the Annals of Internal Medicine estimate physician burnout costs the U.S. health care system $4.6 billion dollars annually. This cost comes from reduced clinical hours and high turnover rate attributed to burnout. In a study conducted by Mayo Clinic and the American Medical Association (AMA), it was found that burnout rates decreased for the first time in Family Medicine from nearly 60 percent to 45 percent. This seems like a major improvement, but the article goes on to also highlight that the percent of physicians screening positive for depression has risen from 39 percent to 42 percent in that same interval. The burnout rate over those same years amongst the general workforce has lingered around the 28 percent mark. These statistics highlight the need for primary care reform for the well-being of doctors and patients alike. A concern of the model is it will add to current and anticipated shortages in primary care providers. This view does not consider the additional years of practice physicians can add if improving their work-life balance, as opposed to early retirement or career change due to burnout. The model could serve as a recruiting tool for primary care, which is seeing record low numbers of U.S. trained allopathic (MD) medical students choosing it as a career. Instead, they are pursuing higher-paying specialties with better perceived work-life balance. DPC provides a solution to many of the headaches, inefficiencies, and lack of quality care experienced in health care today.

Alec Wilhelmi is a family medicine resident.

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