Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
“Virtually everyone understands the importance of major medical insurance as it relates to unexpected high-dollar care for severe injuries and significant medical conditions, but the value equation for health insurance is quite different when applied to coverage for primary care services.
The full potential cost for primary care services is neither expensive nor unpredictable. Routine and preventive care and the management of most acute illnesses and the majority of chronic disease processes by primary care physicians would be quite affordable for most Americans even if they had no health insurance. The involvement of health insurance in the relationship between patients and their primary care physicians introduces several major challenges and disadvantages. Here are the six primary areas of concern.”
Troy A. Burns is an internal medicine physician and author of Medical Answers Now!: How Direct Primary Care Guarantees Fast Access to Your Doctor.
He shares his story and discusses his KevinMD article, “6 major disadvantages of insurance involvement in primary care.”
Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.
Did you enjoy today’s episode?
Please click here to leave a review for The Podcast by KevinMD. Subscribe on your favorite podcast app to get notified when a new episode comes out!
Do you know someone who might enjoy this episode? Share this episode to anyone who wants to hear health care stories filled with information, insight, and inspiration.
Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.
Transcript
Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Troy Burns. He’s an internal medicine physician, and he’s the author of the book Medical Answers Now!: How Direct Primary Care Guarantees Fast Access to Your Doctor. There’s an excerpt from that book on KevinMD titled “6 major disadvantages of insurance involvement in primary care.” Troy, welcome to the show.
Troy A. Burns: Kevin, thanks for having me.
Kevin Pho: We’ll get into your book and article in a little bit, but first off, can you share your story and journey to where you are today?
Troy A. Burns: Sure, yeah. I guess I’m a little atypical as a physician, in the sense that I have an entrepreneurial bent, which I’ve kind of exercised from the beginning. I went to a six-year combined BA/MD program and had my medical degree at 24 years old, and did an internal medicine internship, and then decided I needed to be creative and got out and started working in urgent care. And then very quickly, I was hanging a shingle and starting a practice that was a specialty practice that took care of men with sexual dysfunction. So before it was called erectile dysfunction, or ED, it was impotence, in 1988, when I started doing this. And as it turns out, I grew that thing to a national medical practice. We had 36 doctors’ offices in 23 states, and it was a public company, and a pretty big deal. So that was something they didn’t teach me in medical school, that I had to learn from a lot of people smarter than me.
But what I learned in all of that is that guys don’t like to go to the doctor unless they cut their finger off in the lawnmower or if their penis doesn’t work. Then they go to the doctor. And you’d ask them, “When’s the last time you had a physical exam?” And they’d say, “World War II,” or Vietnam or something. And so it was pretty obvious that men had a need for primary care, for preventive medicine.
And so for me, my current medical practice that started in 2001 was a broadening of a men’s health practice into primary care for men and preventive medicine for men, and then, over the last eight years, into this new delivery model of direct primary care. And as soon as I started doing that, all of my male patients were saying, “Well, this is great for me. This is wonderful. I’m saving money. I have this wonderful access to my doctor. What about my wife and kids?” And so we broadened into family practice and added a female family practice doctor, and now we’re kind of expanding from there. So we’re in Kansas City, and we were the first direct primary care practice in this town, and one of the first, probably, 50 in the country to do this delivery model.
Real physician voices, twice a week
Free, and one click to unsubscribe.
Kevin Pho: So for some context, for those audience members who aren’t familiar with the direct primary care model, what exactly is that?
Troy A. Burns: Yeah. Direct primary care is an insurance-free, membership-based, affordable, direct-access primary care relationship. So it’s all of those things. Basically, what it isn’t is concierge medicine. The traditional concierge model is, “Pay me $20,000 a year, and I’ll come to your house.” Well, people don’t really need that, right? They don’t need that kind of access, but they sure need a doctor when they need one, or they end up accessing more expensive and inefficient care.
And so direct primary care is generally along the lines of less than a $100 membership fee per month that gives people unrestricted access to their personal physician. So they can call, text, email, or portal message 24/7. Within an hour, we’re getting back to them, at all hours, and same-day or next-day appointments. And then other than that, it’s primary care. It’s just a much higher level of access for a retail, kind of a low retail, price.
Kevin Pho: So give us a sense of what your typical day is like.
Troy A. Burns: Yeah. When I transitioned from a very busy, 25- or 30-patients-a-day primary care practice, which was insurance-participating, over to direct primary care, my days shortened. So instead of working 10- or 11-hour days, I was working patient care hours of probably less than seven. So in total, in addition to running the practice, I probably work 15 hours less per week, and I make a little more money than I did as an insurance-based practitioner. And so it’s much more flexible.
And in the past, when I’d go on vacation, it didn’t just cost me the cost of my vacation. It cost me $25,000 of lost revenue in fee-for-service. And now membership fees come in, and my partners take care of whatever needs to be taken care of. I don’t feel quite as guilty about taking a break.
Kevin Pho: What are the effects of giving patients access to you more frequently than, say, in an insurance-based practice, in terms of your lifestyle? Do patients text you at all hours of the night? Do they call you off hours? Tell me a little bit about that increased access and how that affects your life.
Troy A. Burns: Yeah. Well, I mean, the only reason it’s possible to give them that increased access is because the patient panel is so limited. And so while the average, I mean, depending on who you talk to, the average insurance-based primary care physician has a panel of 2,300 members as an average. Some are 1,500, and I know physicians who have 4,000 patients that they’re responsible for. Well, most direct primary care physicians have a third of that. I mean, they’re between 400 and 800. Most of them are in the 600 range. I have 700 members. We call them members; they’re patients. And I’ve been kind of at my 700 number for three, three and a half years, or something like that.
And because I only have 700, they don’t bug me much. They know that they can access me whenever they need to. If they call me, it’s usually something that, you know, I’m not delivering babies, and so I don’t have to go to the hospital, and we have hospitalists. It’s all outpatient. And so I send in prescriptions, or I tell them to meet me at the office in the morning, or I tell them to go to the emergency room if that’s needed. And so it’s really not very intrusive. On a weekend, I might get a couple calls on Friday as soon as the office closes, and I might not hear from any patients the rest of the weekend. And so being on call all the time really isn’t onerous at all.
Kevin Pho: All right, let’s talk about the excerpt on KevinMD. It’s titled “6 major disadvantages of insurance involvement in primary care.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to share it?
Troy A. Burns: Yeah, I thought that that section, you know, the book in general is really describing the case for primary care in general, and how there’s value in having a primary care physician who knows you and who’s accessible, and the efficiencies that come in that. And then it kind of contrasts the effect that insurance participation has on the relationship between doctors and patients. Any of your clinical audience already knows that in practice, in the real world. But the way I put it is, health insurance is not the same as health care, right? In a lot of ways, we don’t have a health care crisis in America. We have a health insurance crisis. And so, if anything, when it comes to primary care, health insurance really makes things worse in a lot of ways.
And so yeah, the estimates are that it’s about 40 cents of every dollar that is paid for primary care services that goes into the relationship between the physician and the insurance company. So the doctor’s office has overhead to bill and collect and status claims, and the float and all that. And then, of course, the insurance carrier, they have administrative costs to adjudicate claims and to pay, and try to delay and keep physicians from getting their money. And then, of course, they have a profit margin. So you peel all of that out, and the cost of care drops by 40 percent. So that is dramatic. And so that is really the equation that allows me and direct primary care physicians to limit their panels, right? And then, by limiting that panel, to have increased access.
And so the kinds of things that get in the way, these are, what I would call, the insurance-participating process. There are a number of non-value-added middlemen, right? The insurance company, the insurance brokers, the billing and collecting adjudicators, and all those kinds of things. They don’t add value; they just add time and expense. And so they make it harder for us doctors to do our job. And so they also are doing that in a system that is volume-based, right? The only way that we physicians get paid in that system is to turn the turnstile. And if our overhead goes up, well, our reimbursement doesn’t necessarily go up, so we have to turn more turnstiles. And so we have to do that from the standpoint of more visits in a day that happen faster.
Most physicians, whether they’re employed or they’re self-employed and have their own practice, have some kind of benefit that is tied to their ordering practices. So they’ll make some kind of a bonus if they’re billing more labs and more tests and making more referrals to the hospital system that owns their practice. I mean, obviously there are some legal issues there, but at the end of the day, the volume of work, not just office visits, but their ordering practices, really determines their pay. And so that’s a misaligned incentive, right? And that’s huge, and it should be huge for patients to realize that they aren’t aligned with their physicians. Even if they’re well-meaning, it is very difficult for physicians not to have that affect their decision-making.
So I encourage people in general to ask the question, “Who pays your doctor?” Who pays, right? That’s who they work for. They work for who pays them. And those misaligned incentives really mess things up. It ends up that the incentives are misaligned, and if a service isn’t covered by insurance, a physician is less likely to order it, even if it’s needed. And if it is covered, they’re more likely to order it, even if it’s not necessary, right? So you’ve got overutilization of some things and underutilization, maybe, of important things that don’t happen because of these misaligned incentives and the way the system is set up.
And there are hidden costs that people never know, right? They sometimes are penalized by the way their insurance is set up, and they pay more than the going kind of cash rates for services. If I’m ordering an MRI on somebody, their insurance copayment on an MRI almost always exceeds my negotiated cash price, which I provide as a pass-through and don’t make any money from. We’ve negotiated with local imaging centers, and they’ll do an MRI of somebody’s knee for $250, and their co-payment might be $800 or $1,000 on an MRI. So those kinds of hidden costs are really an issue with our system in general.
Kevin Pho: So what are some of your answers to the problems that you just described? Can direct primary care be an answer to the problems primary care faces?
Troy A. Burns: Yeah, I think that, again, the value proposition of direct primary care is, my patient pays me, and I take care of them. And then I’m their advocate, and I’m their concierge, in the sense that we’re the personal shopper, right? We’re the Sherpa that helps them navigate the system and not waste money on expensive drugs or expensive referrals or ER visits. If I sew up somebody’s finger and keep them out of the emergency room, I might save them two years’ worth of membership fees in one fell swoop.
And so the solution here is, when it comes to things that are neither expensive nor unpredictable, and primary care is very predictable, and it’s not expensive, putting those services under the umbrella of insurance simply makes them more expensive and less efficient. And so just cutting out those middlemen allows the physician to be available remarkably consistently to people who really need them, when they need them.
Kevin Pho: Now, most clinicians who transition to direct primary care, as you said, have much smaller panel sizes. So that brings me to one of the criticisms I often hear about direct primary care is that we already have a primary care shortage, and if more clinicians are seeing fewer patients, how is that going to help the shortage?
Troy A. Burns: Yeah, that’s an absolutely good question. Why is there a shortage, right? That’s really the point. Why is there? Sure, the reason is that primary care physicians work really hard, as hard as any other doctor, and they get paid half as much. And so, especially since the cost of medical education has gone up so much, and people have humongous debt that they have to pay back, it’s not very attractive to go into a field that isn’t reimbursed as well, and then know that you’re going to be seeing 30 patients a day just to pay your bills.
And so my strong belief, and I’m seeing this not only with existing primary care physicians, who are a little bit jealous of my lifestyle and my practice and are wishing they could get rid of insurance; I have a son who just graduated from medical school, and there’s a lot of discussion in medical schools and residencies about direct primary care. And so I think the cure to a primary care shortage is to make primary care more attractive from a lifestyle standpoint, and that’s exactly what direct primary care does.
Kevin Pho: We’re talking to Troy Burns. He’s an internal medicine physician, and he’s the author of the book Medical Answers Now!: How Direct Primary Care Guarantees Fast Access to Your Doctor. Here’s an excerpt from that book on KevinMD titled “6 major disadvantages of insurance involvement in primary care.” Troy, for those physicians who are interested in transitioning into a direct primary care practice, how can you do that?
Troy A. Burns: You know, it’s a challenge, in the sense that if they are employees, they probably have non-competes and things like that. And most physicians really have no experience in running a business. And so you have to have a lot of nerve or insanity to go hang a shingle and hope that you can attract enough patients to pay the bills. And so it is a cottage industry, so there aren’t a lot of practices that are out employing physicians to do this. I guess my practice is a little bit unique in that we’re expanding and we’re adding physicians and locations and things in our area, and there are a handful of those around the country.
But if they’re employed, then if they’re going to do something entrepreneurial like that, they’re probably going to be moonlighting, doing locums work or urgent care or something, while they are building their patient panel within their DPC practice. And if they’re one of the few remaining privately owned, insurance-based primary care practices, then it takes some guts to swallow hard and start firing your payers, right? Which is something that we did. And you just have to be able to predict what’s going to happen. And we kind of released those insurance carriers one at a time and calculated what kinds of retention rates we were going to have.
And you can kind of calculate that. For most direct primary care practices that transitioned from an insurance-based practice, they probably have maybe 10 percent, at most, that stay with the practice, because they’re all conditioned to just, they can only go to a doctor that takes their insurance. And so we probably had 17 or 18 percent of our patients that stayed, because we were already kind of a specialty practice for men at the time.
Kevin Pho: I’ve had a few direct primary care physicians on this show, and like yourself, a lot of them are successful. Now, are there cases where physicians aren’t successful in making that transition to direct primary care because of the obstacles that you mentioned?
Troy A. Burns: I don’t know. I don’t know that many stories about that. I do know that sometimes they are kind of huddling together, comparing notes, trying to figure out how to operate a business, because we physicians tend to be a little bit overconfident sometimes in our abilities. And just because we’re technicians that have an entrepreneurial seizure, as Gerber says in The E-Myth, right? We have the seizure, and all of a sudden, “Oh, we’re business owners now,” and we don’t know what we’re doing. They then scurry around and try to figure out how to operate a practice a little bit.
And there have been a couple in Kansas City that have gone by the wayside, or have chosen to move on and do other things, or to have a hybrid-type practice. But it is, like I say, I mean, running a business, especially in these times recently, with a tight job market and other things, to get support, is not for the faint of heart.
Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?
Troy A. Burns: If they are all over the board in terms of their medical backgrounds and things, it’s just to recognize that direct primary care is really growing like wildfire across the country. Like I say, when I started doing direct primary care only eight years ago, there were about 50 practices, and now there are about 1,500 or 1,600 practices in every state, all across the country, and all the major markets.
So I’d say be on the lookout for these practices, for yourself and for your friends and family and your patients, because we are invariably providing superior access to personal physicians, and care that, because of the time that we have, triple the time per patient, really is better and faster and cheaper care. And of course, if primary care physicians are interested in getting into it, there are probably other direct primary care practices in their town where they could meet with physicians and talk about it.
Kevin Pho: That’s right. Thank you so much for sharing your time and insight, and thanks again for being on the channel.
Troy A. Burns: Thanks for having me, Kevin.
Listen and followApple PodcastsSpotifyYouTubeMore apps · Browse all episodes
