My change from a traditional practice to direct-care has caused me to challenge some of the basic assumptions of the care I’ve given up to this point.  Certainly, the nature of my documentation will radically change with my freedom from the tyranny of E/M coding requirements.

Perhaps the biggest change in my care comes courtesy of the way I get paid.  The traditional way to be paid is for service rendered (either at an office visit or procedures done).  This means that I am financially motivated to give the bulk of my attention to people when they are in the office.  They are paying for my attention, so I try to give them their money’s worth.  The corollary of this is that I tend to not think about people who are not in the office to be seen.  The end-result is an episodic approach to care that is entirely dependent on the patient paying for an encounter.

There is a huge problem with this approach to care: people live their lives between encounters.  Life does not go on hold between office visits for my patients, and the impact of my care is not dependent on what happens in the encounter, but what happens between visits.  My ability to help my patients depends on my ability to affect the continuum.  If I do a good enough sales pitch for a person taking their medications, and if I consider the life-circumstance which may affect their ability to take the medicine, then I am successful.  I don’t learn about the success until their next visit (usually), and I also don’t learn about problems until then.  People are reluctant to call with problems they are having with medications, new symptoms, or other important details, often waiting for many months to tell me things I really want to know.  Perhaps they don’t want to be “one of those patients who calls all the time,” perhaps they don’t understand what I said, or maybe they’re worried I will “force them to come in” to pay for another office visit.  Regardless of the reason, I get very limited interaction with my patients in this episodic care model.

My new practice model allows for, and even encourages interaction between face-to-face encounters.  I intend on spending a significant part of my day systematically reviewing records to make sure they are up-to-date, and initiating contact if need be.  I will also give them resources to be able to manage their care (or their wellness) without having to pay for each encounter.  One reader (of another blog to be left unnamed) suggested that under this system he would get his “money’s worth” by using my service as much as possible.  For him that meant coming to see me often, but in the model of care on the continuum it would involve going to the web site and updating records, sending me questions, or watching videos I’ve made on a particular subject.  My hope is that all my patients would “get their money’s worth” between visits, and that perhaps this will reduce the need for actual face-to-face encounters.  In fact, that is the whole point of what I am doing.

There are some specific types of care that the view on the continuum is significantly better than the traditional episodic approach:

  1. Pediatric/Well care – We traditionally see babies at 2 weeks of age, then at 2, 4, 6, and 9 months of age during the first year of life.  After that the care becomes less frequent, to the point that many pediatricians don’t see children in school-age and teenage years more than every 2 years for well care.  The reality is, however, that children grow between these visits, and much of the advice given during these visits (“anticipatory guidance”) is forgotten by parents.  Care on the continuum means parents have access to the information about a wide range of problems as well as having the ability to ask questions any time they want.  Things like “I can’t get my child to sleep in her own bed,” or “Jonny is still wetting his bed” are problems parents will hold off on asking until the scheduled visit.  Certainly there will still be scheduled visits for measuring, assessing development, and physical exam (not to mention that the pediatrician needs his baby fix), but these visits are enhanced by what happens between them, allowing problems to be addressed sooner.
  2. Psychiatric problems – Much of the follow-up care of anxiety, depression, or attention deficit disorder (which are the three staples of psych in primary care) involves assessment of interim symptoms and/or problems.  Care on the continuum can happen with monthly (or more frequent) reports of how things are going, how the child is doing in school, or if there are problems with medications.  Many people with these problems are reluctant to come to the office, much less talk about new problems.  I hope having direct access to my care will give them an easier avenue to give me the real view of how they are doing.
  3. Controlled drugs – Prescribing and refilling controlled drugs are a huge part of my work stress, and one I wanted to address in my new practice.  Traditionally I write refills of these medications and manage them with intermittent office visits.  On the continuum I can require a symptom questionnaire before refilling medications, allowing me to address increasing use as it is happening and moving people away from more addictive short-acting drugs to the more effective and safer long-acting drugs.
  4. Chronic disease – Diseases like asthma or diabetes are much better cared for on the continuum, as a regular log of blood sugars or peak flow readings can be sent to me on a regular basis.  I can see early, not waiting for the 3 months A1c, that the sugar is not coming down as expected.  I can hear about early symptoms of asthma, not waiting for the patient to come in with a full-blown attack.  Adjustments can be made much more frequently without the need for face-to-face care just to hear about symptoms or blood sugar readings.

I keep getting new ideas of how to handle problems differently in this new model of care, but all of them benefit from the fact that it looks at patients before problems pop up, or at least at the time of the problem instead of after a potentially dangerous delay.  The waste in our system is, as has been noted often, huge.  But the assumption that episodic care is the proper model could be the most costly mistake of all.  People are afraid to engage our system because of the cost, and that fear ends up costing everyone by not dealing problems until they are “bad enough.”  Care on the continuum seems to accomplish the main goal of my care: keeping people away from the rest of the health care system unless it’s absolutely necessary.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind)where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player.  He is a primary care physician.

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42 Responses for “Care On the Continuum”

  1. BobbyG says:

    Very thought-provoking post. Thank you.

    This is perhaps a weak analogy, but, nonetheless:

    I used to work in Risk Management in a subprime credit card bank. I was the principal “portfolio management” officer/analyst. It was a big part of my job to monitor ongoing the shaky financial “health” of our financially halt and lame cardholders (we used to joke that it was like giving whiskey to alcoholics, granting credit lines to subbies). We had effective data mining pxs and predictive models for everything. Once we booked these people, he had to try to keep them profitably “healthy.”

    I was a SAS and S-Plus and all-around RDBMS whiz.

    I had access to tons of customer activity data every day. I could track your every transactional “move.”

    The principal concerns were, of course, our “patients” “dying” on us (charging off and stiffing us), as well as the relentless outright fraud stuff (i have some funny stories).

    We made successively record profits every year of the five that I was there. Data-driven, baby.

    See http://bgladd.blogspot.com/2008/12/tranche-warfare.html

    Before you go cracking on me, I quit in 2005 to go back into HIT work, at a 23% salary reduction. Today, I could make 3x my current salary (which is not quite what I earned at the bank back then when I left) were I to go back into “distressed consumer debt modeling and management.” The comp package numbers give me pause, but, I will not. Ever again. It’s just too jive. I have to sleep. And look in the mirror.

    I will stay in the HIT space until I retire.

    I have utter respect for clinicians. I work with them every day. I don’t see how y’all do it.

  2. J. Stefan Walker, M.D. says:

    Rob, thanks for the intro summary to the principles of the new practice. It strikes me that your core values are not at all dissimilar to the PCMH model; and also strikes me as a loss to our profession if good docs like yourself exit the mainstream rather than remain as necessary agents of change within it. Could you not remain within the traditional payment system, but re-boot your practice as a certified PCMH? The funding streams may not be yet ready at present for a subscription model, but I foresee something like that (? grants from payers per annum) for well-functioning PCMHs, which have the same goals you spell out here. One final thought – for better or worse, traditional health insurance is apparently going to be more ubiquitous or even mandatory; and most patients will thus be (obligatorily) in that mainstream, as paying customers. I still think there are good ways that good docs can remain within that basic construct and provide great care; especially as the PCMH movement thus far has allowed a great deal of flexibility in how you get meet the parameters. All things told, it would likely be less frustrating on the whole to become a PCMH (which certainly requires a team, not just one provider), than to try to invent something completely de novo. And with proper organization of the medical practice business model – especially keeping overhead / expenses low – you can likely still do your model of continuum, but make it run in the near term by assuring you get the patients in for face visits at regular intervals. This can work, Rob. Regardless, I wish you well, and your patients.

    • Rob says:

      The question is: can substantial change come from within a system, when that change would require significant downsizing of that same system? I think the system doesn’t change itself because it would cause it too much harm to do so, and perhaps the only way to truly change the system is to offer a different and better alternative. This goes along the “disruptive innovation” concept which has wrecked many entrenched industries. The PCMH, which my practice was working on, became the DCMH (data-centered medical home), and was taking a lot of the attention off of the patient and on to the proper collection and reporting of data. It is a basically good idea, but like EHR/Meaningful Use, the execution becomes more important than the goal.

      I’ve got lots to write about.

      • J. Stefan Walker, M.D. says:

        Indeed, points taken. Key questions for reform-minded doctors: what is my overall goal? and equally important: can I realistically achieve that goal? If the goal is to reform the system, I have concluded that the train has left the station: health reform is one of the top domestic issues of the US political and economic discussion, for going on 4 years now; and the PCMH movement is growing exponentially, and as you note, is a ‘good idea’. How much could (should) one doctor do against massive forces like that, in developing a whole new approach – is it worth it for anyone involved in such an attempt? Or are there niches within these emerging reforms wherein we impatient reformers can find a peaceful resting place and be productive / sustainable, while still facing ourselves in the mirror and getting a good night’s sleep…and pay for our kids’ college? If the current practice is a DCMH, could it be re-oriented to the goal of better patient care and good business sustainability, through appropriate physician autonomy and leadership? If not, can like-minded docs join you and form a more clearly focused PCMH effort? In my analysis over the last few years, the critical element is physician autonomy and leadership. The ones who have to sign the death certificates, who have to look at the patient and agree to be ‘their doctor’, must be allowed to wear the pants in the family. This does not negate a team approach, or demean the vital roles of business, nursing, or other roles; but when the real leadership is not carried by those with the real ultimate responsibility, the system (whichever system) falters. I believe a well-organized and physician-led PCMH model can weather the current storms and afford primary care doctors the opportunity not just to survive the crisis – but help lead the system out of it with this new model of care…on the continuum.

        • Rob says:

          For me there were two considerations: first was the little-picture of the people I care for. They are being hurt by the system and I see much of the immediate damage it causes. This cost me enough emotional energy that I was pushed to this choice. I am (and always have been) the kind of person who, when I see a problem I think I can solve, is compulsively drawn to solve that problem. That is what makes me a good clinician, to some extent, and why our practice adopted EMR 16 years ago. I can’t sit on my hands if I think I can solve a problem (in this case, that problem is not the big-picture of health care, but the harm done by it to my patients).

          The second thing comes from my experience with EMR adoption, which seemed like a no-brainer to me 16 years ago, and which I used to make my office much more productive and profitable. Despite my passion and the rightness of my ideas (for which I am being vindicated more and more), I saw a huge irrational resistance to change by the “system.” When it is finally being adopted, it is not patient-centered, as I hoped, but data-centered and system-centered. Yet my going out of the box did have some impact on the system as a whole, debunking the myth that EMR’s were not possible for small private practices.

          I don’t really know if my current flailings will change the system, although the prominence that my posts are being given on THCB gives me heart, but it doesn’t matter all that much to me. If I can fix things in my own little system – making my life better, my patients lives better, and saving them money – then I will be happy. If, in the process of doing that I debunk another myth – that we are stuck in our current system and that change has to come from within (something history argues against) – then that would be even better.

          • J. Stefan Walker, M.D. says:

            I understand the clarification. I would further push however that, happily perhaps for you and your patients, your own proposed new system most likely could be fit fairly easily into a PCMH model that would allow you to continue to take insurance; save even more patients money, perhaps; allow you proper autonomy to manage and innovate; and likely qualify you for future cooperation with payers in terms of grants for level 3 homes. I’m not saying stay in your original mainstream clinic construct; I’m proposing you do almost exactly what you were planning to do – just within parameters that will achieve much gains for you and the patients by staying within reach of the greater community of care.

            This said, however, I do think some kind of direct care model will always be valid within whatever emerging ecosystem we are evolving towards; there will always be a few (or maybe more, depending on if true reform comes, or just more bureaucracy) who will pay for direct consultation and access, and this is ultra-valid. And who knows, maybe the time is now for you to jump into that. But it is just very ironic that your core values and plans mesh so very well with the PCMH goals; perhaps your first iteration was just not the right one. Regardless, I respect and admire you and your efforts and values; Godspeed.

        • southern doc says:

          I honestly don’t see how the PCMH model addresses any of the issues that motivated Dr. Lamberts to make this change. Meaningless MU, insurance interence, low fee schedules are still there, with a truly mind-numbing level of bureaucratic chores that come with certification.

    • southern doc says:

      How can you keep overhead low, but use the services of an entire team as opposed to one doctor?

      The finances of the PCMH are disastrous without huge external financial support: it’s a very expensive way of delivering primary care.

      • J. Stefan Walker, M.D. says:

        There are a lot of ways to skin the PCMH cat. A small staff can do so by proper organization; a reasonable but usable EMR; and the small staff each wearing several hats within the construct. It’s the concept and the results that matter, not the size of the team. It can be done.

        • southern doc says:

          Don’t get it.

          Case in point: in our office, we run on one doc, two staff members with in-house billing. We’re extremely well-organized, and there is NO give to do the DCMH chores that Dr. Lamberts describes. For example: we’ve always done same day access, our patients know we do same day access. What is the advantage to me, my staff, my patients, or the system for me to pay someone time and a half to come in on weekends to document per NCQA guidelines what we’ve always done?

          Dr. Lamberts wants a less administrative-heavy practice, and you’re recommending what seems to me just the opposite.

  3. pcb says:

    “The ones who have to sign the death certificates, who have to look at the patient and agree to be ‘their doctor’, must be allowed to wear the pants in the family. This does not negate a team approach, or demean the vital roles of business, nursing, or other roles; but when the real leadership is not carried by those with the real ultimate responsibility, the system (whichever system) falters”

    This is an essential point. Unfortunately, it has been largely ignored.
    I would like to add that having an MD behind your name does not necessariliy mean you carry the “real ultimate responsibility” mentioned above. I know many MDs who might as well change the letters to MBA at this point in their career. They might still see a handful of patients a week, many haven’t treated a patient in years.

    • Rob says:

      I agree, and do think that clinicians should always lead should be the ones leading the reform, as we are the ones who see the real effects of a broken system

  4. The original PCMH concept has been severely distorted lately, and a year ago, while commenting on a new study, I actually called it Process Centered Medical Home, because that’s what it became, and it is now used to further discredit small practice in spite of all the “study” results pointing to the contrary….
    http://onhealthtech.blogspot.com/2011/07/process-centered-medical-home.html

    • southern doc says:

      I do an informal survey with my patients:

      1. Do you want your medical care from me or from a team?

      2. Do you want me to “transform” my practice or run it as I always have?

      The answers I receive certainly indicate that the “P” In “PCMH” doesn’t stand for patient. Yes, “process,” but more and more “payor.”

      • The word “team” has also been co-opted for policy use. Unless you are a micropractice, there has always been a team. There is the lady helping you with appointments and referral appointments, and there is the lady who shows you in and takes your blood pressure, maybe even gives you a shot… and there is the doctor who treats you…
        Now “team” means that other people treat you and the doctor “leads” the team by reading reports on how things go and if you’re ready to keel over and drop dead may come in to see what’s going on.

        As to “transformation”, I honestly have no idea what that means and I don’t think the transformers know either, but it sure sounds like an “innovation”….

        • southern doc says:

          I would describe it as a new paradigm.

        • pcb says:

          Interestingly, there is no team medical license. So if physicians simply said, “I’ll take responsibility for the medical decisions made under my license”, a lot of this team based care would have trouble functioning.

          We can say No when asked to extend our liability and license beyond our own medical decision making.

  5. DeterminedMD says:

    “Psychiatric problems – Much of the follow-up care of anxiety, depression, or attention deficit disorder (which are the three staples of psych in primary care) involves assessment of interim symptoms and/or problems.  Care on the continuum can happen with monthly (or more frequent) reports of how things are going, how the child is doing in school, or if there are problems with medications.  Many people with these problems are reluctant to come to the office, much less talk about new problems.  I hope having direct access to my care will give them an easier avenue to give me the real view of how they are doing.”

    This is very disheartening to read. Why are PCPs/Fam Prac’s treating psychiatric disorders in this setting? Oh yeah, all mental health is a biochemical imbalance. Sure is doing wonders as all these people are just healing so rapidly and restored to the community.

    Check out this bridge I want to unload in the Nevada desert.

    • Rob says:

      You read too much into this. Certainly the vast majority of pscyh problems are handled in a PCP setting, just as hypertension is handled there instead of by a cardiologist. Most of the time I “treat” people I talk about a holistic view on things (I hate that word, but it’s true in this case) that considers medicines as an optional adjunct to be used to assist with the relational, psychological, and even spiritual issues that have led to this problem. In the traditional practice I am often reduced to throwing pills at things (which is one of the reasons I am leaving), and this set-up gives me a whole new way to avoid that bad practice.

      • DeterminedMD says:

        Hope patients will not force you to do more of the same.

        • Rob says:

          Early in practice I may have been “forced” to give Rx, but now I am pretty good at saying no when it’s appropriate and (even in the lousy paradigm of care we have now) make sure they understand the bigger picture. That’s the difference between doing a job and being a clinician.

  6. RUCertain says:

    Great post. Please continue to update challenges and success…and I hope for much success.

    Regarding JS Walker, MD: ” All things told, it would likely be less frustrating on the whole to become a PCMH (which certainly requires a team, not just one provider), than to try to invent something completely de novo.”

    This encapsulates the two main approaches to solving system problems: inside out and outside in. To be pejorative, the PCMH model seems to be the tail wagging the dog. It doesn’t fit Dr. Lambert’s practice style perfectly, like a custom tailored Italian suit but you can find something close enough off the rack to fit you; and remember the societal benefits to adhering to the model will be great even though from the front lines you are treating individuals.

    I submit that the very nature of a patent centered practice is at odds with this type of conformity causing more frustration and eventually dropping the model. I take it, Dr. Walker feels there are tailors who can fit anyone into the suits that have been made. However, when insurance gets between me and the patient I think there will always be an admonishment that “you really need to lose some weight, doc” or we don’t carry that size in the future.

  7. Barry Carol says:

    Rob –

    I would be interested in your estimate of how many hours of your practice day or week is currently devoted to documentation needed to get paid, especially with respect to Medicare patients that would disappear under your new practice model. Conversely, to what extent might you need additional staff to keep track of a continuing stream of data from patients regarding their BP, weight, glucose level and the like?

    Also, it seems that at least your more educated patients might be able to learn about some of the potential concerns you talked about from websites run by Mayo or WebMD or from an insurer’s nurse hotline. I’ve personally used a nurse hotline on several occasions including once while on vacation over 2,000 miles from home. It saved a potential trip to the ER all three times.

    • Rob says:

      I think it is reasonable to say that I spend 50% of my time doing documenting beyond what is absolutely necessary for care or searching for information that is hidden in the “packing material” of E/M coded notes, etc. that is required by Medicare. We’ve streamlined things with the EHR we use (I am obsessed with streamlining processes), but often that results in time taken to work on the process improvements and over documentation with the EHR templates.

      My hope is (and I can’t say beyond that except that other direct-care doctors have experienced it) that the time I am not spending seeing patients who don’t need to come in, and with the cut in my overall load of patients by 1/3, I will have enough time (and so will my nurse) to systematically go through people’s records and dealing with what we find. I plan on hiring one nurse and an administrator/nurse, with the latter coming once the cashflow is established. I also plan on giving a $10/month discount to patients who update their own records on a monthly basis (really just charging $10 more and discounting it back down for people to do what I want them to do). I am not sure how hard this will be to track, but it is this kind of method I want to use to motivate people.

      Regarding the other websites, I agree that they will be able to go elsewhere (and many do), but I also know that they routinely want to check what they’ve learned against what I think. Because I don’t get mad at them for coming with articles (I encourage them, actually), they aren’t afraid to ask me what I think about what they’ve discovered. My philosophy has always been that more information is almost always better, and I’ve learned new stuff from patients’ research quite often. Again, I am just offering people tools to manage their own health and am the resource they trust most to accomplish that.

      I had a guy who is going to be in India for the next few months, and he realized that under my new system he could still reach me if he needed to (almost as easily as if he were at home). Pretty cool.

  8. If you are interested in learning more about the DPC clause in the ACA, I’ve done an indepth study of it over the last year. I call this clause the “David Clause” (as in David & Goliath) in the ACA as it has the potential to slay the healthcare cost beast. I call DPC the “Triple Aim Champ” as it exceeds anything I’ve seen on the Triple Aim objectives by a wide margin.

    If you want a pre-release draft of the DPC paper (it’s about 40 pages but needs to be tightened up to <30 pages so having a fresh set of eyes will be beneficial to me), email me at dave at {avado} dotcom. I can share a rough cut. It should publish in the next month or two when I have time to get it out.

    If DPC can prove it can scale, I see the PCMH being a bridge to the DPC. Most aren't willing to let go of the insurance model as it's the "devil they know". As the Rob's of the world prove it can be scaled, why would purchasers continue to want to pay the 40% "insurance bureaucracy tax" of laying on insurance for the medical equivalent of taking your car to the shop? The results are staggeringly positive from what I've seen. Docs who aren't ready to take the leap should celebrate Rob for working on an unencumbered medical home model.

    • southern doc says:

      “I see the PCMH being a bridge to the DPC”

      Disagree. The PCMH ties the doctors even tighter to the insurers. Practices are required to make enormous up-front investments in staff and infrastructure,such that they become hooked on something as small as $1 PMPM. It doesn’t come close to covering their expenses, but any little bit helps. Patients do not pick up any more of the cost. From a financial point of view, it’s a terrible way to run a practice.

      • I’m talking about altering the care delivery side (i.e., a more proactive model vs. strictly the reactive model that is pervasive today)…not financial. I agree with you on the financial side. Dr. Rushika Fernandopulle stated the PCMH payment model as “putting wings on cars and calling them airplanes” (meaning his model is an “airplane”). As an outside observer, I’m glad primary care is being recognized for the value it brings. However, the simplicity of DPC makes much more sense to me as a patient and as an employer.

  9. Cindy says:

    As an administrator for a small primary care practice (15 clinicians) I see the PCMH movement as great job security for administrators, but alot of fundamentally unnecessary waste/ overhead from a health policy and tax payer perspective. Insurance is for high cost, high risk events – not low cost, fairly predictable services like primary care. We don’t use our auto insurance for oil changes and tune ups – why do we do it in health care? All it does is drive up the cost and contributes nothing to the quality of care.

    BTW – direct primary care is specifically allowed in the ACA, so hopefully Dr. Lamberts will have more patients able to access him in the future rather than less.

    • BobbyG says:

      “We don’t use our auto insurance for oil changes and tune ups – why do we do it in health care?”
      __

      See JD Kleinke (and, plenty of others have addressed that issue as well).

      It’s not properly “insurance.” It’s (poorly structured) pooled “pre-payment.”

  10. MikeS says:

    Rob -
    If I was in your area, I would run, not walk, to sign up with your new practice. I predict a happy healthy practice.

  11. Winston says:

    How will you coordinate referrals to other specialist doctors? This business model sounds like a good idea for PCPs, but do you think it is adaptable to specialists?

    Also, do you lock your patients in with contracts? If there’s a rift between you and a patient, can the patient cancel the subscription at any time?

    • Rob says:

      My plan is to not do referrals through my “referral specialist” but instead email directly to specialists that are willing (securely, of course). I would like to take a hand in making sure the referrals are done in a way that the specialist knows what I’ve done and what I am asking. Not being required to keep a full office allows me to do these out-of-the-office tasks that are critical and not worry about revenue. I’ve got lots of specialist friends who will cooperate, and those who choose not to may not get referrals. I don’t think I’ll have a lot of trouble at this point, as most of the docs in town I’ve talked to are rooting for me pretty hard.

      If my practice fills up, then there should be no trouble keeping people from leaving, as they would have to go back onto the waiting list. That’s part of the reason I am opening up in phases – to keep it running well and keep it full.

      I do think specialists like rheumatologists, endocrinologists, and other less procedure intensive specialties could do well in this model. There are also aspects of procedural medicine that could be done with a retainer and an eye to keep patients healthy and home, but I haven’t really thought much on that level. In truth, it’s far better as a primary care model.

  12. Talking with DPC MDs, there aren’t major differences with specialist referrals (i.e., if there’s a situation requiring specialists, they refer) but there are a few…
    1)in DPC, PCPs aren’t “loss leaders” that have a practice model that maximizes the potential for referrals — after all, if your “productivity” #’s force 8 minute encounters there’s a high likelihood that you’re inclined to get the person in & out as quick as possible by referring out or prescribing drugs. 2)DPC MDs have more time so they can discuss the pros/cons of various treatment options. One gave the example of a patient with a migraine who he said he would have likely ordered a CT scan for her when he was in a hamster wheel model of primary care. With the benefit of time, he found out his patient’s mother-in-law had moved in and he “prescribed” setting boundaries, walks, etc. – that solved the problem
    3)They also tend to follow-up more after a referral — again with the benefit of time
    4)Many have worked out deals with specialists as the DPC MDs often have patients who are on high deductible plans. They agree on a cash structure that works for the specialist as they get immediate payment without insurance/billing hassles. I regularly hear the specialists discounting 80+% as that is equal or better to what they get after all the discounts, costs, etc.

    Is it adaptable to specialists? I have heard of some cardiologists doing DPC models with a monthly retainer. Generally, I would say the applicability is more to do with no longer dealing with insurance. They’ll generate paperwork for the patient if they want to get reimbursed for costs but they no longer deal with insurance.

    Contractual arrangements vary but I haven’t heard of anyone “locking in” patients. What some do is require a re-enrollment fee so people don’t stop and start the monthly retainer just when they plan on coming in. One thing I think DPC MDs could do a better job of is increasing communication in between appointments. Smart ones like Rob are going to proactively communicate — e.g., let’s say there’s a flu outbreak or some new SARS-like thing that breaks out or some new drug or study that is getting buzz…they can curate and comment on those items.

    One of the many things I like about Rob’s plan is he’s going to spell out exactly what his charge is and exactly what you get (and don’t get) for that monthly fee. Seems basic to just about anything else in our life but that’s novel in healthcare where billing surprises are the norm, not the exception.

    In the aforementioned DPC paper, the evidence suggests a significant decrease in ED visits, surgeries, hospitalizations and specialist visits. That may be good for the patient and whoever is picking up healthcare costs but obviously one person’s cost savings is another’s revenue. It’s clear why some orgs won’t embrace DPC if they see it harming their bottomline.

    • BobbyG says:

      “In the aforementioned DPC paper, the evidence suggests a significant decrease in ED visits, surgeries, hospitalizations and specialist visits. That may be good for the patient and whoever is picking up healthcare costs but obviously one person’s cost savings is another’s revenue. It’s clear why some orgs won’t embrace DPC if they see it harming their bottomline.”
      ___

      This has long been the reform conundrum.

      “Every misspent dollar in the health care system is part of someone’s paycheck.”

      - Brent James, MD, M.Stat, IHC, 1995, during our CQI training sessions in SLC

      Brent also noted (paraphrasing here) “Let’s not kid ourselves that we’re gonna QI our way out of the larger problem. Giving the best possible care today only ensures that you’re gonna have an older and sicker and more expensive patient down the line.”

      See also “Allocating Health Care Morally,” 1994

      http://www.law.harvard.edu/faculty/elhauge/pdf/82califlrev1449.pdf

      It continues to be a socioeconomic and moral perplex.

      • Rob says:

        This is why the solution to out-of-control spending must come from outside of the system, with a disruption rather than an inside change. Those with the most to lose will do what they can to preserve their jobs. This is what finally convinced me to step outside of the system and change it for my little corner of it. My goal, by the way, is to get all of my patients old, but to keep things as simple as possible. It is far easier to focus on quality of life for someone in their 80′s and 90′s, avoiding unnecessary treatments that will potentially decrease the quality of life. Good geriatrics does not have to be expensive, in fact most elderly will choose quality of life over aggressive care if given the choice. Most aren’t, and are kept on Lipitor and get their colonoscopy.

  13. Winston says:

    Not long ago you did a post on email explaining that you don’t accept emails from patients because they are a distraction and eat up a lot of time for no pay. Given that you are now going to be able to focus more on patient relationship building than the administrative burden of getting reimbursement, have you views on using email changed?

  14. Jake says:

    Great post, understanding the continuum and how care providers interact with it is vital to what I do. Can you elaborate more about how you have reorganized your practice and what tools you use to accomplish this research and communication effectively? I was unable to find other pre-cursor blog posts; maybe you can just point me in that direction.

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