Going off the Grid – The Rise of ‘Direct Practice’ Medicine

Grid (grĭd) n.

1. Something resembling a framework of crisscrossed parallel bars, as in rigidity or organization

2. An interconnected system for the distribution of electricity or electromagnetic signals over a wide area, especially a network of high-tension cables and power stations.

3. The interconnected system employed by the Medico-Industrial complex to create a third party payment systems which artificially creates complexity, increases costs, reduces quality, eliminates accountability, and destroys the patient-physican relationship.

As has been documented in this blog, I have been on a health care finance reform journey for the last six months. I was fortunate to be given the opportunity to work with Lemhi Ventures (outstanding group of health care innovators) on looking at new models of health care delivery, financing, and insurance. During the course of that project, I learned a ton about the nature of health insurance, current status of health plans (there has been plenty of interesting news the last six months on them here, here, here, and here), followed closely the presidential debates on health care reform and become familiar with many of the innovators within this space (Prometheus, Alan Goroll, etc)

A new article just published by MDNG Live (the same magazine that featured my cover story “Meet Your New Patients” last month) showcases Jay Parkinson with the catchy title, “Jay Parkinson Sells Out!” Catchy because one thing I don’t think you will be able to call Jay is a sellout. In fact, his “stick to my guns; this is how I believe medicine should be practiced” approach has enamored him to the public media and vicariously documented the groundswell of interest in this “new” health care delivery model. “New” in quotes, of course, because there is nothing new about this model of care delivery – a patient and a physician entering into a trusted relationship wherein the physician provides services that are valued by the consumer who pays cash for them. The millennial update is that physicians can now do this in new ways, with new devices that have become commonplace in every day life except for in the inane and archaic world of health care.

The article provides some excellent insight into Jay’s serendipitous
timing, his unprecedented publicity, and the phenomenal response from
what must feel like the entire civilized world (7M hits the first six
months his site is up). I particularly appreciate Jay’s candor with
regards to the unsustainability about his original model, and how the
timing of meeting with someone of Nat Findlay’s
caliber has helped him accelerate his compelling vision. It is a great
read and highlights what I must say feels like a groundswell of
interest of people wanting to increase the value they are getting from
their health care expenditure. In fact, the current disdain of the
market has to do with the incredible complex, archiac, byzantine, and
backward health care morasses that has been built up, institutionalized
(”thats the way we have always done“), and now will be jealously
guarded as innovators continue to chip away at the very foundation of
what has become the American Health Care “System”.

This revolt of both patients and providers off the traditional
medico-industrial grid, is similar to the “awakening” that occurred to
Keanu Reeves in the Matrix. The overwhelming theme in all my
conversations with both the physicians and the patients who are
entering into these “direct practice” (the PC way to say Concierge
Medicine) relationships is one of liberation, of freedom, and of doing
things the way that they should be done. The providers get to provide a
much higher level of care, to truly get to know their patients as they
are incented to spend appropriate time with them, and over time get to
know them within their unique social/cultural context as well (hence
the house calls become important). The patients love the access, the
attentiveness, and are willing to spend cash to have the type of
unhurried, contemplative time with their physicians that is required to
develop a trusted relationship and deliver high quality care.

The numbers are compelling as well:

  • Current Hamster Wheel Model (Dr. running in between patients in 12-15 min increments)
  • 2,500 patient population
  • OK, its actually 17.5 minute increments
  • Tons of paperwork, administrative burden, frustrations, lack of care coordination, questionable quality
  • Even
    when patients satisfied with the physician, they hate the experience
    (long waits, no personalization, unintelligible interactions with
    health care system)
  • Avg Salary = ~$150,000
  • Direct Practice Model (Direct relationship with patients)
  • 500 patient population
  • $1,500 access/retainer fee
  • Paced, minimal practice overhead, positive interactions, care coordination, increased quality
  • Love the physician, love the experience (no headaches, no paperwork, transparent pricing)
  • 24/7 access, same day appointments, multiple other amenities
  • Avg Take Home = ~$500,000 + (this is conservative)

So if these numbers are this compelling, what prevents the entire
Primary Care Physician pool from Going off the Grid to practicing
medicine in this way? Courage? Fear? Lack of Systems? Inertia? Clearly,
the case is more complicated than I make it hear. Clearly, there are
major policy implications, and reverse access issues for those who
can’t “afford” this type of model (but certainly find a way to buy
$2,000 plasma TV’s).

Ultimately, as more physicians move this direction (or are dragged
by their patients), the biggest challenge will be from the
medico-industrial complex itself who has fed off the plugged in
physician nodes
for decades. How many breakaway nodes will it take
before enough people are “off the grid” that the grid begins to lose
its source of power and ultimately collapses. It is coming.

To quote the Silver Surfer: “All that you know is at an end“

3 replies »

  1. Thank you for your excellent article.
    I am the president of SIMPD, the Society for Innovative Medical Practice Design. SIMPD is the national professional society open to all concierge and other direct practice doctors (including MDVIP physicians who wish to join). We are strong proponents of the “medical homes” these practices represent. In fact I run one in Torrance, California. SIMPD now has hundreds of members in 30 states providing such medical homes coast to coast.
    The concept of “medical home” is a critical one. Every American needs one, a place they can access top notch primary care immediately and fully like one can access a concerned family member. And they need to buy that home directly, not with other people’s money. When they do so the cost can be very low and the benefits very high. Fees average $150 per month but in some settings are as low as $39.
    Direct practice doctors and those who wish to adopt the direct practice model can join the society and get many benefits including up to 55% discounts on malpractice insurance, internet practice marketing help, national care networks for traveling patients and many other services. Membership is only $500 per year, an incredible bargain considering the huge benefits.
    Patients can go to SIMPD’s web site at http://www.simpd.org for information and to find such a doctor in their own community at the “find a physician” link. This is the ideal way for patients to get personalized, prompt, excellent primary medical care in a unhurried, pleasant setting.
    One of our SIMPD Board members Steven Knope, MD, operates a direct concierge practice in Tuscon. He has published an excellent book called “Concierge Medicine” available at any book store or on Amazon.
    Thomas W. LaGrelius, MD, FAAFP President, SIMPD http://www.simpd.org (contact me there)
    Owner, SPFC Torrance, CA http://www.skyparkpfc.com (or here)

  2. Retainer practices ARE doctors trying to compete in the marketplace. They are saying, “look, you want excellent care? Well here is what it costs…” and the customers are apparently willing to pay for it as the idea seems to be spreading. Opponents of the idea should consider several things: 1) the cost will gradually come down – all new things cost more at the outset. 2) The drop from 2,500 to 3,000 patients per doc to 500 patients per doc is not what it seems. Most of those 2,500 see the doc either infrequently for a single chronic problem (hypertension) or are only seen for minor care (colds, etc). These patients are not candidates for retainer practices and are just as well served at minor care clinics. As they age and aquire the usual litany of chronic illnesses they will appreciate the value added by the slower pace of the retainer practice. 3) Retainer practices help show the difference between care provided by MDs and NPs. Do you really think patients are going to pay a retainer for a NP? I currently have a traditional family practice, but am seriously considering opening a walk-in clinic staffed by mid-levels and supervised by myself, while operating a retainer type practice concurrently with a retainer fee in the $300-500 range. I see this model as meeting the needs of almost all my patients better than a traditional practice.

  3. Just a few comments, Scott.
    First, I enjoy reading your take on healthcare.
    As regards your article, Millennial Patients, you say ‘we may be a long way from patients as providers’, patients better hurry, because the ‘grid’, as you call it, is dissolvng into the sunset as we blog.
    The ‘grid’ is to healthcare as analog TV is to digital.
    Consider what is really happening.
    ‘Traditional’ offices are failing as reimbursements decline and competition emerges. Reason- doctors allowed themselves to be inserted between payors and patients eliminating fee-for-service, and the ‘profession’ with it.
    ‘Concierge’ medicine is an unhealthy change for many reasons. One is physicians, apathetic and impotent, again relinguish control to organizations (e.g. VIP) that govern their practice. Still in the middle. Worse though is the discarding of those 2000 people per practice. Can we hold our head up on that one? So cast off the needy, keep the well and the well-heeled.
    ‘Direct’medicine, which I believe is the term for ‘retail medicine’, is no better for physicians. Most of these, TakeCare, MinuteClinic, Walmart, CVS, etc. are displacing physicians with Nurse Practitioners. Worse their coding is indicating more complex care by less trained ‘providers. Good job we doctors are doing here.
    There are going to be over 200 programs graduating Doctors of Nursing. “OK, Mr. Jones, Dr. Nurse will see you now”. Good job by docs and the useless organizations once thought there to preserve the integrity of medicine and the professionalism of its practioners, that is DOCTORS, not PROVIDERS. Head still up?
    There’s more.
    In Florida, pharmacists are licensed to give Flu shots.
    Further, hungry pharmacists, rather the companies that employ them coupled with big pharma are pushing for ‘behind-the-counter-medicine’. If you don’t know that’s when the pharmacist, at his/her sole discretion prescribes and dispenses, likly first simvastatin, then antibiotics. Supposedly the pharmacist will be following up on these. Good job docs, keep seeing patients and don’t look up because you arte dissappearing.
    Well, let me tell you my take on what is malpractice. It is the wholesale abandonment of patients by doctors, as described in part above, and the relinquishment of the trust society placed in doctors to safeguard medical care to those whose interest is SOLELY profit.
    Scott, you say the ‘Millenial patient’ will demand higher quality care. From whom , exactly?
    Solution? There was one when doctors cared a little about themselves and their responsibilities to their patients. That would be in my view to insert the patient back where the patient belongs, between the payor and the doctor. Give doctors a chance to compete in the marketplace by having and adjusting fees. Make payors compete with each other to pay patients what the market bears. It is always about money.
    But now, I don’t know. Young doctors, it seesms don’t want to work to much and don’t want to be responsible too much.
    Did I mention the internet?
    The Wall of Apathy has risen too high.
    Louis Siegel, M.D.
    see my strategies for surviving healthcare at: