Yeah, I know I used that line once before, but it’s a special day for me today. Humor me. Five years ago today I earned my last money from an insurance company. Yep, today is my five year sobriety date.
That was before the Affordable Care Act, before the Cubs won the World Series. Before anyone knelt for the national anthem, and if they had, people would’ve probably not minded. It was before the election of a reality TV star to our highest office, before “fake news” became a thing (there was plenty of it, but nobody called it that). It was before half of the rock legends died, before Anthony Wiener went to jail, back when Hamilton was a guy nobody knew much about who was on the 10 dollar bill, when the world wasn’t quite this warm, when Oprah hated me. Actually she still does. I’m not sure why.
I left my old practice because of “irreconcilable differences” with my ex-partners. Instead of going to the VA, joining another practice, or moving to New Zealand, I started a different kind of practice. My Yoda, Dave Chase (who wrote a book that you MUST read) told me about “Direct Primary Care,” where doctors don’t charge a lot, but are able to see a lot of people and give good care because they are paid by their patients. It made sense to me. There were a few folks doing it, and I talked to a couple (I’m looking at you, Ryan) who made it sound possible.
So I did it. I dumped all insurance and started charging people a flat monthly fee. People were skeptical and only my most loyal patients followed me (about 200). It took a while, but we figured out how to make it work, and my patients figured out that this was the best experience they ever had in healthcare.
And we grew.
I added a second nurse, went through several medical record systems (even built my own) before finding one that actually focused on patients over billing. Had some squirrels in my attic (some of them dead), went through an ice storm, a couple of earthquakes, and a hurricane. I also got socks with llamas on them.
And here we are. I have over 700 patients and still have room to grow. My busiest day was when I saw (gasp) 15 patients in the office. I still average between 9 and 10 (although much of the care we give is done via messaging or over the phone, so that number’s a bit deceiving). I still take Monday mornings off, still get home around 5:30 most days, and still seldom get bothered on weekends. My life is still much better than it ever was.
And there is still room to grow.
So what of my critics? What of the people who said I was shirking my duty to Medicare, abandoning my patients, and putting myself over what was best for others? They are idiots. Was it truly better when I was unable to give good care to any of my 3000 (give or take) patients, or is it better when I can give excellent care to 700? Am I truly abandoning my duty to the system by keeping people healthy, taking people off of medications, and keeping them away from ER’s and hospitals? Have I truly put myself above others by taking a huge cut in pay and spending my retirement money? Yeah, that last bit is finally changing, but I’ve got 700+ people who say I made the right choice (and I am still seeing old patients who finally come back to me from my old practice).
What about the criticism that says that this model can’t work in the big picture? What about the argument that if all docs convert to practices like mine, they would not be able to meet the care needs in our country? Again, I am actually giving excellent care to 700 patients. That’s 700 more than I was giving good care to before switching, and 700 more than most doctors give. And there is room to grow that number beyond 700 through increased system efficiency, use of midlevel providers, and improved technology enabling better care, automation, and better communication.
This model works. It is able to give truly good care to people, decreasing their use of the system and dropping the overall cost of care. Do I have proof of these claims? No, but direct primary care has dramatically grown in popularity with both patients and doctors over the past 5 years, to nearly 1000 practices around the country. Patients and doctors chose it because it’s better. It makes sense. I don’t have to waste people’s time, force them to wait in my office (my wait time still averages about 30 seconds), or spend most of my time staring at a computer screen.
So I will pick up my medal for 5 years’ sobriety. There is no temptation to go back to my old life. I hit rock bottom and have been actually enjoying the job of doctor. My future is bright. My income is growing. My schedule still has plenty of room. My patients are happy. How many doctors can say that?
And we are growing.
And I am happy.
The way medicine used to be…
Rob, out of curiosity, how much do you charge per month or per year? Also, what percentage of your 700 patients would you categorize as complex as opposed to basically healthy? I could see where DPC could be an excellent value for a complex patient but not for someone who is healthy and rarely needs to visit a doctor. Finally, how often do you need to refer patients to specialists or even send them to the ER now as compared to your old practice?
Between $30 and $70 per month (depending on age), although we are going to cut peds to $10 and $20 soon, as I want to grow that side of the practice. As far as complexity, the percentage is about the same as my old practice. While the perception by many people (including patients) is that the less complex people don’t get value, in truth we try to make sure people can get same-day appts if they need to be seen, and extremely low wait times. We also handle many things that require an office visit (UTI symptoms, for example) without requiring a visit. The fact is that many people simply avoid going to the doctor because it’s so inconvenient and unpleasant, when maybe they should be discussing things with the doc. So we do encourage people to ask questions – to keep small problems from becoming big ones (there’s this strange mindset that you have to let yourself get “sick enough” to warrant visiting your doctor, and we encourage folks to handle problems before they get big). Finally, regarding referrals/ER visits, I try very hard to encourage people to contact me before going to the ER or going to prompt care, and often I’m able to help them avoid doing so. I have always been of the mindset to use specialists sparingly, so I’m not sure about that side of things.
Thanks Rob. It sounds like your DPC practice is working very well for both you and your patients. The economist in me can’t help thinking, though, that the fallacy of composition could be at work here. Suppose, for the sake of argument, that everyone in the country could afford the subscription fee for a DPC practice and would subscribe to one if it were available to them. If the typical traditional panel is 3-4X the size of a DPC panel, it suggests that we would need 3-4X more primary care doctors than we have now. While I get that you save a lot of money by not having to hire people to help you deal with billing and collecting from insurance companies, including Medicare and Medicaid, you still must have significant practice overhead for office space, equipment and supplies, malpractice insurance, and staff, including nurses and techs, to do everything from schedule appointments to respond to emails to treat patients with minor complaints. So, perhaps you could tell us how your practice overhead compares to your old practice and how much gross revenue you need to generate from subscription fees to produce an acceptable income for yourself.
Even if all these DPC practices could reduce ER visits and shrink the use of specialists, people are still going to develop chronic diseases and conditions that account for 75%-80% of all medical spending today, including by the way, virtually all of my own claims. The big tickets for hospitals are surgical procedures and cancer treatments even as more of that care can be done on an outpatient basis or an ASC today. Pharmaceutical spending is still growing rapidly, especially specialty drugs which only account for 1% of prescriptions written but over 30% of drug costs and probably heading to 40% within five years. There is lots of mental illness along with alcohol and drug abuse which don’t seem to lend themselves to mitigation by DPC practices as, say, hypertension or asthma.
The bottom line is that even if we could staff all of these DPC practices, I’m not convinced that total healthcare costs across the system would decline. It reminds me of single payer advocates claiming that since Medicare works well and seniors like it, we should just implement Medicare for all and save on administrative costs and pay less per service, test or procedure. Medicare only works as well as it does because there is still a significant commercially insured sector to shift costs to.
That all said I like the idea of same day appointments and the ability to reach a doctor on a timely basis with a phone call or by email. Even though lots of minor medical issues resolve themselves within a couple of days, reassurance is a comforting thing for patients which many would value enough to be willing to pay for.
Barry: I share the same concern in terms of generalizing this to the population, and I can’t say that this is a panacea. That remains to be seen. But in terms of volume, that may be a solvable problem if the need to solve it is great enough. There are many things that can be done to make a system work more efficiently if there is enough pressure to do so. I’ve been talking to my son (an engineer who is getting his masters at Georgia Tech in machine learning/artificial intelligence) about how to apply what he does to my practice. Could he develop tools to handle problems more efficiently and with greater accuracy? Is there a way to augment my ability to see people and care for their problems using an AI assistant? This is an irrelevant problem in the current system, as it is an economically foolish things for docs to do (the goal is to have as many sick people as possible, and efficiency is penalized, not rewarded). So if there is an overwhelming demand for DPC, would not the system strain to find ways to extend the outreach. Plus, if suddenly being a PCP was both an enjoyable and financially rewarding job, would there be a sudden flood of docs wanting to do it (including many specialists who wanted to do primary care, but couldn’t stomach the hassle for the poor pay)? I don’t know. But this is a very rapidly growing trend and there are lots of people who see it as a potential game changer. There is finally someone playing defense against all the wonton spending. That’s one of my goals.
The “skip and whistle” in your post is easily discernible. With health care based solely on collaboration, reciprocity and trust, the effect for you and your panel must by incredible.
What one patient wrote recently: “Dr. Rob Lamberts has been our family doc for almost two decades. Since he changed over to a Direct Primary Care model, we’ve enjoyed excellent and convenient healthcare and the only thing we had to give up was the waiting room! Unlike the experience at traditional practices, we’ve never had to worry about feeling rushed through like we were a number (or cattle!). In fact, there have been many times our needs have been met via direct communication with a smart phone app. We didn’t even have to come into the office for care and medication needs! I strongly encourage you to give these folks an opportunity as they offer convenient quality access to a great physician and friendly staff!
Did I mention it is extremely affordable?”
There is recently well considered research that the prevalence of trust in a community promotes better HEALTH in the community and also correspondingly further increases the level of Trust in the community.
[ Giordano GN, et al. TRUST AND HEALTH: Testing the reverse causality hypothesis. J.Epidemiol Community Health 2015;0:1-7/jech-2015-206822
The folks who study political economics as a view of population HEALTH have a lot to offer. I am particularly interested in the “Design Principles” as a basis to successfully managing a COMMONS, as defined by Professor Elinor Ostrom. For health care, its COMMONS is represented by the portion of our national economy devoted to health spending. Since 1960, health spending as a portion of the GDP has increased from 5.0% to 18.2 in 2016. This represents an increase, in addition to economic growth, of 2.33%, compounded annually. All of the other OECD nations spend less than 13% of their GDP on health spending with better outcomes. See “Mirror, Mirror…” report posted on the commonwealthfund.org website last July. Last year, the difference for our economy between 13% and 18.2% was nearly $1 Trillion.
In the mean time, our Medicare eligible population is in the throes of doubling between 2000 and 2030. And, since about 1970, our nation’s citizen’s level of social mobility has virtually stopped for citizens growing up in poverty. For the details, read OUR KIDS: The American Dream in Crisis by Robert D. Putnam, 2015.
By the way, the “Design Principles” for managing a Commons have been validated by volumes of research.