Going off the Grid – The Rise of "Direct Practice" Medicine

15 May 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 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, ? 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

11 Comments
  • Ian Furst
    Posted at 22:36h, 15 May Reply

    Hey Scott — Bet you a coffee (starbucks – large, fancy one) that you’re wrong and time will prove it. Staying “on the grid” with third party payment systems lets patients (i still prefer this term to consumers) insure themselves against hellish bills in the event of a major medical problem. And direct practice medicine is great for minor problems but the second you need anything more complicated than an otoscope to diagnose the problem off to the specialist you go. I’d like to see a study at the end of a year that shows the real times savings to patients. Yes, the don’t wait in an office for their GP but they have to make more trips elsewhere. Anyway, I didn’t come to comment on direct care but the new millenium model. The new millenium model for all businesses is about velocity not social interactivity. Patients will expect their GP to provide definative care quickly and with a high degree of organization. It’s not direct care that doctors need to embrace but the concept that quality and velocity are going to become highly valued by their patients. Which brings me back to direct care. If there is a mass movement by GP’s (and if payment plans continue the way they are I think it’s a real possability) 1/5 the number of patients per doctor without 5x greater doctors is going to equal skyrocketing costs and limited access. How does that change the speed of care?
    Good blog btw — enjoyed reading. thx. ian.
    waittimes.blogspot.com

  • Our Own System » Blog Archive » It’s Called Direct Practice
    Posted at 00:10h, 16 May Reply

    […] What is old is new again.  I’ve been calling it the wrong name all along. Alas, we call it Direct Practice. Crossover Health compares the old and new: […]

  • scottshreeve
    Posted at 00:57h, 16 May Reply

    Ian,

    Unfortunately, I don’t drink coffee – perhaps a large sports beverage of your choice?

    You raise some valid points which I will clarify.

    “Going off the Grid” implies dropping out of the insurance paradigm only for those small expenses that consumers should not be using insurance for anyway. Please see my recent article on “True Insurance” which provides the most succinct description of what the term insurance should mean within health care. People in direct practice models still need to have insurance – a financial risk instrument that protects them against catastrophe (lets say anything above $50,000 in a single year). They could also benefit from having some type of financing mechanism for everything between (lets say $10,000 to $49,999) that “insulates” them from the full cost either through price discounts (the network) or through some type of risk/cost sharing program coupled with some sort of financial planning/long term repayment program. In this model, you have three layers of coverage:

    1. Cash
    2. Co-Share (variety of cost sharing means)
    3. Catastrophic (True Insurance)

    Interesting concept. I bet somebody is working on it. ; 0

    You are also right about Millennial Care. I am not making the argument that it is about social networking. I am making the argument that it is about a new social contract between the provider and the patient as partners. The velocity aspect comes in with using technology to enable the new relationship – extend it, deepen it, and make it more personal (not less!) by the smart application of technology. This is seen in terms of access to the physician (email, text, etc) on terms that are efficient to both parties while simultaneously removing the dead carcass administrative burden of the current paradigm.

    The policy implications of the direct practice model are concerning. If all physicians jump ship to this model, we will be in a worse crisis in terms of primary care. However, Wal-Mart has already got that figured out. Those NP degrees just went from gold to platinum, baby. The only way I see to do this is to extend the concept of primary care to providers who are trained, can follow algorithms, and can be distributed to the new delivery system – big box stores on every street corner in America.

    In terms of your bet, I could be way off. But I am comfortable with my knack to predict next waves. See you at takeoff.

  • Steven D. Knope, M.D.
    Posted at 01:45h, 23 June Reply

    Scott is correct in his analysis of true health insurance, as opposed to the traditional $500 annual deductible plan that most people have through their employer. This is little more than pre-paid health care – health care that most patients never receive!

    I opened one of the first concierge practices in this country 8 years ago. I’ve just written the first book to be published on the subject, “Concierge Medicine, A New System to Get the Best Healthcare” (Greenwood/Praeger, May 2008). I used the politically incorrect term in my title, because most people don’t know what a “direct practice” is.

    Though there are controversies, concierge medicine is now available for the middle class and is quite affordable in many areas of the country. Most of the arguments against concierge medicine fall apart under scrutiny. I have an entire chapter in my book devoted to this issue.

    Concierge medicine is driven by patient dissatisfaction over our present fast-food medical model of HMOs, PPOs and a failing Medicare system. Patients love the time they have with their concierge doctors. Doctors love having the time to do what they were trained to do. Unless primary care medicine becomes more attractive to young doctors, by implementing models such as concierge medicine, no one will opt for a career in internal medicine, family practice or pediatrics and the shortage of primary care doctors will only worsen.

    Steven D. Knope, M.D.

  • Hamster Wheel Medicine - Getting off the treadmill « Crossover Healthcare
    Posted at 22:37h, 10 December Reply

    […] Shlain and I opened the morning session of the 2009 WHIT Conference by introducing the notion of Direct Practice as a model for enhancing access, reducing costs, and improving quality.  Our presentation is found […]

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    Posted at 05:13h, 03 March Reply

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    Posted at 16:57h, 22 May Reply

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  • SHibdon
    Posted at 15:22h, 08 June Reply

    1. Where does one find such a doctor? This sounds great, but there’s no “Direct practice medicine” listed in the phone book, and obviously the insurance companies aren’t listing them.

    2. How does one know that he/she is a good doctor? I would rather have a doctor who knows me better, has time to listen, etc., but even if I somehow find one who follows the direct practice model, I’ll be missing the reassurance that a large practice gives (namely, that the doctors in a large practice have been closely evaluated and chosen because they are good doctors). There’s no screening process for a doctor who decides to go it alone.

    • Scott Shreeve, MD
      Posted at 06:05h, 11 June Reply

      Susan,

      Thanks for your post. We are lacking right now in the direct practice space a national directory of providers. The closest thing is what SIMPD is doing, as well as the work by HelloHealth who is creating a University for physicians who want to learn to practice in the way I describe.

      In terms of the quality of the physician, that is still open for discussion. I realize that you feel that practicing in a large practice implies that your physician has been “screened”, but I can tell you from the inside that physicians themselves have no idea how good they are because there is very little information that even they have to actually know. The variations in care are astounding, and disappointing, and we need to continue to push for doctor rating systems that are based on objective evidence of quality – instead of the Zagat-style popularity contest. We need real clinical outcomes measures to help people know that their knee surgeon has performed 4,123 arthroscopies, is currently 75 days without an adverse outcome, has a 2.5% infection rates, and and overall patient satisfaction score of 4.23 (out of 5) with access to former patients comments and contact information.

      It is only in that environment that you are going to be able to truly judge the quality of the physicians. We are not there. but heading there.

  • CPT Codes-Why physicians always get screwed, thanks AMA « Crossover Healthcare
    Posted at 19:27h, 08 July Reply

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  • Russ McDaniel
    Posted at 14:15h, 11 August Reply

    I am proudly studying to become a Physician’s Assistant and I am intrigued by this healthcare model. Thanks for sharing! One comment I would like to contribute: Even if Direct Practice develops, expands, and becomes widely regarded, I believe the average citizen will still be punished monetarily because they will still have to pay the taxes which support the seemingly inevitable socialized system which is being railroaded through congress. It will be like having to still support public schools while also paying for private school tuition. Luckily, the free market has found ways for even low-income families to do that. I believe healthcare has the potential to do the same, so long as Washington DC is somehow kept from interfering too much with the innovative potential of our society. Can you tell I’m not a big fan of the government?

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