Episode 097: Understanding the Direct Primary Care Practice Model

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J. Baugh: Hello everyone, and welcome to this edition of Your Practice Made Perfect. My name is J. Baugh, and I'll be your host for today's episode. Today we're going to talk about concierge medicine and some of the different models that are involved in that field. Joining us today we have Dr. Charles Marable. Dr. Marable, it's good to have you here today.

Dr. Marable: Well, thanks J. It's good to be here with you.

J. Baugh: Well, thanks for your time. Before we get started, tell us a little bit about yourself.

Dr. Marable: Well, I've been a physician in family medicine for 25 years. I completed residency in Florida and then practiced with a small group in my home state of Arkansas for about five years, and then for the past 20 years, I've been a solo practice doctor in Franklin, Tennessee.

J. Baugh: So I know that there are varying models out there. There's the direct primary care model, there's concierge medicine, the MDVIP model, and I'm just wondering if you could speak on the differences between all of these models?

Dr. Marable: Oh, absolutely. You know, the field has changed quite a bit over the last several years, and I would go back to 2005. At that time in solo practice, I realized that being involved with the insurance payment system was unsustainable as a solo doc, and I was facing burnout trying to see enough patients to make it work, to the point I was ready to quit clinical practice. But I thought if I could find a better business model, I would try to make that work. And that began my journey into direct medical practice, specifically the concierge model.

So I guess in simplest terms, direct primary care, or DPC, is distinguished by the source of payment and the practice size. Payment for either of these models, DPC or concierge, it comes directly from the patients we care for and we don't contract with any insurance companies for payment. Also, the other point is that the practice size is small enough to preserve the patient-physician relationship and allow improved communication and give adequate attention to preventative care, patient education, and disease management.

The names that are given to this model of practice have varied through the years. When I started, boutique practice was popular, and I didn't like that at all. And then concierge practice, and I didn't really care for that either. It seemed to connote an exclusive practice just for the rich and famous, which it hasn't been my experience that it's exclusively that at all. Retainer practice, and now direct primary care or DPC. But overarching concept is a practice that doesn't involve insurance payments, has a smaller patient load, and provides unparalleled access to care.

Patients still generally maintain their health insurance for catastrophic needs or for payment of their labs, X-ray, study, specialist care, medications, hospitalization and that sort of thing. So the basic difference is the price point and size of practice. But the common denominator is with either model, either a concierge practice or a direct primary care practice, the doctor doesn't participate in any insurance plan for compensation.

For a concierge practice, it typically has fewer patients than a DPC practice, but a higher price point. I think a lot of references would say a concierge practice often has about 300 to 600 patients with an annual fee starting around $1,500 a year and going up from there. And this is the model of most of the earliest DPC practices, which we're basically concierge models. I say direct primary care because of that compensation issue, but certainly, DPC now tends to refer to practices with a larger number of patients and a lower entry point or price point. So it has a greater appeal for different geographical and demographic regions.

J. Baugh: How about the MDVIP model? How would that be different from the other models that you've talked about so far?

Dr. Marable: Right. So MDVIP is a company that was started in Boca Raton, Florida in 2000, and it helps doctors to start or transition their practice to what some have called a hybrid model, one that's similar to a concierge practice, but it's not a direct practice. These practices do bill insurance for covered medical services and also charge a direct fee paid by the patients for medically relevant services that focus on early detection, prevention, wellness, and enhanced access and service.

So MDVIP provides a turnkey service to help a doctor move to a concierge-like model of practice, but it's not a DPC because they do participate in insurance. Their website says that they are not a concierge model, though there are many similarities. The greatest distinction is that they continue to bill insurance.

J. Baugh: Let's start with the direct primary care model. What is your experience with that model? And maybe you can tell us some of the pros and cons of a physician going to a direct primary care model.

Dr. Marable: Back in 2005, I was feeling like I was approaching burnout and it didn't make sense to me to try to work harder to get paid for the work I'd done months before. The effort at coding and billing and documenting for the purpose of justifying payment, it wasn't what I went to school to do, and I wanted to find a way to give the very best healthcare I could and have a simple business model.

So I began to look and remembered reading in a journal about a couple of doctors in Seattle, Washington that started a business called MD². As far as we know, that's the first concierge practice that began in 1996 by doctors Howard Maron and Scott Hall. Their story appealed to me at some level because they created something new in the marketplace. They had been providing medical care to some professional athletes in that area at a very high level of service, and they thought maybe there'd be a market to provide that level of service to some of our regular patients. So they began MD², and they limit their individual practices to 50 families and it's at a very high sticker price.

But that's sort of an exception in the marketplace. There's few practices like that. But shortly after they began, practices sprang up that had panels of patients than MD², and they charge much lower fees. They were still the concierge practices of the day.

Nine years after they began is when I began building my new model, which became the first concierge practice in Tennessee. I think at that time, different estimates, but there were about 400 doctors in the country doing this model of practice at the time. So I networked with several of them and listened to their stories and I found a lot of inspiration and encouragement from them in my journey. They showed me that this concierge model was a viable business, and more importantly, they showed me that they were able to care for their patients to the best of their ability, enjoy their practice, and their patients generally like them as well. So it was working out really good for them.

When I started, I just tried to imagine what the ideal practice would look like, and spent a couple of years building that out, and wanted to focus on preserving the relationship I had with patients and kind of did that by removing as many of the barriers that came between us. The biggest barrier, the third-party payer system, I had about 3000 patients in my traditional medical practice and I had six or seven insurance contracts. I canceled them all on December 31st, 2006, and started the next day with just a few families that had agreed to go with me in this new journey.

I removed other barriers like the waiting room, so I don't have a waiting room. I see patients at the time of their appointment. I see one patient in the office at a time, so there's no rush to get from one room to the next. And don't have a complicated phone tree, don't have that sliding glass partition that separates folks. Directly available to patients. The small practice size is very doable. It may be hard to imagine for those who still have a patient load of thousands of patients like I once did, but patients are able to connect with me by cell phone or text, email, video chat, house calls. And then I can usually see patients in the office the same day that they have need.

It gives me the opportunity to listen well to my patients when they tell me their story. The average time before a physician interrupts a patient's story to get the essence of what they need is about 11 seconds as reported in an article last year. Patient care becomes more of an ongoing conversation rather than a one and done visit. And I think being focused and unhurried helps build trust and enhance the relationship, which is important for longitudinal care.

This model of practice has given me more time to do procedures in my office rather than having to send those things out. I'm more hands-on with the process of care coordination, seeing the process through, and connecting the dots for good outcomes for patients. So, that's how I got started in it.

J. Baugh: Well, it sounds like you've got several great pros in using the model that you're currently using. I'm thinking about the people who are listening to this podcast and thinking about maybe going to one of the different models that we've been talking about today and I'm wondering if maybe you could shed some light on the staffing needs that would be related to the model that one of our listeners might choose in this regard?

Dr. Marable: It really varies according to the type of model and the practice size. A larger number of patients, the more staff is needed. But I think it certainly looks and feels a lot different than a traditional practice. So depending on the size, someone might have an office manager or business manager, they may well have a receptionist, and they may have some sort of medical assistant or nurse. It's certainly smaller than most traditional practices. You don't have to have the billing component, coding issues, and things like that.

My particular practice, I would describe as a micro practice. So it's a little bit unique in that my practice is small enough that I only have an office manager that works part time to help oversee patient accounts and onboard new patients and help with marketing efforts, but I've remembered how to take blood pressures and things like that. It just gives me more face to face time with patients to build that relationship. So I have an extremely small overhead and support staff.

J. Baugh: Yeah, I'm sure that your patients really appreciate the amount of time that you're able to spend with them with this type of a model. So I'm guessing that your patients really enjoy being able to interact with you in this type of an office setting, considering the model that you're using. What are some of the questions that a physician might anticipate that a patient would ask regarding one of these new models?

Dr. Marable: Sure. J., you know, the first question that a patient usually asks me is do you take my insurance? And I usually tell them that I take all patients regardless of their insurance. Their insurance will work for them for anything it normally would outside of their time with me. So if they need to see a specialist, go to the ER, go to the hospital, get some medication, get an X-ray, get some lab tests, they use their insurance just like they normally would. The only thing it doesn't cover is my time. They pay me directly for my time, and I translate that into better service, better access, and I think in some cases a point could be made that there are better outcomes.

For example, there is some data by MDVIP that direct primary care reduces hospitalizations by 80% and reduces readmission rates by 95%, and that's a huge savings. DPC reduces wait times for appointments, it reduces waiting time at the office, it increases face to face time with the doctor.

Some patients ask me if they can use their HSAs for payment of my membership fees. The current status is that HSAs cannot be used for membership payments. There's some effort to perhaps get that changed, but as it currently stands, membership payments for direct practices cannot be paid by HSAs. They can be used, of course, for those other areas like medications, lab work, X-rays, and specialist care.

J. Baugh: So tell us how Medicare might factor into one of these models that we've been discussing today.

Dr. Marable: There is a particular situation with Medicare patients in order to be treated and do that legally, and I do have a number of Medicare patients. The situation there is that a doctor must opt-out of Medicare, it's an easy process, and then privately contract with a Medicare insured patient.

J. Baugh: So what are your primary takeaways that you've learned from your studies and practices regarding these alternative models of medicine?

Dr. Marable: Some of the key takeaway points I would say would be that direct primary care eliminates pulling teeth to get paid by insurance companies for the work you did months ago. That's just one of the biggest things that has released a huge burden, I think, in the business side of medicine. It's so simple now. I see patients, they pay me for the work I do, and I think that some of that satisfaction that you mentioned really comes out.

There's so many times in the traditional practice where I began the patient visit by walking in the door and apologizing for being late again to see them.

J. Baugh: Right.

Dr. Marable: That was a regular occurrence. So now to be waiting for my patient to show up at the office and be able to accommodate them if they're early, if they're late, and we're not rushed, I think they just appreciate that. They feel well cared for and it makes going to the doctor a little bit more enjoyable for them. One of the satisfying things about this business model is it eliminates the middleman and the time required to checkboxes for them, which translates into more time with patients.

I think these new models of direct care demonstrate the potential for continued innovation in design, and it's even more possible to have a successful direct practice in most demographic and geographic areas. It's not just limited to metropolitan areas. There are affordable electronic health records that are more practical and useful for direct practices to facilitate the business model. There are numerous resources to give guidance along the way if you're transitioning your practice.

J. Baugh: So we've talked about several pros regarding these different models, what kind of criticisms are out there about concierge medicine models?

Dr. Marable: I think the biggest criticism that I hear is if more doctors went to this model where they only had a few hundred patients, there would be a huge gap inpatient care.

J. Baugh: If every physician went to that model, there wouldn't be enough physicians.

Dr. Marable: So a couple of things about that. First of all, we know that more doctors are retiring early, getting out of clinical practice, working part-time, or graduates are going into subspecialties rather than primary care. So that creates underserved areas. I would have been one of those doctors that would have left the marketplace. This gives me a way to stay in it and at least see some patients.

J. Baugh: Mm-hmm (affirmative).

Dr. Marable: Second, most doctors aren't going to adopt this model. It is scary to transition.

J. Baugh: Yeah.

Dr. Marable: It's not a walk in the park. It's work like everything else. It's just that the work makes more sense to me.

J. Baugh: Mm-hmm (affirmative).

Dr. Marable: Working hard to build a business that serves people that pay me directly and I'm accountable to makes a lot more sense than trying to please the person behind the curtain pulling the strings they'll never see that makes life difficult for me. You know, it's work, but it's worth it.

But I think that because a lot of doctors are sort of over-invested in things, in the system they're in, it's very difficult to break out. I was in a place where I didn't have much to lose and I just did it. And the other thing is if it was more financially attractive for a doctor to go out and make a sustainable business model, more doctors would go into this and there would be plenty of doctors around to take care of folks in a better way.

J. Baugh: So as we begin to wrap things up with today's episode, what is the message that you would like to leave our listeners with?

Dr. Marable: DPC and concierge practices are certainly not the cure for our broken system, but for some physicians, it's a way to change our little corner of the world and remain in practice to care for some patients. It's a great way to offer very high-quality care to patients, improve outcomes, and achieve high patient satisfaction. I think for the doctor, it's a way to recover the joy of practicing medicine, avoid burnout, and have higher job satisfaction.

It makes the business of medicine become much simpler. When you don't have to spend so much time gaming the system to get paid, checking boxes, going to seminars to learn how to be a savvy coder, or hiring someone to do that, that leaves a lot of time to be creative and think about what would an ideal practice look like.

That's why I encourage people not to get too stuck in thinking about one of the big examples of direct care models like a concierge practice of 15 years ago or a certain model. Think about what would be best for you and then go out and do it. Some of the younger doctors who are very tech savvy and social media savvy, they have done this with excellence, and they have set up their own direct practice and have been so successful at it that they now help others become successful and set up their practice as well.

J. Baugh: So if someone wanted to find additional resources that would help them to decide whether they want to go to one of the different models that we've talked about today, where would be a good place for someone to go find those resources?

Dr. Marable: I will leave you a list of some of the references that I'm aware of and that I've used in the past. There are some societies and some websites, some foundations that are supportive of direct practice. There are some businesses that offer practical and useful electronic health records and services for back office work. There's some annual summits where these doctors get together and interact with each other. That, I think, is one of the most helpful things somebody that's curious could do. Then there's some individual physicians who have direct practices that have been very innovative and creative and also serve to assist other doctors transitioning their practice.

J. Baugh: Well, it sounds like there are a lot of resources available to someone who wants to do a little further research, and we'll be sure to include those resources in our show notes for this episode.

Dr. Marable, I want to thank you for being here today. I know that you've given our listeners a lot of great information concerning the type of models that might be more effective for their practice, not only from the physician standpoint, but from the patient's standpoint as well, and we want to thank you for being here today.

Dr. Marable: Thanks a lot.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect, with your host J. Baugh. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast.

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