Saturday, February 8, 2014

Prospects for Direct Private Physician Pay

The heart of medicine is the relationship of one doctor to one patient.  In medicine, as opposed to a “health care delivery system,” the training and experience of the physician are placed at the service of a sick person, agreeable to both.  In medicine, the patient is at the center of the universe.

Jane M. Orient, MS, Your Doctors Is Not In; Healthy Skepticism about National Health Care (Crown Publishers, 1994)

The right thing to do is always simple and direct.

Calvin Coolidge (1872-1933)

What are prospects for direct payment by patients to physicians without an intervening 3rd party – an insurance company or government?

Proponents of a national health program will say, “Not great.”  So too will health insurers.   And employers who use health benefits to attract employees.  And large health care institutions who believe collaborative care by health care teams is the answer to improved care.   Most 3rd parties, by the government, insurers, employers, or health care institutions, may regard direct pay by patients to physicians at the time and point of care is a throwback to the past.

Maybe  they are right.  Maybe solo physicians, acting alone, are obsolete.   But maybe they are wrong, too. 
Solo direct pay of patients to physicians,  in the form of an  annual or monthly retainer or transparent up-front  payment at the time of service,  in return for  direct access to doctors,  being seen on the day they call, more time with physicians,  free physicals or other services, and referrals to a trusted physician or hospital network, is a growing movement.

Whatever critics say, solo direct pay is growing, doubling each year.   It is a movement partly in response to physician shortages.  It is a movement partly in response to growing waiting times to schedule an appointment.  It is in response partly in response  to shortened 10 to 15 minutes spent with physicians, as physicians try to meet bottom lines to maintain their practices.   It is partly in response partly in response  to news that health plans are dropping physicians and hospitals from their networks.  It is partly in response to anxieties and  uncertainties  over high premiums and deductibles secondary to ObamaCare’s consequences.

Critics say direct pay is a fringe movement,  a foolish return to individualism of patients and doctors who can never know enough to make informed intelligent decisions.   Direct pay, they maintain,  will never consist of more than a few hundred thousand doctors in a nation of 315 million.  

Others, including John Goodman of the National Center for Policy Analysis, father of Health Savings Accounts,  and Grace-Marie Turner of the Galen Institute, co-author of Why ObamaCare is Wrong for America,  believe direct pay will go mainstream as ObamaCare collapses in an unworkable heap and as information technologies empower patients and doctors and allow them to function efficiently in decentralized settings.

There is evidence proponents of direct pay may be on to something.

·         There is The American Association of Physicians and Surgeons (AAPS). It  has 5000 members.  AAPS advocates direct pay medicine, direct contracts between patients and doctors without 3rd party involvements.  Its numbers are growing, its meetings are well attended, and the media is taking them seriously .
·         There are an estimated 5000 to 7500 solo direct pay practices in the U.S.   These practices are concentrated in Washington State,  Washington, D.C. and suburbs,  California, Texas, Florida, and New York City, and affluent metropolitan areas.

·         There are national organizations and the Direct Primary Care Coalition,   SimpleCare, MDVIP, and AAPS telling patients how to break away from 3rd parties and to set up direct pay private practices.
·         There are individual leaders commanding national attention like Robert Berry of Greenville, Tennsessee,  who posts his fees in his office and who takes all comers, the insured and uninsured.  He has testified before Congress.  He doesn’t accept insurance.  He doesn’t have to fight with insurers to get paid.

·         There is Gerald Moore.  Dr. Moore is a family doctor on the faculty of the Institute of Healthcare Improvement in Boston. He specializes in setting ideal and lean care systems.   In Rochester, New Yokr,  he conducted (he has since moved to Seattle) a 24/7 computer-driven solo practice in one room with one employee.  He had nothing to aid him but an Internet broadband connection and a set of best practice algorithms.   He did well, pulling down an income of $155,000  his first year.  Doctor Moore said his success hinged on constant access and more time spent with patients.  Yes, the computer sped communication and eased open scheduling, but information technologies paled in importance to his renewed bond with patients..

·         There is Seattle.   Rain-soaked Seattle is America’s leading innovation center.  Micorsoft, Amazon, and Starbucks started there.  Its innovative climate extends to health care.   SimpleCare started there.  So did Qliance, Inc, founded by  Internist Garrison Bliss, who also co-founded the Direct Primary Care Coalition, which list more than 60 Direct  Primary Care  Medical Homes in the U.S. in 24 states.  Qliance physicians are salaried, reducing the incentives to perform unnecessary tests.  They keep costs low by sidestepping bureaucracy associated with insurance and reducing unnecessary and expensive trips to specialists.  Its physicians treat more than 100,000 patients each year.

·         There is Doctor Allen Wenner of Columbia, South Carolina.  Nearly 20 years ago,  Wenner, a family physicians,  asked a series of Why Not questions.  “Why not develop software consisting of clinical algorithms asking questions based on age, sex, chief complaints, symptoms, and family and social history?”  “Why not integrate these algorithms and produce a readable narrative history?”  “Why not let patients answer the questions and enter their data from their home or the reception room?” And, “Why not let them appear in the exam room with the narrative history in hand?” Working with Doctor John Bachman of Mayo,  Wenner and Bachman refined and perfected their computer interview, available ato, and it is now in daily use,  saving an average of 6 to 9 minutes for each patient seen, serving as the basis for coding claims, and effectively warding off misunderstandings that might otherwise evolve into malpractice suits
There are are all sorts of available and developing information-based computer innovations and connections that allow doctors and patients to interact and communicate directly,  like email and Skype, which fall under the umbrella of telemedicine, that permit doctors to diagnose, track, and monitor patients even when they are not physically present.

When it comes to direct pay solo practices in short,  there is a there there.

While medicine in centralizing and consolidating into larger organizations,   it is also decentralizing into smaller units such as solo practices.   Bigger is no longer necessarily better, and many patients and doctors prefer a one-on-one relationship based on trust, immediate access, and a deeper more personal relationship.   There is more to medicine than data, team care, and extensive health record documentation.   There is a world beyond 3rd parties telling you what is good for you, your health, your disease, making your personal decisions,  and what tests and procedures you can and cannot have.

Tweet:   There is a growing movement towards solo direct pay one-on-one care between the patient and doctor,  aided and abetted by information technologies.

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