Nearly 40 family physicians from 16 states descended on a hotel south of Phoenix on a recent Saturday morning to learn everything they could about direct primary care (DPC), an emerging practice model in which physicians charge patients a flat monthly or annual fee in exchange for access to a broad range of primary care and medical administrative services.
Angela Kerchner, M.D., of West Branch, Iowa, (left) and Erika Levis, M.D., of Pleasant Hill, Iowa, listen carefully as other family physicians share their ideas about direct primary care; both are new to practice and already disillusioned and ready for a change.
The one-day workshop drew physicians from as far away as Hawaii, Wisconsin and Massachusetts. Some physicians came on a fact-finding mission; others were transitioning to a DPC practice or were already engaged in the model.
Take James Woodmansee, M.D., of Provo, Utah, who, after practicing in a traditional family medicine setting for 20 years, is in the midst of transitioning his two-physician practice to direct primary care. He defined the model for AAFP News in three simple words: "True private practice."
Woodmansee verbalized what all family physicians know to be true: "Family medicine is not an eight-to-five job; it is the heart of medicine and takes a '24/7' commitment," he said.
With 11,000 patients counting on him for their health care, Woodmansee explained how he talks with patients about the change his practice is undergoing. Two months into the transition, he's signed up 150 people via face-to-face conversations. "The first five minutes into these patient conversations, they get it," said Woodmansee.
- Nearly 40 family physicians from 16 states recently converged on a hotel south of Phoenix for the AAFP's first one-day workshop on direct primary care (DPC).
- Some physicians came on a fact-finding mission; others were transitioning to a DPC practice or were already engaged in the model.
- An AAFP moderator was joined by two DPC experts -- a family physician and an attorney -- to lead discussions and answer questions.
"I explain that I can no longer practice medicine the way it's practiced today and that this is something I must to do to continue practicing," said Woodmansee. He invites patients to opt in and come along with him.
"Basically, when we accrue enough patients to sustain the practice as it now exists, then we'll have to inform the others we can't help them anymore," he said. "We're giving patients plenty of time and plenty of notice."
To date, Woodmansee has pulled in uninsured patients and those with insurance currently not accepted by his practice. He's also snagged about 80 percent of his patients on Medicare who are reluctant to give up their longstanding relationship with a trusted physician.
Experts Answer Questions, Guide Discussion
Joe Grundy, the AAFP's delivery systems strategist, moderated the events of the day and was assisted by two DPC experts. Samir Qamar, M.D., founder and CEO of MedLion Direct Primary Care, practices family medicine in Las Vegas and also serves as the board chair of the DPC United Medical Association.
Michael Campbell, Esq., proved to be a valuable legal resource for attendees. Campbell, an associate with Higgs Fletcher & Mack LLP, is a litigation and transaction attorney with a background in supporting physicians as they transition to DPC practices.
Grundy said he receives inquiries nearly every day from physicians with questions about DPC. "There is no prescriptive model and no single right way to do direct primary care," he told attendees. "Find a physician who has done it and knows how difficult and rewarding it can be, and find a lawyer who can help you make it work," he said. "Figure out how to make it work for you."
From his attorney perspective, Campbell advised physicians to slow down and take a long hard look at the DPC model before proceeding. "Don't move too fast; the compliance issues in each state are different, so it's important to talk to someone who can do the research and find the answers you need," he said.
"Preparation is the key, because if you go into it without proper preparation, things can go wrong pretty quickly," Campbell warned. He praised the AAFP's DPC toolkit as a good place for physicians to begin.
From his physician's vantage point, Qamar stressed that the patient contract was of utmost importance. In his practice, he said, "the contract is a living document; we change it every month, and we have a legal team at our practice."
From left to right, workshop faculty members Michael Campbell, Esq., and Samir Qamar, M.D., take time during a break to respond to questions about direct primary care from family physicians Lamia Kadir, M.D., James Terry, M.D., and Serena Dawn Woods-Grimm, M.D.
Generally, the contract should be clear about covered services. And physicians should walk patients through the contract before asking them to sign it. Grundy noted that the AAFP was working on more specific guidance regarding how to write a patient/member contract.
Also, to meet physician demand on the overall DPC topic, two additional workshops have been scheduled for early in 2015.
Family Physicians Come to Learn
Erika Levis, M.D., of Pleasant Hill, Iowa, is an employed physician who came to the meeting with a purpose.
"I've only been in practice for a year and I'm already disillusioned," said Levis. "I think we spend more of our time doing paperwork than we spend taking care of people. I'm here to explore this concept of direct primary care and learn about its viability."
Based on what she'd heard thus far in the workshop, Levis told AAFP News that she "absolutely would consider this model."
Angela Kerchner, M.D., of West Branch, Iowa, traveled to the workshop with Levis. She currently works as a hospitalist and a physician contractor in several small ERs.
"I'm working on my business plan right now so I can open my own DPC practice," Kerchner told AAFP News. Her plan is to fashion an integrated model of care that would include services such as acupuncture and massage therapy, all of which would be available under the same roof for one fee.
"It's hard to know the timeline," said Kerchner, although she noted that she'd like to have her practice established within two years. Her attendance at the workshop was a giant step in the right direction. "It's definitely a good meeting, and it's nice to see that I'm not alone in wanting a change," she said.
George Payne, M.D., and Joseph Hakes, M.D., are partners in a family medicine practice in Farmington, N.M. They told AAFP News they came to Arizona on fact-finding mission. "We're looking at transitioning into this type of model and whether it's realistic for us," said Payne. "We want to understand the pitfalls so we don't step into them as we go along."
The AAFP's interactive direct primary care workshop relies on volunteer table hosts like Cheri Blacksten, M.D., of Albuquerque, N.M., to jot down comments from other physicians to be shared later with the entire group.
He said the prospect of spending more time with patients was appealing, but he also was interested in reducing expenses. "About 35 percent of our overhead is spent on dealing with insurance claims; the whole process is catering to the insurance company, not the patient," said Payne.
As for Hakes, he said he bristles when letters from the insurance company arrive saying a requested medical service has been approved. "It feels like the insurance company is making medical decisions for my patient; this is about getting them (insurers) out of the way so that I can practice medicine," he said.
Still, the pair wonders how they would transition from their busy practice. "That's the challenge," said Payne. "We have eight full-time family physicians, all with patient panels of 4,000 to 5,000. This DPC model suggests each physician could handle only about 1,000 -- do the math. If we have 40,000 patients with eight physicians, where do the other 32,000 patients go in a town of 50,000?"
Hakes agreed that leaving patients in the lurch was the biggest concern. "We go to church with them; our kids play together. How do I look my patients in the eyes and say I'm switching to this model if I can?"
Some Making a Run, Others on the Verge
Julie Gunther, M.D., of Boise, Idaho, opened her solo DPC practice a few months ago and was one of a handful of physicians in the room already immersed in the model. Currently, her patient panel stands at 172, and she's adding about 45 new patients a month.
She came with a few questions of her own, but she also hoped she could inspire other physicians to jump in and take the risk.
Experts Address DPC Regulatory Challenges
Samir Qamar, M.D., and Michael Campbell, Esq., served as expert faculty for a recent AAFP one-day workshop on direct primary care (DPC). One of the issues they addressed was the regulatory challenges physicians face in moving to the DPC model.
Qamar and Campbell offered attendees a short list of general state law compliance solutions. For instance, they suggested that physicians
- avoid promising unlimited services for fixed fees collected in advance,
- identify services that may trigger added charges,
- adopt fair and reasonable patient termination and refund policies,
- ensure capacity to refund as needed,
- ensure capacity to responsibly manage anticipated patient needs, and
- implement a clear written agreement.
"Direct primary care is health care simplified and health care reconsidered," Gunther told AAFP News. "Traditional family physicians offer top-line scientific care, but we try to do it in seven minutes." FPs offer the best products but have the worst packaging, and that has driven patients to go to different modalities, she added.
"Physicians need to speak with their feet or health care is never going to change," Gunther asserted.
Gunther admitted she's had problems controlling start-up costs. Five years out of residency, she has accrued a debt in the upper six figures. Even so, she said, "It was purposeful." Gunther bought and renovated a building to fit her needs and eventually wants to add three more physicians to the practice. "You have to decide what your goals are, both financial and personal," she said. "I do anything in line with my training, board certification and self-confidence."
Jeffrey Gold, M.D., of Marblehead, Mass., is currently employed by a big health system, but on Jan. 1, he'll open the doors to his solo DPC practice. Almost 10 years after completing his family medicine residency, Gold described the act of opening the first private DPC practice in Massachusetts as "terrifying."
But he's keeping his eye on the ultimate goal. "I want to be a doctor again. I want to do what I went to school for; I don't want to be a bean counter. It's my job to judge the quantity of patients I see."
Wrapping Up a Day's Work
At the end of the long day, Grundy ask for a show of hands. "How many people are going to move to the DPC model?" he asked.
Nearly every family physician present shot a hand in the air.
Then Grundy tossed out the final question of the day, asking attendees how they would know that changing to a DPC practice was an improvement. A flurry of responses erupted from around the room. "When patients are completely engaged in their care," said one physician. "When everyone wants to go into family medicine," said another.
But the response that drew a solid round of applause was this: I'll know, said a physician from the far side of the room, "When I think about practicing medicine more than I think about retirement."
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