Family physician Clint Flanagan, M.D., owner of the first direct primary care (DPC) business in Colorado -- Nextera Healthcare -- has been on a collision course with the status quo since he hung out his DPC shingle in 2011.
Danielle Culjat, lead medical assistant for Nextera Healthcare/North Vista Medical Center, prepares patient information after fielding a call from a patient needing to have his hand stitched up.
Just before kicking off a Dec. 2 Ask the Doctor session at Left Hand Brewing Co. in Longmont, Colo., FP Clint Flanagan, M.D., (far left) answers an employee's question.
Left Hand Brewing Co. employee Morgan Zamora (left) asks Clint Flanagan, M.D., about the benefits of exercise tracking devices such as Fitbits, while Ryan Call listens in.
Clint Flanagan, M.D., (left) explains that biometric screenings help shape how major health insurers charge companies based on the health of their employees, as Left Hand Brewing Co. employee Reed Sitler listens intently.
Eric Wallace, (right) president of Left Hand Brewing Co., explains his concerns about insurance companies using body mass index (BMI) in setting their premiums to Clint Flanagan, M.D., and others at the Dec. 2 session.
Both the craft beer business and direct primary care demand a spirit of innovation, and each has seriously disrupted its respective industry.
That's according to Clint Flanagan, M.D., who owns the first direct primary care (DPC) business in Colorado -- Nextera Healthcare -- along with a group of three fee-for-service practices in the Boulder area that, together, fall under the North Vista Medical Center banner.
Flanagan discussed his DPC successes during a Health is Primary panel in Denver on Oct. 2. The event marked the fourth stop on the Health is Primary campaign's City Tour. Health is Primary is a communications campaign sponsored by Family Medicine for America's Health.
So when the AAFP asked Flanagan to come to Kansas City, Mo., and speak at the first Direct Primary Care Summit hosted in the Midwest back in July, Academy staff asked whether he would be willing to bring a representative from one of the employers with whom his DPC business partners to present the client's perspective. The decision, he said, was a no-brainer.
- Family physician Clint Flanagan, M.D., opened Nextera Healthcare -- the first direct primary care business in Colorado -- in 2011.
- Currently, Nextera Healthcare boasts 18 health care professionals (physicians, nurse practitioners and physician assistants), including those located in its affiliated practices, plus roughly 40 support staff.
- When Nextera Healthcare added Left Hand Brewing Co. as a client in 2012, the brewery's health insurance broker was able to negotiate a 4 percent reduction in its major medical insurance policy premium.
Flanagan tapped the human resources team from client Left Hand Brewing Co. in Longmont, Colo., to join him onstage, and their presentation caught conference attendees' attention right off the bat.
"Left Hand is very innovative, and one of its innovations is putting nitrogen into a bottle of beer," Flanagan recently told AAFP News. "They have a beer called Milk Stout Nitro that is a first of its kind."
And that's how the group got things started: At 9 a.m., in front of a packed house at the InterContinental Hotel, each person onstage poured a Milk Stout Nitro into a glass and quaffed it.
Apparently, the gesture was met by good-natured hecklers in the crowd yelling, "Why didn't you bring beers for everybody?!"
Road to Nextera
Flanagan began his journey to becoming a DPC champion through traditional channels. He went to medical school at the University of Nebraska Medical Center College of Medicine in Omaha; did his residency at the Family Medicine Residency Program at St. Mary's Medical Center in Grand Junction, Colo.; and in 2004, went to work for a startup private multispecialty group practice in the Frederick/Firestone, Colo., area (a bedroom community of Boulder) for a number of years. His small medical group introduced the first physicians to the town.
As if opening a new clinic wasn't stressful enough, Flanagan was deployed the same year to Iraq, where he provided care to soldiers throughout 2005 as part of the Army National Guard. When he shipped out, the news was splashed across the front page of the local newspaper with the headline "Doctor Goes to War."
After returning and deciding he wanted to own his own medical center someday, Flanagan went to work for Centura Health, the largest provider of health care in Colorado, for a few years, eventually transitioning back to the Frederick/Firestone area in 2009, when he opened the first of three North Vista Medical Center locations.
It was around this time, Flanagan said, that he noticed some of his fee-for-service patients were struggling in the current health care system, and he began investigating an alternative care delivery model.
"I had patients saying -- for one reason or another, be it copays or 'I just got fired from my job -- I can't come see you,' or 'It's too expensive to come see you,' or 'My company just signed up with Kaiser and you aren't a Kaiser doc, so I can't come see you,'" he said.
Family physician Clint Flanagan, M.D., (left) answers Left Hand Brewing Co. employee Jim Bruckner's question during a Dec. 2 Ask the Doctor session at the brewery in Longmont, Colo.
What Flanagan said he eventually discovered was that the bar is set so low for traditional primary care practice in America, it's pretty easy to step over it and find a better way to answer patients' needs.
"You can't get in to see your doc, you have to wait in the lobby for way too long and sometimes you don't even see your doc -- you see another doc or a mid-level," he said. "Then when you go in, your doc spends three to five minutes with you. Or you get kicked out to the urgent care and you have a $50 copay. What other industry would be satisfied with this?"
Flanagan was already well-versed in the frustrations of trying to run a fee-for-service practice, including high overhead and the slow process of getting insurers to pay.
"Imagine your plumber showing up and you say to him, 'I know it's $100, but I'm going to pay you $70, and I am going to give you that money in a month or two from now,"' he said. "Your plumber would say, 'Are you crazy!?'"
According to Flanagan, working in a fee-for-service setting comes with the "noise" of prior authorizations, insurance paperwork and coding that, collectively, create major barriers to delivering great patient care.
"I truly feel it's important to protect the patient-physician relationship, and we should try to do as much (as possible) in this country to push away the noise that gets in the way of this relationship," he said. "That's why it was crystal clear for us as a startup to say, 'Here's what we're going to do; is it going to work? I sure hope so, because we're banking on this, and it's got to be better than where we're at.'"
So to bypass these barriers, Flanagan decided to offer his patients and employer groups the option to pay for their health care directly for less than a monthly phone bill. And like that, in 2011, Nextera Healthcare was born.
Nextera Healthcare Today
Currently, Nextera Healthcare boasts 18 health care professionals (physicians, nurse practitioners and physician assistants), including those in its affiliated practices, plus roughly 40 support staff.
Nextera offers month-to-month DPC contracts, so if individuals, families or employees decide to pursue other health care options, they can leave without penalty. But so far, most clients have stayed with Nextera long-term, supplementing that care with a major medical, high-deductible plan for big-ticket health care needs.
"You are going to pay less than the cost of a latté every day to have connectivity to your doctor, so in case the 'stuff' does hit the fan or you want to talk about your sleep problems, your weight problems or your challenges with high blood pressure, you have a primary care provider who is there for you," Flanagan said.
Connectivity is a big selling point for DPC and Nextera, and Flanagan gives each of his patients his cell phone number and encourages them to contact him with any health questions. He said he typically gets a text or a call from a patient at least once a day.
The day AAFP News visited, for example, a patient texted him a photo of a rash that had just appeared, and using this technology allowed him to respond immediately instead of waiting the three or four days it would have taken for her to get an appointment under the traditional fee-for-service model.
DPC has brought the role of the physician back to that of "coach, guide and Sherpa," Flanagan explained -- someone who coordinates efforts to get and keep patients healthy.
During the session, Left Hand Brewing Co. employee Erik Henning sings the praises of Clint Flanagan, M.D.'s direct primary care practice, Nextera Healthcare, which has treated his 17-year-old son during the past year for chronic back pain caused by degenerative discs, arthritis and pinched nerves.
And if a DPC patient needs to leave what he calls the "primary care ranch," his role is to help guide him or her on that path, as well, he said.
"Whether it is to help a patient with a newly diagnosed cancer by connecting him or her with specialists like a hematologist-oncologist or a good surgeon -- my job is to help the patient navigate through that scary time," said Flanagan. "And that is when the patient will use their major medical, high-deductible policy."
Left Hand Man
Before coming onboard with Nextera Healthcare in 2012, Left Hand Brewing Co. only offered its employees a high-deductible plan. But the brewer immediately felt the impact of partnering with the DPC business when its insurance broker successfully negotiated a discount from its major medical policy provider, Cigna, thereby reducing premium costs by 4 percent upfront. The broker made the case that by having access to DPC, Left Hand's employees would be healthier overall.
"That's a big deal, when many times employer groups are getting double-digit increases in their premiums year in and year out," Flanagan said.
Nextera also handles Left Hand's workers' compensation claims now. "A lot of times with workers' comp, you have to go to a doctor or a practice you don't know based on where the (human resources) director tells you to go," he said. "With Nextera, you can actually see the doctor who takes care of you regularly."
Another benefit Nextera offers Left Hand and all of its clients is on-site visits from the physician team. The visits are scheduled anywhere from quarterly to once a month and are called "Ask the Doctor" sessions.
These informal events typically last about an hour and occur at most clients' campuses over lunch. But in Left Hand Brewing Co.'s case, it's a happy hour in the tasting room.
Before each session, a note goes out to employees asking them to reply with any questions or concerns they might want the Nextera team to address. Spontaneous questions are also fielded during these events.
During the Dec. 2 Ask the Doctor session at the brewery, topics included tips for staying healthy during the holidays and the benefits of using Fitbit-type exercise tracking devices.
Having physicians come out and visit with employees in a setting they are used to really sets them at ease, Flanagan said.
"I think it's important for people to feel relaxed … in this case, it's a craft brewer sitting down in their location over a pint," he said.
The Nextera team also has visited Left Hand Brewing Co. to provide flu shots and draw blood samples for preventive screenings. Any extra value DPC practices can offer clients helps solidify these business and patient-physician relationships, Flanagan said.
And what is the perceived value of Nextera's DPC approach from the client's perspective?
"Nextera, for us, is a way to combat what's ultimately this ever-increasing geometrical progression in the cost of health care, which is ultimately unmanageable," Eric Wallace, president of Left Hand Brewing Co., told AAFP News. "If you draw it out, you eventually explode because you can't pay the money."
Clint Flanagan, M.D., (far right) closes out the Ask the Doctor happy hour at Left Hand Brewing Co. on Dec. 2 by answering a small group of employees' questions after the official session ended.
Layering DPC on top of a high-deductible catastrophic insurance plan has proven to be the best option for the brewery and its employees, Wallace noted.
"This is a great way for us to be able to manage our overall costs and improve the level of care and relationship with our doctors," he said. "This is our third year in, and people really like it."
On to the Next Adventure
As for the future of DPC, Flanagan said he hopes that by 2020, the model will account for a double digit percentage of health care provided in the United States.
"This is pretty aggressive, as right now, it's about 2 or 3 percent," he said. "But it's almost 2016 and we're four years away. To see what's happened in direct primary care in the past year, and see my email and cell phone lighting up like it has the past year -- it's just a matter of time.
"There is going to come a time when if you as an employer are not offering direct primary care to your employees, you are going to be an outlier."
Flanagan said his goal is to add more Nextera offices in other Colorado towns and more affiliated practices around the state. Down the road, the plan is to expand across state borders, including into the state he grew up in -- Nebraska.
Another selling point, according to Flanagan: For burned-out physicians looking to rekindle their passion for caring for patients, DPC offers a compelling escape route.
"There are a lot of doctors out there who are throwing in the towel and selling their practices to big hospital systems and going to work for them," he said. "But a lot of these physicians have done this now for a year or two or three, and they want to get out of these systems.
"Direct primary care is a way for them to get out … and we're hiring."
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