DPC, VBC & Me: Finding Your Fit Within Family Medicine Payment Models

Transcript

Tamaan Osbourne-Roberts: Welcome to CME on the Go, the podcast crafted specifically for family physicians by family physicians. Whether you're seeking clinical insights, professional development or simply a sense of camaraderie, you'll find it all here. Plus, you can learn CME credit with every listen. So grab a beverage of your choice, hit play and let's embark on this journey together.

I'm Tamaan Osbourne-Roberts, a federally qualified health center physician, consultant and happiness expert from Denver, Colorado.

Jason Marker: Hey, everybody. I'm Jason Marker. I'm a core faculty member and associate director of the Memorial Hospital Family Medicine Residency Program in South Bend, Indiana.

Lauren Brown-Berchtold: And I'm Lauren Brown Bechtold, and I'm the program director of the VCME Family Medicine Residency in hot, hot, hot, Modesto, California.

TOR: It is fantastic to be back with both of you on the go today and today. We have a particularly interesting and fascinating topic, at least for me, since I feel like I've worked in this field for a fair portion of my career. Today we're discussing two particular sorts of practice models, broadly writ: direct primary care, which you will hear us refer to as DPC, pretty much from here on forward; and value-based care, which you'll hear us refer to as VBC.

LBB: Have already fallen asleep, man. Help me help you. Why do I care about D-B-C-D-P-C? I can't even get the letters right.

TOR: Well, there's a lot of fantastic reasons to care about both of them, Lauren. First of all is, whether or not you know it, you have probably been working in value-based care or VBC systems already. We'll talk a little bit more about that as the podcast goes on, but a lot of folks who are kind of like, well, this doesn't touch me. What? No, it probably actually does, and we'll discuss that in greater detail.

The other reason is that, especially like you, Lauren, if you're in education, there're going to be a lot of our residents and medical students who are likely going to head into these sorts of systems. So knowing a little bit about it, even if it's not directly touching you, is probably useful.

LBB: I knew I would have to learn something about this eventually, and I tried to avoid it as long as possible.

TOR: Sorry for that. We'll, we'll make this as painless as we possibly can. Jason, tell us what do the terms DPC and DBC mean to you specifically

Understanding Direct Primary Care (DPC)

JM: We're gonna talk about some official definitions here just a little bit. When I think about direct primary care, I think of it as a practice model that offloads the administrative burdens of dealing with insurance companies and trades them for the administrative burdens of running a practice. They’re different burdens, but not always easier ones. I've been researching and writing a paper about physician autonomy, and DPC is great, but not always the panacea that everyone thinks it is.

Now, we're gonna talk more about that today, and I admit that I'm a little bit of a DPC curmudgeon, so this is great that we're having this conversation. Now when I hear the term value-based purchasing, I think of a modern twist on pay for quality. Now, what's being purchased in value-based purchasing is us and the value we bring through our work toward achieving the triple aim. So, for those who may not be familiar with Triple Aim, that's better care for patients and better health for communities at a lower cost to the system. Really, only primary care can bring that to the table.

Anyway, some insurers are willing to pay a premium outside of fee-for-service for us to provide and document our high-value care for patients. Now, that can happen within most traditional payment models, as you already pointed out, but also within newer models like DPC.

DPC vs. concierge medicine

TOR: Yeah, I think that's a really, really good on the ground sort of a definition. To add to that, and to do a little further differentiation, right now we're gonna really discuss DPC. We’ll get to VBC, but since those two acronyms sound very similar, we're gonna take them one at a time.

So DPC, direct primary care: There are some additional pieces to that. One of the things I actually hear from a lot of people is: Wait a second. DPC, isn't that concierge? I don't wanna do concierge. That doesn't align with my value set. The two are actually not the same thing. I tend to think of concierge medicine as a subset of DPC.

So what really DPC is, is a sort of a practice model where you have a membership-based subscription to provide comprehensive primary care, typically without any billing of insurance. It is a relationship between a family physician and their patient that is direct in terms of the financial relationship.

It frequently includes office-based labs, access to low-cost common medications, occasionally some simple procedures depending on the model and the exact financial structure. It sometimes includes vaccination. It's an attempt to provide as much primary care for a given cost. And typically, in most DPC practices, that cost is exceptionally reasonable to the payer. Oftentimes, you're looking at an average of between $80 and a hundred dollars per member per month. Or actually I should say per member per month is actually typically how, how that gets structured per member per month might be around 50 or 60. It really depends on the nature of  the DPC and where things are. But the long and the short is, that’s DPC.

Concierge medicine is kind of a highly subspecialized subset of DPC. There's oftentimes an annual retainer fee paid specifically to the physician. Oftentimes the per-member-per-month or the retainer fee is a lot higher. It tends to have a much lower total panel size. There tends to be a lot more contact and comprehensiveness of the relationship between the physician and the patient.

If the patient picks up the phone at 3:30, the physician is expected to be there and be on and to take care of all things that the patient needs. And sometimes in, in this arrangement, you can still see billing for insurance. It really is the idea of having not just a personal physician as being part of that physician's panel, but having a personal physician as in, this physician is at your beck and call. And it's a very, very, very different subset model of direct primary care and one many people don't want to do.

LBB: I have a confused look on my face, and you know, and our listeners might know, like, we prepare for these episodes. And I will admit that with preparation, I still don't totally understand DPC versus concierge.

So I have a nuanced question for you. When we think about DPC versus concierge, one of the things that you talked about is DPC being a more reasonable fee and gives that comprehensive primary care without insurance billing, but concierge, you're sort of on call. And one of the things that I also heard you mention is that values for some of the people that you talk to might be inconsistent with using concierge medicine. Is the idea that DPC is accessible to patients who might not be able to pay quite as much for that on-call concierge medicine type model?

TOR: Well, it depends on the nature of the model. I will say that in my experience, oftentimes yes. I have in the past considered forming my own DPC practice to take care specifically of lower middle class and lower class folks. Specifically, the working poor folks who might fall out of, say, a Medicaid doughnut hole but perhaps earn a bit too much for that but are earning too little to necessarily afford a decent product on insurance exchanges. And it might be more appropriate to have a more affordable monthly fee paid directly to a practice. So DPC really does encompass folks who really can't pay that much.

Concierge is really, by definition, for high-net-worth individuals, typically. I'll put it this way, Lauren: IF you are going to give a small panel of patients your cell phone number and have them able to call you at any hour of the day, every day of the week, are you going to charge a reasonable amount for that or not?

LBB: Yeah. I, I'm gonna be not charging anything, that's how much I'm gonna be charging. It's not gonna happen. It's like the Mona Lisa: You can't put a value on that for me. Look, that is a really good, helpful differentiator for me as we start to go through this. So thank you.

JM: I would like to add a point that my wife often makes, which is that when I was in my small rural solo private practice, I didn't know it, but that was a concierge DPC sort of practice. My cell phone number was on the answering machine when we left the office at 5:30, all my patients had my cell phone number and they could text me whenever they wanted tom 24/7. I took all my own calls, delivered all my own babies and when I was away, even sometimes I kept my cell phone available.

Now, some would say that's antithetical to physicians’ wellbeing. But even in a rural practice of 2,500 patients who I knew and loved, and we all were just in community together, it was rarely observed. And it was a great blessing to be able to be that intimately involved in my community and taking care of their needs in rural health care. So I think there are some family physicians out there in very traditional small-scale practices who have been offering service lines like DPC and concierge medicine in a fee-for-service payment model, and doing OK with that.

We're not the richest doctors in the room, but we enjoy the fact that we have that intimacy with our patient panel, and it turned out really well for us along the way.

Exploring DPC models

TOR: Yeah, no, that's a great point. Jason, I was wondering if you actually might expand a little bit. I think you were starting to get into that being perhaps a version of a practice model very similarly aligned with DPC. Can you talk a little bit more about other sorts of practice models inside the DPC universe? Because there are a lot of 'em.

JM: Sure, and I'll admit right off the bat, like, I'm not in a DPC practice. I'm working at a residency program. But when I made that transition, it occurred to me that there were some ways that I could maybe lean into DPC as a hybrid model. And there are doctors out there who do that. Some of their practice is traditional fee-for-service. Some is in a DPC sort of model. That's some out-of-the-box thinking that doctors should be thinking about. I know a couple of doctors who have partnered with local businesses so that the business is the payer of the DPC fee. So the families that are in that business come to that DPC provider and the fees are paid by, uh, a business, so not directly from the patient. So that's an interesting model that's out there within the DPC world. I know one of our residency graduates who went into a practice where she paid a small fee to a DPC management company, and a company managed her DPC practice, so she didn't have the administrative burdens of running the practice nor of dealing with insurance, and she had a fee that she paid for that luxury to have that.

So I think our DPC friends would say, like, you've seen one DPC practice, you've seen one DPC practice. There's actually a lot of spin around different ways that you can do that.

And I was looking at the agenda for the DPC summit that's happening right now and, like, there's a whole bunch of sessions being run about different styles of DPC practices. So if the idea is intriguing to any of our listeners, you gotta take a deep dive into that and research it. Man. The AAFP has a huge website on DPC and the DPC summit and in September, they'll launch the on-demand course based on the DPC summit. That's happening right now for folks who want to know more about it. It's not something anybody should just, like, I'm retiring tomorrow and opening DPC on Monday. No, no, no. Requires a lot of research and preparation to learn about all the different types of DPC models.

TOR: Well, thank you for that, Jason, and that's a really, really important reminder that you're not alone out here. There are resources if this is something that you're interested in doing. So, Lauren, coming to you, I understand that you don't work in DPC, that this is a thing that you're teaching faculty, but one of the things that comes up about DPC is why. I have found that for the vast majority of physicians who go into DPC, while there are financial considerations, because practice is a practice, it's a business.

Oftentimes the reason that various physicians look at DPC or are incorporating it in their practice or changing to that practice model entirely, there's an approach to values, an approach to how people want to take care of patients. And as somebody who teaches and is helping to create the next generation of family physicians, I was wondering if you could talk just a little bit about what it means in terms of the residents and students you're seeing. How their value sets may align with the DPC model.

LBB: Well, for the first time in this podcast, I feel like maybe I'm bringing a reasonable contribution to the podcast conversation because yeah, I'm in the teaching world, but I will say that I think of myself in this topic a little bit more like a flamingo. I've got some chosen ignorance, and I am just sticking my head in the sand. I don't actually know if flamingos stick their heads in the sand, but that's the image I have in my head.

TOR: I think you're thinking of ostriches, but we're running with it.

LBB: Yes. I'm a single-leg-standing flamingo. I'm some sort of bird hybrid. The point is I don't know anything about this stuff, but I do talk to a lot of people, mostly my residents, but also a lot of medical students. And then just the physicians that I get to meet across the country at various events and things that are mostly hosted by the AAFP about like, what matters to you and what are you looking for? Right? And so with the residents a lot of times I'm counseling third years who are looking for: What job am I gonna do right outta this training?

And the thing that I open those conversations with is, Well, what are you looking for? Because it is always exponentially more powerful to run toward something attractive than to simply run away from something that might be onerous or unattractive. And if I have a resident who's saying, I want to do my job, I wanna go home at the end of the day, I don't wanna think about the rest of what my job is going to look like when I'm home, then I might say: “Hey, like, are you wanting to do finances? Are you wanting to, to be thinking about how you're in practice? If that's not what you're interested in, then maybe like pure employment—however that looks; there are so many different models—that might be appropriate.

But if I have a resident who's coming to tell me, I want to take care of patients how I want to take care of patients, and I want to be in charge of it, Then I might be saying, “Hey, you might need to be thinking about going into some sort of private practice, which could potentially look like DPC.”

I also think that so many of of our listeners and myself also have feelings about how insurance and the way that insurance is run in America really disserves medicine in general and the patients that we serve. And so this idea about, man, could we do a membership-based subscription and get around that insurance model is really attractive as a theoretical construct.

The other thing that I'll say: Again, in case no one has heard, I don't know anything about DPC, but here's what I know, is that within the last several years, I started hearing and seeing a lot more conversation within physician communities and our residents about like, what is DPC? Would DPC be something that I might want to start looking into?

And that goes back to what you said, Jason. There is a huge webpage that is hosted by AAFP, hosting a variety of different resources. There's a summit, there are editorials, there are briefs about what is DPC, what could DPC look like? And I think that that is becoming more interesting perhaps because of, again, what you said, Jason. If we're thinking about physician wellbeing and burnout, there is a huge subset of the American physician population who is saying, whatever this has been as a career is just not working for me. Right? Something like 40% at any given time of physicians are experiencing the clinical syndrome of burnout, and if I am not succeeding and living a life that I want to be living in my current job, what is this other thing? And I think that that's where the explosion of the conversation around DPC has really come in.

And like you said, we in New Orleans are having a bunch of people who are talking about that right now at the DPC Summit.

TOR: Well, thank you for that, Lauren. I think that was a pretty comprehensive explanation and exploration of really how values and choices can drive this entire movement, as really what a lot of folks in the DPC community think of it as.

Introduction to Value Based Care (VBC)

TOR: Speaking of movements, let's discuss value-based care. VBC, the other acronym for today.

So, as we get into DPC, I'm reminded of what Jason said, which is, if you've seen one DPC< you've seen one DPC. I would say if you've seen one VBC, you've seen probably one quarter of a VBC.

Value-based care is such a diverse field. It is, honestly, very difficult to talk about in a time-limited podcast such as this. But we're going to try, and one of the things that comes up around VBC, of course, is, well, what is it? What's the definition of VBC? And I think BBC can best be described by the phrase tying to switch from volume to value. That's kind of a going phrase inside of VBC.

The general idea is you want to get paid for engaging in the quadruple aim, or the quintuple aim, depending on which definition you're currently using. But you really want to move from this idea that we're producing widgets, those widgets being procedure visits or patient visits that we get paid for on an individual basis, and say, you know, let's pay in a different manner.

That might be a global payment. That might be per member per month, the capitated attributed payment. That could be a whole lot of different ways. But pay for seeing patients in a way that doesn't drive us to just see more and more patients, regardless of how well we're taking care of them, how good their experience is, how it's burning us out, or not really, all of those sorts of things. The idea is that, you know, move us off the hamster wheel, I think is a good way of putting it as well.

Right now, inside of the universe of practices, VBC is not gigantic. It's about 7% or so of the practices out there, but it continues to grow. That's continuing to attract interest from industry. I used to work for a value-based care outfit, Iora, that was subsequently bought while I was working there by One Medical, which was subsequently bought, shortly announced, but then finalized in a transition period for me, by Amazon. So if Amazon's interested in you, that probably means there's something to you, that there's something going on there that folks should pay attention to. And the market is seeing consolidation around various value-based care outfits out there.

There's really overall a lot to be said for the ways that value-based care tries to get around the traditional models. One way is by looking at the quality of care actually being given in a very traditional model, since it really only kind of occurs inside of the four doors. You do what you're supposed to do for a patient. You have some contact with specialists and hospitals and other facilities in your area, but you're not necessarily paid based on how well that coordination of care or the overall health of the patient works. There are multiple features of many VBC models that do attempt to determine, well, how well is the patient doing and a portion of your payment may be related to that.

I already mentioned coordination of care. There's some VBC models that attempt to integrate care as highly as possible, to ensure that no matter where a patient is in the system, that you get the care and flow of data and information between all of the important people, including the family physician who is essentially quarterbacking the care and making that.

Again, a, a possibility for, for sorts of things. There are options for paying for things that are not traditionally paid for by insurance. There may be agreements between payers and insurers and a practice to, say, pay for transportation, which not all payers traditionally do. That's the primary barrier that patients have, and they can actually be healthier if they can, actually, I don't know, get to an appointment.

And there are many, many other sorts of innovations out there. And that really is a big piece of it, as well as the idea that these models tend to be innovative. Not so much innovative in terms of the problem being new, but innovative in terms of actually having a new solution to a problem, and oftentimes problems that have plagued family physicians in the medical ecosystem as a whole for decades. So that's the best I think we're gonna do, or I'm gonna do, for definitions.

VBC in government plans

TOR: Lauren, you're gonna talk about value-based purchasing in government plans, right?

LBB: A little bit, yeah. Yeah. I'm gonna talk about my experiences that I did not know until I was about two-weeks-ago old that was value-based care. So, I'm in California, and what I learned from y'all, my colleagues, is that the way that some of our Medi-Cal looks out here in California is like value-based care.

And as I am sitting in this podcast, what I realized is, huh, when I was on the commission for the health plan of San Joaquin, which is the Medi-Cal in the San Joaquin County that I was a part of for the last eight years, I guess I was watching value-based care being formed at the highest level of that local Medi-Cal. And so how interesting that I didn't even recognize that that was what was happening.

Man, if you guys were talking to me, like, two years ago, how would you have educated Baby Lauren in recognizing and opening my eyes to: What you're doing and watching and helping form is the value-based care that we're talking about. Any thoughts?

TOR: You know, as I think about it, I might've just pointed it out. It's one of those things where oftentimes in the world of family medicine, we all think we're kind of out here doing this alone, And it's just, I think, a part of the fragmentation of the system. So folks doing private-based value-based care may not necessarily think about government payers when it comes to it. If they're working entirely through a partnership with a private insurer, they may think, Oh, well, value-based care is really kind of a private thing. On the other side of it, folks who are doing value-based care through Medicaid, through Medicare, because really the MIPS program is an attempt to get into value-based care and other sorts of public systems, they may think this is just quote-unquote policy reform.

That's all this is. Because value-based care doesn't necessarily work its way as a term into this. So I, think one of the things that all of us need to do is to realize we're kind of all in one big fragmented system, and that reaching across, we can find lessons with each other in different places. And maybe you, you might have realized that a little sooner had somebody from a VBC system just said, “We're doing that too.”

LBB: I was on the board. How did I miss this? But part of the reason, I mean, I do think it's pretty funny and I'm so willing to throw out my inadequacies in recognizing things that perhaps you would say, this is really obvious. But part of my purpose and also sharing that is, if our listeners are here and they're like, Wait, but I still like feel a little bit lost or Why haven't I been able to recognize this? I do think that there's some of this that feels perhaps not intuitive, perhaps really confusing or perhaps just out of a person's wheelhouse and that that is OK. And it also is overcome-able. You can be doing these things without understanding every little nuance.

TOR: Yeah, much agreed. Much agreed. And I would say there's much like with DPC, you know, with VBC, there's a whole range of resources out there that are particularly helpful, some produced by our very own AAFP. Jason, I was wondering if you could lead us to a few of those.

JM: Yeah, there are a lot of resources on the AAFP website about value-based purchasing. In fact, there's a value-based care curriculum for residents. There's a basics-of-value-based-care course. There's all sorts of things out there on our website. We'll link to those in our show notes, of course.

But it is an area that requires some special education to really understand because it's not just, like, we'd like to give you a little more because all of your patients got their mammograms. It's a very comprehensive look at: What are the quality metrics that actually move the needle for the health of your community, and what barriers to accessing care can be broken down through social determinants of health work, etc.? It can be an extremely comprehensive, community-focused initiative within an insurer, governmental or otherwise, and you really wanna be able to see how that’s different in subtle ways than just a regular old quality-improvement program that an insurer might have for me. And those of us who work around a lot of physician administrators or physician leaders in health care systems know that they're working on value-based purchasing all the time because we as family doctors are perfectly positioned to be able to be the success story for value-based purchasing for health systems of care, and are often on the front lines of designing those programs and helping roll out how they're operationalized within health care systems.

I will say that if I want to put on the most cynical view that I could have about this, like, I do see it as being part carrot and part stick. Oftentimes, I think there are certainly private insurers in the for-profit world have seen that they can capture some additional market share or margin that they can pass along to their shareholders through the initiation of value-based purchasing models because they will hold hostage sometimes to health systems and end-of-year shared savings payment back to the practices, which allows them to maintain interest or other market-based profitmaking through those dollars that they're not paying in a prospective manner, which is where I would like to see them do that.

And even though we may get a little bit more at the end of the year than we would've gotten under traditional fee for service, there are certainly easy ways to see that they can take some additional profit out of the system for their shareholders in that same model. So I have a love-hate relationship with value-based purchasing. I think it can be great to move the needle in value and quality within health care systems, but there's also some darker underbelly there that you've got to really ask the hard questions to see that there could be more dollars flowing into communities and health care systems than are currently flowing in because of the nature of who's offering the perks.

Final thoughts and gratitude

TOR: Well, that makes a lot of sense. I think it's the always important to look at the dark underbelly of anything and see how best you can turn it into bacon.

JM: There we go.

LBB: That took a turn.

JM: We’re going to have a hyperlipidemia episode next.

TOR: That is not dietary advice. As much as I love bacon, I make no apologies. And with that, I think that's a great note to end on. Bacon is always a great note to end on. But before we end, I suppose we should move to our regular moment of gratitude. Lauren, why don't we start with you?

LBB: Ooh. I am grateful that I have been able to be an ostrich-flamingo hybrid, and that I have colleagues who can talk me through some of the pertinent aspects of this that I just have chosen for me to lean a little less into than y'all have.

JM: I have a lot of gratitude for all my friends and our colleagues in the DPC world. I know that I, I'm not an apologist for DPCI know it's not my favorite model, and I've got my own reasons for that. But what they have done is they have sparked a national conversation about how we practice medicine and the ways that it is dysfunctional and have shown us a way out of that. And even if there's docs listening who aren't ready for a jump into DPC, those folks have added a lot to the national dialogue about administrative burdens, how we tackle those, why they exist, who's the fault for them, how we begin to move away from them.

Some of the work that I do and that I know Lauren does in the wellbeing space really has been driven by friends in DPC who have said, this is not normal. This is not how we're supposed to be practicing. We need to be more: Well, and I got there through DPC, they say, and I say, well, that's great. Now let's talk about that; there's other ways to get to more wellness also.

So. I appreciate the huge national dialogue that was stimulated by the DPC movement, especially within family medicine and my friends who've been leading the way to that. These are folks that have really been at the forefront of some of the work here, and I appreciate it greatly.

TOR: Well, Jason, as usual, you've said everything I could have possibly said, so I'm just going to say that I am remarkably grateful for bacon.

JM: Wow. You're fixated on that today, man.

TOR: I think we know where I'll be headed after this episode.

LBB: Yep. Yeah. Right.

TOR: And with all that having been said, that is all the time that we have for today.

Thank you for joining us for another episode. We appreciate you joining us on this journey to elevate family. To continue this journey, stay tuned for new content brought to you twice a month with CME on the Go. Visit the show notes for instructions on how to claim CME credit and find additional resources for today's episode.

Until next time, serve from your values, pursue your vision and, whether it's direct primary care or value-based care, keep in mind that the operative word is care. See you next time on CME on the Go, a production of Inside Family Medicine.