Family Physicians, Patients Embrace Direct Primary Care

AAFP Recognizes Benefits, Creates DPC Policy

May 14, 2013 04:30 pm Sheri Porter

(Left to right) Michael Palomino, M.D., who joined Atlas MD on May 6, pauses for a moment with colleagues Doug Nunamaker, M.D., and Josh Umbehr, M.D.

Around 10 a.m. one recent morning, Atlas MD, a family medicine practice in Wichita, Kan., fielded a call from a frantic parent whose 14-year-old son had just been bitten by a dog. As a direct primary care (DPC) practice, however, Atlas gives its patient "members" unlimited 24/7 access and a bevy of in-office procedures at no additional fee. The rate for children is $10 a month, and today was the payoff for this family.

"We got him into an exam room by 10:15, washed out, sewn up and on the way home by 11 a.m.," said Doug Nunamaker, M.D., who spent two years as a hospitalist before joining the practice full time in 2012. He calculated that if the child had been treated at the local emergency room, his $680 bill wouldn't even have included the physician's fee.

"That one episode was worth five years and eight months of membership for that child," said Nunamaker.

AAFP News Now recently visited Atlas MD to get a first-hand look at direct primary care, a practice model in which patients pay a monthly fee for unfettered access to their physicians and a wide variety of primary care services.

Story Highlights
  • Direct primary care (DPC) is a model in which practices charge patients a monthly fee in exchange for access to a broad range of primary care services.
  • Physicians working in DPC practices do not take insurance but encourage patients to carry major medical health insurance to cover hospitalization and other high-cost medical care.
  • The AAFP recently established a policy on direct primary care and created a frequently-asked-questions document for members.

Cure for Nation's Physician Shortage?

Providing quality health care at a lower cost and at a relaxed and reasonable pace makes every day at the office a good one for Atlas MD co-founders Nunamaker and Josh Umbehr, M.D.

Welcome to the world of direct primary care, where, as Umbehr puts it, "We work with insurance, not for insurance." The practice does not accept insurance but encourages all patients to obtain major medical coverage. "Patients will always need insurance for expensive medical care -- like surgery -- but in combination with a clinic like Atlas MD for everything else," said Nunamaker.

The FPs pride themselves on having found a way to cut the red tape that has some physicians looking for the exit door. "We're going to lose docs in their 60s who could work another 20 years," said Umbehr, who started the practice fresh out of residency.

On March 18, Nunamaker traveled to Topeka to testify before the Kansas House Insurance Committee. He told lawmakers, "I want to make one thing very clear; whether on a state or national level -- whether you're covered by insurance or not -- you won't be able to find a provider regardless of your coverage because we're going to be anywhere from 50,000 to 100,000 short (on doctors) by 2020."

Nunamaker said he and his partners are undeterred by charges that DPC practices are selling out traditional patient care for profit and lifestyle issues. "We've tried to create something that's reproducible to help foster change. If we can get past this 'You've abandoned us' mentality and show that we're trying to provide a model to save family medicine -- if we can get that message out there -- then we will have succeeded," he said.

Doug Nunamaker, M.D., spends all the time he needs to answer questions posed by potential new patient David Wells.

Creating a DPC Network

Erika Bliss, M.D., of Seattle, has been immersed in the DPC model since 2006. She's one of the founders of Qliance Medical Management, and now, as president and CEO, she oversees a network of DPC clinics in the state that benefited from millions of dollars in start-up funds from private business.

Bliss, an FP who carves out 25 percent of her time for direct patient care, said that the Qliance clinics had grabbed the attention of payers, purchasers and the government. "Large purchasers of health care (corporations) are saying 'This makes sense -- you work hard on things that matter, not cranking out a bunch of visits and billing for them.'"

Insurers recognize the potential for this model, as well, and some are looking at insurance plans that work with DPC clinics and keep costs and premiums down, said Bliss.

AAFP Creates Policy on Direct Primary Care

The AAFP has created a series of frequently asked questions to accompany the Academy's newly created policy on direct primary care (DPC), a model in which practices charge patients a flat monthly or annual fee in exchange for access to a broad range of primary care services.

"The AAFP supports the physician and patient choice to, respectively, provide and receive health care in any ethical health care delivery system mode, including the DPC practice setting," says the policy. It notes that the model is structured to "emphasize and prioritize" the physician/patient relationship to improve health outcomes and lower costs and is consistent with the AAFP's advocacy of both the patient-centered medical home and a blended payment model.

According to AAFP Board Chair Glen Stream, M.D., M.B.I., of Spokane, Wash., "There is more than one way to build a patient-centered medical home (PCMH)." He noted that the number of AAFP members developing DPC practices was still small but increasing.

"The model eliminates the insurance middleman and provides revenue directly to the practice to innovate in both customer service and quality of care for the patients they serve," said Stream. "This is one option that is particularly well suited for small family medicine practices that are struggling financially in environments not yet supporting PCMH with a viable payment model."

In Wichita, the Atlas MD physicians recalled a small 50-employee company with which they contracted last year. During those 12 months, employees filed zero claims with the company's major medical plan because all employee health care needs were handled by Atlas MD.

As for Bliss, she's no longer tethered to fee-for-service billing and doesn't experience those uncomfortable mental pauses in the middle of a patient exam to consider if one more element would bump the visit to a 99214 level CPT code. "That's a very destructive thought process," said Bliss. "As a physician, it's hard to have all that noise in your head; it leads to mismatched incentives."

Bliss pointed out that a clause in the Patient Protection and Affordable Care Act may help support growth of the DPC model. "The law states that if a direct primary care offering is coupled with an insurance product -- and that together they meet plan standards -- then a state has to let that entity participate in the state exchange," said Bliss.

Making the Model Work

Some physicians don't want to dive straight into the DPC pool and, instead, opt for a hybrid version. Pat Jonas, M.D., of Beavercreek, Ohio, said he would rather "ooze in to get warmed up."

Jonas recently opened 200 patient slots with a slight twist on the DPC model. "We only take whole families, and everybody in the household has to sign up at the same time," said Jonas, who figured he could handle 60 family units. "We can relate to families; we've been doing that for more than 30 years," he said, adding that he will continue to take Medicare, Medicaid and private payers in his hybrid model of care. So far, three families have enrolled, and Jonas is fielding a steady stream of inquiries.

Gerry Tolbert, M.D., of Florence, Ky., has another "toe-in-the-water" story. In January 2012, he opened Total Access Physicians with his father. Patient numbers have grown to about 200, and Tolbert reported that the practice was in the black.

Even so, Tolbert said, starting a DPC practice from scratch was tougher than anticipated in a northern Kentucky market where one hospital system owns all four hospitals and most of the primary care practices. "Patients don't want to pay $75 a month (his retainer fee) when they pay a $10 copay through insurance."

A third physician recently joined the practice, but Tolbert conceded he may not meet his goal of attaining 1,000 patients in three years. He's modified his business plan and added a pay-as-you-go option, as well as a payment track for patients who are willing to file their own insurance. In the meantime, he's taking care of patients part time at another local health care group.

Patients Appreciate Value

What do patients think about direct primary care? "I was skeptical," said Lois Fullbright, who, along with her husband Scott, signed on as an Atlas MD patient in August 2011. "But they actually do sit down and talk to you about your health."

There's no charge for the laser treatment Doug Nunamaker, M.D., uses on Ellen Schaefer to diminish a scar, even though he treated the original wound in the office weeks ago.

Scott Fullbright called DPC a business model that focuses on customer service. "You don't get that when physicians have to churn out seven-minute appointments," he said. "These guys offer something that I didn't even know could exist."

Ditto for Atlas MD patient Mike Scheidt, who said that he and his wife, now deceased, were "high-volume medical consumers." He used the term "exquisite" when describing the end-of-life care his wife received during her final months. These physicians "are around to deal with you in the best possible way while you are in their presence," said Scheidt. "It appears they are going to have staying power."

At Atlas MD, adult memberships start at $50 but are tiered and top out at $100 per month for patients older than 65 because older patients with chronic conditions require more attention. Patient panels fluctuate between 400 to 600 patients, and appointments last at least 30 minutes. At no extra charge, patients have access to in-office procedures and diagnostic testing, and they save as much as 95 percent on the cost of outside lab testing and wholesale medications dispensed in the practice.

Moving Forward

Umbehr and Nunamaker built a DPC practice that, in just 32 months, has attracted 1,075 patients. With patient panels filling up, they just hired a third physician.

Bliss reported the recent opening of Qliance's fifth clinic and predicted a surge of primary care physician participation in the DPC model in the next five years. "We expect, in the next year or two, to have compelling data about health outcomes and cost of care to help drive that," she said.

"If we do this right, there could be a pretty strong uptake. Think about large employers who have millions of covered lives and who want to change the course of history," said Bliss. "This is the future of health care."

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