Direct Primary Care

I've been on this hamster wheel just a year and a half and it's already killing me.

Let me explain:

For the first 10 years of my medical practicing days, I worked extremely part-time holding clinic hours one day per week. I did this so that I could raise my children at home. Being a stay-at-home mom was a priority for me and my husband and we made it work. I have ZERO regrets that I got to see all of my kid's milestones reached and focused on my children's welfare instead of building a medical practice. I'd recommend every woman that can, STAY AT HOME WITH YOUR KIDS!

But I digress.

Working as a 1/5 physician equivalent actually worked out well for me, because I felt like with a small panel of patients, I spent a lot of time with them and took great care of the ones who became my regulars. I know them by name and love them dearly. I LOVED going to work in those days because I got to take a break from the kids and talk to adults! Win-win!

However, those same regulars always wanted to see me more. People complained for 10 years that I needed more days in clinic. My intent was to open up access once both my kids were in grade school, but never go full time.  The opportunity finally arose last year so I doubled my time, spreading it over 3 days and scheduled patients through lunch so I could be done with clinic by the time my kids got off the school bus.

Before I made the jump, my husband had reservations. I had a sweet gig and he knew what was in store for me as soon as I opened up the faucet to see more patients. "Babe," he said. "You're going to get killed with more paperwork, phone calls, med refills, labs...just wait. You'll see."
"But, Babe," I said (rolling my eyes). "I'm ready for this! I've been biding my time for 10 years waiting to open up my practice more and I think it'll be fine."

Famous. Last. Words.

In a mere year, I have become a statistic of modern day medicine. I bit off just enough that now I live in the thick of the current model of medical business lovingly referred to as "managed care." Sounds so personal, right?

Insurance, Medicare and Medicaid are killing me and every other doctor in America. Particularly the Guardians of Healthcare: your Primary Care Physician. It's even happening under the guise of a so-called "Medical Home!"

How my husband does this full time, I have no idea.

Have you ever wondered why your appointments with your PCP are so brief? Do you walk out of an office visit feeling that your PCP never hears you out? Do your feel like your doc spends more time on that damned computer than they do making eye contact or even doing a physical exam?

If this frustrates you, it frustrates me too. Apparently, it frustrates a lot of docs, because since the mid- 2000s about 1000 doctors across the country have left managed care and gone back to their roots in a business model called Direct Primary Care, or DPC. Is DPC the answer? I'm trying to sort that out and will pose the question to you, my reader, in this post.

But first, where lies the problem with today's healthcare system? This is a multi-faceted issue, but I'm going to bring up the biggest ones that bite my butt today...

Public Enemy #1: Acronym Soup

One glaring problem in the US healthcare system lies in all of the accumulating rules associated with Medicare that trickle down to all medical insurance companies. CMS (The Center for Medicare Services), sets the standards for all medical insurers. CMS has aggressively added rules of physician decision making and measures called "metrics" since Obama took office and the Affordable Care Act (ACA) was passed into legislation.  What are metrics, you ask? They are a bunch of supposed quality measures (QMs) that tells CMS whether or not your doctor or hospital is worth paying, based off of their performance on these metrics (P4P).

In a word, bureaucracy.

We have a Wall of Shame at my current office, which shows each doctor's performance side by side on these measures every quarter. The bosses seem to think public shaming incites productivity. ?!?!?!

Public Enemy #2: A Bastardized Electronic Health Record

The major reason your time at a hospital-affiliated clinic is soaked up with your doctor on the computer is because we are constantly documenting on the computer to satisfy all of the aforementioned Quality Measures (QMs). The Powers That Be have even programmed the computers to pop up the necessary information that has to be satisfied or we can't go on documenting.  They even keep a count on the number of clicks to satisfy the pop ups! If physicians don't, we are constantly reminded how we will make the group lose our promised $$ from Medicare. Large amounts of money is spent educating us to keep us "in compliance" and "close the gaps." Other large insurance companies look at these QMs too, so basically everyone gets over-documented to cover our butts. This is also why a medical record that should be a couple of paragraphs long now is 10 FREAKIN' PAGES LONG,  PER VISIT!!!! Needless to say, I hate it when I have to request your old medical records. Out of the 50 pages faxed to me I keep about 3. Paperless, my a--!

Public Enemy #3: The Notorious 15 Minute Appointment

Since the 1990s, primary care doctors sold out to managed care and assumed responsibility for huge panels of patients. Then, they promised to take good care of them to the tune of thousands of people! (1:3,000 or 1:4,000 don't seem like good odds for quality to me)
Here's the dirty little secret about primary care: we are the lowest paid physicians, even though we take care of 90% of the average human's healthcare needs. Because we are the lowest paid physicians, in the business model of managed care, we can only make more money the more patients we see. Ergo, The 15 Minute Appointment. I'm not sure about you, but I think only one complaint per visit fits in 15 minutes. With a copay now of about $25 a pop, and deductibles sky-high, I bet you won't make many subsequent appointments! This means not much gets accomplished in a visit, which stinks. As a good doctor, I want to see you improve and get better but in our current arrangement, "better" seems to constantly elude us.

Public Enemy #4: The Physician as a Manager

To keep "access to care" open, I've compromised with 20 and 40 minute appointment slots in my current practice. This would probably work out great if I weren't inundated with an entire schedule full of complex cases.
You see, most days, I'd die to see a cold or two. That's right! There's nothing more satisfying than treating The Crud, flu, stomach bug or even a UTI, but I rarely see them now. Why? Because the mid-levels in the practice get to see them all!
There is a shortage of family practice doctors out there (after reading this post, I wonder why??) and to answer the need for entry-level patient contact, we've raised up an army of PA's and ARNP's to help. The problem is, they can't practice independently, because they're not physicians; they are physician-extenders. 
So, now that we've finally grown the army, all of us PCPs get to manage these extenders, who are really trained to see the low-hanging fruit in medicine: the quick and easy visits that help break up the regular family practice work day. Now, physicians are left seeing complex case after complex case, day after day. A full schedule of complex cases is really Internal Medicine, not Family Medicine.  If I had wanted to do that, I'd be an Internal Medicine doctor...but I'm NOT!
And to really ice my cake, my current employer says I'm not busy enough to justify a full time nurse, much less hire me a part-time or full time PA to make my practice full time. Wow.

So, DPC. What's that, again?

Direct Primary Care is a model of medical practice where we can mend this broken-down system and restore the doctor-patient relationship through transparency.

I, the doctor, get out of insurance and Medicare/Medicaid altogether and start to work on YOUR behalf. I bring to the table: drugs at wholesale cost, labs at 80-90% discounts, otherwise high dollar procedures for free and give you 24/7 access to me and not the answering service. I can do house-calls. I can treat stuff over the phone. You can text me a picture of your kid's rash. We can arrange office visits same day or next day that are 30-60 minutes long, whenever it's convenient for us both, without sitting for an hour in a waiting room full of sick folks! What if I could also hold seminars in my office covering all kinds of health topics that interest you? What if I could give my pool of patients access to even cosmetic procedures, hormone replacement or other pricey ancillary services at lower cost?

Sounds good, right?

Sounds good to me too.

More to follow on DPCs in my next post.

Leave me your comments below as you contemplate my rant.

To your good health,

Dr. Lydia