Direct Practices: Bringing the Best of Concierge Care to All of Us

1
Direct Practices Bringing the Best of Concierge
Care to All of Us

• Erika Bliss, MD
• STFM NE Region Conference
• Baltimore, MD
• November 1, 2008

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History of Direct Practices

• Insurance used to be for catastrophic health
  events to prevent bankruptcy
• Rising healthcare costs gave rise to concept of
  managed care insurance companies HMOs take
  over management of all healthcare costs,
  including primary care
• Backlash against care restrictions, increased
  transactional costs
• Pricing becomes irrational in response to
  shrinking insurance payments, growing uninsured
• Reimbursement system inherently stacked against
  primary care (RBRVS)

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History of Direct Practices

• Primary care chronically undervalued in US since
  WWII
• Growing demands on primary care physicians
  coupled with decreasing autonomy, relatively flat
  reimbursement
• Increasing costs of processing insurance claims
• Job dissatisfaction, stress ? reducing to part
  time, early retirement, fewer students choosing
  primary care specialties

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History of Direct Practices

• 1995 MD2, a high-end concierge practice
• 1996 Seattle Medical Associates, a
  moderately-priced concierge practice
• MDVIP converts practices to access model for an
  annual fee

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History of Direct Practices

• Currently about 300-400 known practices that
  follow some type of concierge model, number
  growing
• Most have small practice size, slow growth
• Years of backlash by the medical community
  against the perceived elitism of this approach
  doctors criticized for worsening the primary care
  physician shortage

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Basic Principles

• Re-establish the direct relationship between the
  patient and their doctor
• Give the patient more control over how they
  purchase and obtain health care
• Improve quality of care by improving access,
  technology, service, time spent
• Eliminate the waste created by funneling all
  primary care dollars through the insurance system
  (keep insurance for expensive and catastrophic
  care)

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What is a Direct Practice?

• Prior iterations go by various names Boutique
  practice, concierge practice, carriage trade,
• Various types Some are cash only (either fee
  for service or monthly fee), others charge an
  access fee on top of insurance
• Historically have targeted wealthier people
• Direct practice refers to one where patients pay
  a monthly fee directly to the practice, no
  insurance billing

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History of Qliance

• Started by Garrison Bliss, MD as a way to expand
  availability of direct practice model to a
  broader segment of Americans
• Set up as a private, for-profit company supported
  by investors to allow for maximal independence
  and flexibility
• Goal was to operate completely independently of
  the insurance system

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The Qliance Model

• Direct medical and financial relationship between
  a patient and provider no insurance middleman
• Flat monthly fee to streamline billing so focus
  can be on affordability, access and high quality
  of care
• Routine primary and preventive care only does
  not try to replace insurance where insurance is
  needed
• A true medical home

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The Qliance Model

• Monthly fee covers unrestricted visits and other
  contacts (phone, email, etc.).
• Additional charges may apply for labs,
  medications supplies.
• Practice panels are small and visit times are
  longer.
• Practice is open 7 days/wk for extended hours.
• Targets a broader audience by keeping monthly fee
  low (39-79/mo based on age)

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What does it look like?

• Office open 7-7 M-F, 9-2 Sat, 12-4 Sun
• Appts for 30-60 minutes (more if needed)
• Patients do not wait (for appt or on day of appt)
• All electronic records
• Multiple services on site (lab, x-ray, stress
  treadmill, procedures, etc.)
• No per-visit fees
• No hidden costs
• Easy access to clinic (in person, phone, email)
• After hours direct access to a physician
• Small office with limited practice size

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What does it feel like?

• For the patient unhurried, attentive, thorough
  care in a relaxed, inviting and non-threatening
  environment where everyone works for them to
  ensure the highest quality of care and service
• For the providers opportunity to get to know
  patients well, think about their care in depth,
  create a close and trusting relationship, provide
  high quality care, work directly for patients
• For the staff opportunity to meet patients
  needs and feel a real sense of job satisfaction
  in an unhurried, service-oriented environment

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How is this different?

• Typical primary care hurried, short visits,
  somewhat impersonal care, coding and billing
  hassles, overwork, dissatisfaction, and spend
  over 0.40 on every 1.00 on costs related to
  processing insurance.

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Insurance-based Primary Care PracticeProcess
Flow (simplified) - Pneumonia
Approved
Go to ER if unable to wait for appt.
Review Charge
Send EOB to Patient
Insurer Transaction
Send Payment
Provider InsuranceRequired Transaction
Denied
Primary Care Provider
Reconcile/ Send Stmt.
Code Bill Insurance
Patient PaysBalance
Patient

Patient has cough, high fever
Wait 2-5 days
Calls Provider for Appt.
See Patient
Diagnose/Call Patient
Update Ins. Coll. Co-Pay
Go to Pharmacy for Meds
Patient recovers
Results
Patient PaysBalance
Send to Lab Center or SendBlood Sample for CBC
Update Ins. Coll. Co-Pay
Results

Go to Radiologist for Chest X-Ray
Reconcile/ Send Stmt.
Update Ins. Coll. Co-Pay
Code Bill Insurance
Code Bill Insurance
Reconcile/ Send Stmt.
Patient PaysBalance
Send Payment
Denied
Denied
Code Bill Insurance

Review Charge
Send Payment
Review Charge
Approved
Denied
Approved
Review Charge
Approved
Send EOB to Patient
PayPharmacy
Send EOB to Patient
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Direct Primary Care PracticeProcess Flow
Possible Pneumonia
Primary Care Provider
Patient
Go to Pharmacy for Meds
See Same Day
Patient has cough, high fever
Call Provider for Appt.
See Patient
Patient recovers
Dispense Meds
Immediate Results
Immediate Results
Or Diagnose Prescribe via Phone
Run CBC
Take X-Ray
Collect Cash for Meds
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What are our goals?

• High quality care
• High patient satisfaction
• Reduction of morbidity and mortality
• Reduction of costs in the rest of the system
  (especially urgent care/ER use)
• More rational pricing system with total
  transparency to the patient
• In short, a patient-centered model that serves
  the individual while also benefiting society as a
  whole

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The Future of Direct Practices

•  Core of the healthcare system the primary care
  medical home
• Wrap around insurance (could be various models)
•  Patients have control of their healthcare
  dollars (society must assure that all people have
  access, i.e. healthcare dollars)
• Patients drive competition and improvement

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The Future of Direct Practices

• Rationalized pricing
• Reduced costs
• Improved outcomes
• Rewarding primary care practice that is
  intellectually satisfying, personally gratifying,
  and financially rewarding
• Increased interest among medical students in
  primary care practice