Family Doctor Trying New Practice Model of “Direct Care” with no insurance Accepted
I am sure that many people are/will be shocked at the news of me leaving my practice of eighteen years, but it is true. I am going to be setting out on a new venture – a solo practice that will break a few of the rules of what a “normal” practice should be. Now, the fact that I am breaking rules shouldn’t surprise anyone. But many of you, especially those who are my patients, are probably wondering what this means for you. Can you join my practice? How will things be different? On this page I will attempt to answer these questions.
When is this happening?
While I am not sure of the exact timing, my last day at Evans Medical Group will be in the fall of this year. I won’t be opening up my new practice until it’s ready to be opened, but I expect that to be at or around the start of the year.
Why is this happening?
While at Evans Medical Group, I was able to use my talents as a doctor along with my desire to do things differently to mold out a new form of health care. Our practice was one of the earliest adopters of electronic (computerized) medical records, and has been recognized for our creative use of them in improving care. I have always pushed for new ideas and creative ways to solve the problems I faced in offering the best care possible for my patients.
Success in this has caused the practice to grow, now with 5 physicians and 2 physician’s assistants, serving thousands of patients each month. I am proud of how the practice I helped found has become such a successful business and a center of excellent care. Yet my itch for innovation and change continues, and that doesn’t work quite as well with this many other providers. Some of my ideas are good ones, but some have not worked out so well. This is perfectly fine with just me, but the bigger the practice grew, the more I had to curb my appetite for change.
I’ve recently come upon a new form of practice style, called the direct care model, which has some real advantages for both me and my patients – advantages that allow me to once again think creatively and push the idea of what doctors can do for patients to a whole new level. It became increasingly clear to me that I had to choose between staying with my friends at Evans Medical Group, serving my patients to the best of my abilities within the “normal” rules of practicing medicine, or make a fresh start on my own. After very difficult deliberation, long discussions with my family and the other doctors in our practice, and lots of praying, it became clear that I needed to make the change.
What is a Direct Care practice?
Direct care has several things that define it as such:
- Insurance is not accepted.
- Patients pay a monthly subscription fee for access.
- Office visits are free or very low cost.
- Patients have much more access to their doctor via phone, Internet, or immediate appointment availability.
- The number of patients is kept relatively small.
The thing that differentiates a direct care practice from a “concierge” or “boutique” type of practice is the amount charged to be in the practice. Concierge practices charge a premium (up to $10,000 per year) for exclusive access and undivided attention from their doctor, as well as for extra care (more lab tests, stress tests, x-rays, etc.) that are not available to normal patients. Direct care, on the other hand, is cheaper, costing between $50-$100 per month for access to the practice and focuses on giving good care without doing more and more.
Did you say “No Insurance?”
Yes, I did. Insurance complicates life beyond explanation, tying me down with rules I must keep to be able to accept their (not-so-generous) payments. If I want to really innovate in the kind of care I offer, I have to let go of the money tied up in insurance and offer something truly unique; something I hope will be worth the price.
This does not mean, however, that I won’t accept patients who have insurance. Let me repeat that: YOU CAN STILL BE MY PATIENT IF YOU HAVE INSURANCE. If you want to file your visits with me toward your insurance, be my guest. I just don’t want to play that game of “keep away” (with insurance companies doing the keeping) any more. Certainly, (as long as the lawyers say I can do it) people with health savings or flexible spending accounts can pay for my monthly fee from these accounts.
What about Medicare and Medicaid?
I will be happy to see people with government insurance, and sincerely hope I do, but again I can’t file that insurance. My goal will be to keep things as uncomplicated as possible, and the minute you start dealing with the government the word “uncomplicated” is no longer used (except when being ironic). I don’t know all of the rules associated with Medicare and Medicaid, but I’ll do my best to make myself accessible to as many of my old patients as possible.
How much will it cost?
I don’t know how much I will charge, and don’t want to make any commitments at the moment, but other direct care practices I found during my research charge in the $60 to $80 per month range (with discounts for families). I am not doing this to become wildly rich, but I do have two kids in college, and two more on a collision course with college tuition, so I need to charge enough to keep me out of debtor’s prison.
What will be the number of patients accepted in the practice?
The absolute maximum for as long as I stay solo will be 1000 patients (which is 25% of my current practice size), but I will probably start out with only 500 until I get the kinks worked out. If this is really successful and my waiting list grows long, I will figure out some way to extend care to more people without becoming too busy. That would be a good problem to have, but I won’t go that far into the future for now.
What kind of “innovations” are you thinking of doing?
I am looking to undo many of the flaws I see in our current system, including:
- Patients can only get care when they come in to see the doctor.
- Medical records are fragmented and kept away from the people who care about them the most: the patients.
- Most people don’t know what care they should be getting now, and don’t know what care should be done in the future.
- It’s really hard for most people to get good answers to their medical questions when they need them most. Doctors put a wall up around themselves unless you are willing to come in to the office and pay to be seen.
- Doctors are often hurried and distracted by low reimbursement (which forces them to see too many patients), the burdensome rules (which makes them spend more time with the chart than with the person), and the piles of paperwork (which makes them really, really grumpy). This makes them spend far too little time with the patient, so their needs are not met.
- Care costs too much, and is run by people who make a lot of money off of people’s sickness. Nobody seems motivated to keep people healthy and away from care. In truth, healthy patients would put a lot of people in health care out of business, which makes it easy to see why reform has been so difficult.
- People without insurance are hurt or killed because they are afraid of the cost of care. This is true. I have seen this happen many times.
- Even people with insurance are hurt or killed now because their insurance is covering less and less, and care is getting more and more difficult for both doctors and patients.
- Medicine isn’t a whole lot of fun for doctors – even doctors who wear sandals and have Scooby-Doo on their stethoscopes – as we have to watch all of these people hurt by the very system that is supposed to help them.
That’s nice, but you didn’t answer the question about “innovations”
I was getting to that. Be patient. You should know by now that I am not short on words.
Here are the ways I want to address these problems. PLEASE note that these are preliminary plans, and I’ve got a ton more work to do. Don’t take these as gospel, but more as a dream.
- If people are paying a monthly fee to see me, I won’t have to charge extra to give them care. I intend on doing everything I can to keep people away from care they don’t need (be it from me or other providers). I am fond of my auto-mechanic and really like my plumber, but I don’t want to visit them if I don’t need to. I intend on helping people make the right decision about their care in this way. If there is care that can be given outside of the office, I will do it that way.
- I will do my best to give each person full online access to their records, serving as a curator of those records by presenting them in a way that makes sense to them. I believe that much of a patient’s record is actually better maintained by the them. Why do I have to ask if a person has gone to the ER, has changed jobs, has graduated from college, or has gotten married and type it into the record when they could do it? I think a person’s medical record should belong to them, and not be hidden in a vault in a hospital or doctor’s office.
- I also want to give each patient a personalized care plan, a list of tests, procedures, and life milestones from the past, present, and future. When was your last cholesterol test done, or tetanus shot? How often should you check your blood pressure? What is your ideal weight? When is your next cancer screening test due? I think it is time to come out of the dark and make this information clear for every one of my patients.
- I want to be accessible to my patients, and want people to know where to go to find good medical information. I will do what I can to give you immediate access to me when you need it, or at least as soon as possible. It also means that you will have access to me via email, using Internet forms to ask questions, use video conferencing, and whatever other means I can find to make it easiest to give care when and where it is needed. I will write more about the details of this later.
- If I keep the number of patients low enough, I will have time to give to every one of my patient’s needs. If I am not on insurance, and if I am not tied to the government rules of how to document in the chart, I will have far more time to do things that actually matter. If I am not doing all the paperwork, I will be much less grumpy (hallelujah!).
- I will use every tool possible to keep people away from unnecessary tests, away from drugs they don’t need, and out of the hospital whenever possible. I will coordinate care with specialists, making sure they know exactly what I want to know and what has been done.
- People with no insurance, or those with lousy insurance will be able to get care from me without fear of cost. I can’t control what other people charge, but my costs will be clear from the start. Even if I order labs and other tests, my lack of association with insurance makes it possible to negotiate discounts (hopefully substantial).
What about kids?
I think kids are great. They are smaller than adults, in general.
No, you goof, are you going to be accepting kids as patients?
Of course! A practice without kids would be like cake without frosting. I think I would shrivel up and die if I couldn’t get my tickling quota in!
How do I sign up?
I am very serious about not offering anything but excellent care, so I am not signing up patients yet. If you are interested in being a patient, or would like to find out more about this kind of practice, click here and sign up for my newsletter.
There is a ton more I intend on saying. Subscribe to the feed of this website (if you are into that kind of thing), join my Facebook page, and/or follow me on Twitter (beware, I get kind of silly on Twitter) if you want to know when I give more specifics about this new venture.
I will hold sessions for people wanting more information, starting with two sessions on September 29. If you are interested, click on this link, which will take you to a form you can fill out so I can get an idea of interest (and how many refreshments to bring).
Thank you so much for your interest, especially those of you who have given me the pleasure of being your doctor. Please keep me in your thoughts and prayers, as this is quite a big step for me to take. I hope this is a step that will radically change things for the better for me, my patients, and who knows, maybe a lot more people who hear about this new way of giving better care.