DPC and Self-insured Employers: Lifestyle-friendly Care for the 21st Century

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What do patients really want? Most surveys, formal and informal, indicate patients want two things, consistently, above others: one, to feel like they’ve been heard; and, two, to have access to doctors when they need them.


Being “heard” means a desire for meaningful and timely communication, not edicts. We want to feel involved with our care.  “Access” means an appointment sooner than a week from Wednesday.

When we drill deeper into the question of access, patients unanimously express a desire to use asynchronous communication platforms like secure texting, in-mail messaging, or email to communicate directly to their doctor. Without question, most of us are comfortable with the technology we use in our daily life to communicate with friends, family, vendors, and business associates. We prefer to leverage those tools to make medical care more efficient and convenient.  We want lifestyle-friendly care that matches our 21st century lifestyle!

But within our insurance-driven healthcare landscape, barriers to lifestyle friendly communication can impede access and impair timely exchange of information between doctors and patients. These clinical shortcomings abound, stemming from our Fee-for-Coding mentality.  Patient service-related inadequacies take the form of fragmented care, over-utilization of specialists, poor communication and dissatisfied patients; and are often traced back to the moral hazard and poor value proposition fostered by our healthcare payment methods.

There is certainly no paucity of clinical care insults added to economic injury resulting from our dependence on a bizarrely inefficient, expensive, and complex insurance payment system. Our dysfunctional third-party payment system often leads to dysfunctional clinical practices and habits for those physicians and patients who are still at the mercy of the complexities and barriers created by the third-party network billing apparatus.

The current Fee-for-Coding insurance-based system creates an unspoken priority focused on coding & billing as many revenue-generating encounters as possible. This focus redirects valuable time and resources away from patient care, with a focus towards documenting “billable” work in the chart.  Many office visits are so rushed that there is barely enough time to decipher concerns or new symptoms, resulting in a tendency to refer even the simplest problem to specialists just to keep on schedule.

Doctors rarely have time to return phone calls; they’re too busy running from room to room, documenting enough data to “drop the charges”  to cover the excessive overhead forced on them by unnecessary administrative costs tied to our payment system.

The whole insurance network system contributes to patient-unfriendly habits and practices that crop-up within medical care establishments.  These shortcomings are so pervasive that a case can be made that doctors don’t work for the patient’s best interest anymore… but instead play the role of contracted providers for the insurance network.  A consequence of this “gatekeeper” role, and the mentality it fosters, is that the front-desk and medical assistants in many primary care offices have become very skilled at saying “no” to a litany of patient requests:

  • “We can’t work you in, you will have to go to the Urgent Care.” 
  • “We can’t call that in for you, you will have to be seen even if you are feeling fine.”
  • “You have to have a physical on the first visit before any medications prescribed.” 
  • “No, we can’t email it to you, it’s a HIPAA violation.”

Thankfully, alternative payment models like Direct Primary Care (DPC) are not dependent on billing encounters in the office to drive revenue. This liberates the physician and staff to provide the right care at the right time via the right modality; whether that be in-person, over secure texting app, phone, or even a house call.

With DPC and similar practice models, the artificial constraints and moral hazards of Fee-for-Coding disappear, replaced by the satisfaction of helping patients solve problems as life happens and within a non-rushed, lifestyle-friendly atmosphere.

We can refer to this as “everywhere care”.  And it becomes a reality when the doctor is paid to be available and accessible and give their undivided attention to the problem or issue, as opposed to having to “document elements” in the chart to get paid.

“Everywhere care” allows the doctor to be flexible, creative, and innovative in deciding how to deliver the best care for each patient including liberal use of online tools, mobile communication apps, and flexible scheduling.  “Everywhere Care” can offer seamless two-way communication modalities on secure trusted platforms via smart phones, laptops and tablets devices.  A plethora of feedback from DPC patients around the country indicate that they love the easy connectivity and appreciate the accessibility.

In Part 1 of this series, we made the case for Direct Primary Care as a free-market-friendly alternative to traditional insurance-based primary care.  In Part 2, we constructed a new model using Direct Primary Care as the clinical hub of the Self-funded health Plan. Many Self-insured companies are beginning to discover the value and savings in this approach. By contracting with a Direct Primary Care practices and re-routing subsequent encounters away from the more expensive insurance-based protocols, Self-insured employers can utilize creative plan designs to cut costs and improve employee satisfaction.

So, not only is DPC a more cost-effective and affordable way to render highly effective primary care, but revenues result from ongoing satisfaction, and superior outcomes, which drives loyalty and patient retention.

Case^ in point, “Colorado-based DigitalGlobe, a self-insured provider of high-resolution Earth imagery products and services, partnered with Nextera Healthcare, Colorado’s first direct primary care (DPC) provider, to evaluate the effectiveness of DPC membership for employees and their dependents.

The seven-month case study revealed improved health outcomes, enhanced patient satisfaction, and reduced healthcare costs, including a 25.4 percent reduction in claims costs and a 4.7 percent reduction in risk scores for members who participated.”

“Next-day appointments and 24-hour access to providers via phone, email, and text messaging furthered the DPC commitment to providing convenient, personalized care and attention. Eighty-nine percent of employees reported via a post-study survey that they received flexible, timely appointments and follow-up visits.”

In a typical insurance-based practice, meaningful face-to-face time between doctor and patient is somewhere between 5-10 minutes. Interesting, but surprisingly, shorter visits tended to result in more prescriptions being written and less time trying to get to the root of clinical problems.  And prescribing is usually a poor surrogate for good counsel and reassurance.

The quote above is NOT from a Direct pay doctor or advocate, even though it precisely describes the attributes of DPC.  The quote is from the American Association of Family Physicians: The Ideal Medical Practice Model: Improving Efficiency, Quality and the Doctor-Patient Relationship.  

Notice how many of the characteristics of the Ideal Medical Practice looks very similar to the characteristics of a typical Direct Primary Care practice.  The ability to provide exemplary service is a natural element that arises from Direct Primary Care and other direct-pay models.

This direct engagement, absent the complexities and barriers created by the third-party network billing apparatus, enables a level of lifestyle-friendly involvement that naturally leads to a more satisfactory patient-doctor relationship and potentially superior clinical outcomes.

It’s hard to argue with cheaper and better.

Dr. Robert Nelson

About Dr. Robert Nelson

Dr. Robert Nelson received his M.D. degree at the Ohio State University College of Medicine. He is the Founder and Owner of Encompass Health Direct, in Cumming, Georgia; the publisher and editor of The Sovereign Patient blog; and a founding member and spokesperson for the Georgia chapter of the Free Market Medical Association. Dr. Nelson has spoken about healthcare economics and free market healthcare throughout the country, and has been a guest expert on multiple radio programs.

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