Healthcare in the United States in 2017 feels uncomfortably like a factory running an assembly line, with patients as widgets moving slowly along the conveyor belt and often falling off and crashing to the floor. Not enough emphasis is placed on patients being able to establish a trusting relationship with their primary care physicians, leaving patients feeling rushed and frustrated, and paying for care that’s often at best unnecessary and even dangerous. The main cause of this conundrum is the model by which physicians are reimbursed for their services. Primary care physicians are paid per episode of care by patients, health plans, or insurance carriers. This payment model is called fee-for-service, meaning physicians get paid only when they perform a service. Unfortunately, this misaligns incentives for both patients and physicians both. Any prescription to fix America’s healthcare woes and to save primary care must include changing this payment model.
Broken Payment Model
Payment that your primary care physician receives each time he or she sees you is calculated from an enormously complicated set of rules for coding physician visits. It’s tied to medical evaluations, medical complexity, and medical procedures and must be entered into an electronic medical record (EMR) to ensure reimbursement from the insurance provider or health plan. Following the rules for calculating visit reimbursement takes an inordinate amount of physician time. Unfortunately, this process doesn’t just lack any patient benefit; it actually reduces patient benefit by reducing the amount of time primary care physicians can spend actually interacting with patients. Partially as result of this, primary care physicians find themselves essentially working in 15-minute increments as their patients roll into view and then quickly roll out of view and then often on to a specialist for further care. The system encourages reactive rather than proactive care because it only gives doctors enough time to think about their patients when they’re sick.
But primary care isn’t found in a set of transactions from which specific codes are punched into an EMR for payment. It’s found in the relationship between physician and patient as they work together over the long-term to engender lifestyle choices that create better health outcomes.
For the past two years at ImagineMD we’ve been operating under a model of healthcare called direct primary care that allows our patients full and complete access to the best medical minds in the country, who not only provide primary care services but also act as health coaches and as coordinators of care with specialists, hospitals, and any other healthcare providers their patients require. This ensures ImagineMD patients are receiving the most comprehensive and efficient care possible. Our payment model is simple. Our patients—or payors on behalf of patients—pay one monthly fee, which covers all their care with ImagineMD no matter how complex their medical conditions may be or how many times they communicate with or see their doctor. At ImagineMD the patient’s own doctor is always available with same- or next-day appointment slots and via telephone and text 24/7.
All of ImagineMD’s billing is done automatically online once a month and per patient. Simple. There are no insurance companies involved, no billing codes, and no explanation of benefits required. Instead of watching widgets roll into view on the assembly line, our primary care physicians have the ability to focus fully on all their patients to improve their health and keep them out of the hospital and the emergency room, shielding them from unnecessary healthcare utilization.
We don’t have armies of people like health coaches, nurse practitioners, dieticians, and scheduling assistants. Our highly skilled, academically trained primary care physicians handle all these functions. How do we do this? By keeping our physicians’ patient panels small. A typical primary care physician who bills insurance takes care of anywhere from 2,500 – 4,000 patients. ImagineMD physicians, in contrast, take care of only 600. This gives them time outside of their daily patient interactions to think about their patients’ problems and to do research into the medical literature when required. Did you know most medical research takes 17 years to make its way into everyday clinical practice? That’s often because doctors now have little time (or energy) to read the latest studies. One such example of a study that hasn’t yet made it into routine clinical practice but that every primary care physician should know about showed that a compound called n-acetylcysteine, which has almost no side effects or risks, can actually reduce cravings for opiates in drug addicts and dramatically increase the rates of abstinence.
Each physician at ImagineMD is also able to draw on the experience of ImagineMD’s entire physician group in our weekly clinical conference where patients’ medical issues are discussed to ensure the collective wisdom of the entire organization gets applied to the most challenging and complex cases.
We’ve shown dramatic improvements in outcomes and drops in total healthcare costs in our practice. In our first year of operation, we prevented 5 inpatient hospitalizations, 10 specialty visits, and 8 ER visits among a group of 150 patients, who we selected randomly and tracked. When we added to this the unnecessary procedures we prevented as well, the total cost savings was 15% higher than what we billed.
A year ago we had a patient come to us with a myriad of uncontrolled symptoms. He was overweight and over-medicated, and as a result one day feel asleep at the wheel of his car. Luckily the resultant accident was minor. But his diabetes and hypertension were out of control, his diet was poor, and he’d been admitted to the hospital on three separate occasions in the past 12 months.
Our physician took a thorough history and physical exam and outlined a plan of action, which included reducing the number of sedating mediations the patient was on and starting him on a low-carbohydrate diet. Our physician began monitoring the patient’s sugars through ImagineMD’s electronic real-time medical tool. He met with the patient every two weeks over the course of six months, and at the end of that time, he was like a new person! His A1c and blood pressure had come under control, he’d lost 28 pounds, and had regained normal alertness during the day. The patient is now even contemplating getting back into the workforce. His life has been dramatically improved by having a physician who could spend the time necessary to get him back on the path to wellness. Because of these results he’s developed a trusting relationship with his primary care physician, which in turn has made him even more compliant with his physician’s advice. This is how direct primary care is supposed to work.
Because, of course, patients are not widgets on an assembly line, and physicians are not factory workers who only need 15 minutes to focus on each widget. It’s time we take back our healthcare in America. We can’t allow the fee-for-service reimbursement system to persist as the dominant model of payment for primary care. It doesn’t work and it motivates all the wrong behaviors from both patients and providers alike.