1. You could close your practice for a while until things calm down.
2. I saw you're a hospital attending, I assume with house staff. But until the hospitalists came to our area in PA around 2000 all the PCP docs took care of their patients in the hospital and ER. I held out until maybe 10 years before I quit in 2017 and went to office only. That kind of practice was a killer with calls all the time and really long hours. But I loved it. You felt like a real doctor. I did close my practice after a while even though it doesn't seem to be in the M.D. nature to do that. But overdoing it gets dangerous.
Thank you so much for this piece. As a DPC doc for 10 years, I also appreciate your distinction between concierge and DPC. I don't think DPC is without flaws, but I do have some thoughts about the over testing. In my experience, I have noticed that the model itself seems to draw patients with very rigid expectations / 'demands'. Combine that with the early days of practice, trying to make rent every month and feeling pressure to please your 'customers', it definitely did influence how I practiced and led to giving in to things I did not think were necessary. However, over time, as I built stronger connections, more trust and more confidence, those interactions started to change. I spend much of my time talking to patients why something is not necessary and potentially harmful, and patients started to listen and make more thoughtful decisions, which I believe has lowered the rates of over testing compared to if I practiced in a high volume setting. I believe that DPC has allowed that shift to happen. I also credit sensible medicine and all the wonderfully nuanced discussions I've been reading over the years. So again, thank you!
Well articulated. As a patient, I am frustrated with the move to membership models. Take menopause for example, many doctors now have concierge membership models. I don’t need or want much of what is offered. I would just like to pay a fair fee for 30-60 minutes with the doctor.
After reading your post, Adam, I continued to think about the following and felt compelled to share my thoughts: For the past several decades, my brothers and I have helped countless lose and yes, maintain weight loss. We are seasoned, data driven and devoted. We lighten the physician's load. Now, in addition, I support many on The Arc of Life: when diagnosed with disease, when living with a spouse with dementia, when grieving one of life's many losses or "sitting with" and guiding a family while a life ends. Physicians collaborating with us are so relieved to do so, while for many, it does not cross their minds. Perhaps referring to skilled, loving professionals, who deal with the inevitable, time-consuming conditions (overweight and decline) for support and management - and building a trusted outsourcing partnership- could save our precious physicians from the exhausting experiences associated with the practice of medicine in a country overcome by preventable illness and aging. Just a thought...
This post left me nearly in tears because you are simply acknowledging your own humanity. That’s incredibly hard to do. In my surgical residency, this was unheard of. To show vulnerability was frowned upon or even ridiculed. Kudos for expressing what many of us feel but are often afraid to admit. The direct care folks are onto something- I too ended up becoming a patient of a direct care practice because I could never actually talk to my doctor who I suspect was also inundated.
My $150/mo direct primary care practice might seem expensive but the goal was to order fewer tests, spend more time with the patient, use fewer medications, and theoretically place more emphasis upstream of screening, i.e., prevention.
It's not perfect and it attracts a different crowd of patients. Some don't believe in health insurance, some can't afford it.
I have as many patients who are on $20/mo plans as $150 plans. Some haven't been able to pay in a few months. And I love that. Because I wasn't able to do this with Medicare - it's not allowed to render services without collecting copays.
I got a hand MRI for $350 when it was quoted at $2,500 through insurance. I coordinate care for my patients who is temporarily in the Philippines.
My patients can switch jobs, insurance companies, countries, or gender - they'll never lose me as a doctor.
As soon as mainstream healthcare puts the emphasis back on the patient-doctor relationship I'll jump right back into my own UCLA and Kaiser Permanente gigs.
I agree entirely. I have observed a few conscientious, rightly motivated colleagues who have set up DPC practices, and it has been a revelation. They are pricing at levels (~$80/mo for adults) that are not a big reach for the average American, and they are set free to practice good medicine for their patients, whom they can genuinely get to know and partner with. Unlike concierge practices, which make the physician beholden to the patient--and thus easily lead to overtesting and overmedicalization, DPC with ~700pts in one's panel allow the physician margin and freedom from third parties to help the patient AVOID undue medicalization. It allows the physician to develop referral relationships in which the specialist gives counsel to the PCP, who can help the patient integrate what is possible into what fits the patient's particular vocation. And it seems to me evident that it saves the system a lot of $, or at least diverts money that would go to overhead/third parties toward time between patient and clinician. Not to mention it allows physicians to chart in rational ways rather than to please billers. AND it allows doctors to see poorer patients and not charge them, or charge them a reduced rate at their discretion (practices that are illegal if one takes federal insurance).
Having heard me comment about this for years, my son just quit his job as an accountant and is working to develop a company that helps PCPs set up and run DPC practices that are focused on the patient's health (not on selling miracle cures or cosmetics or trying to live forever), and network with one another to practice and publicly promote good medicine. Imagine a world where at a cost of <$1000/yr/person, patients have PCPs who know them and have time to respond to them, and patients trust those PCPs enough to let them determine how to appeal to and then make use of specialists' care. If DPC numbers grow, there will be growing political will to change laws so that employers can offer policies that focus on DPC. There will be political will to innovate with giving medicaid patients DPC vouchers, etc. May a thousand flowers bloom in this area.
Adam - I manage my own DPC / direct primary care practice in Washington DC. The demand for doctors who a) have time to address the nuances of people’s complex bio-psycho-social and medical issues and b) aren’t burned out and crispy with frustration with the demands on our time is vast. Yes we doctors generally a well paid bunch compared to other professions. But the commodity patients value most (and the thing I need most to care for myself and others) is TIME. We need to scale this concept in the US and allow every American (not just wealthy ones) unfettered access to a “primary care medical home” where doctors have a smaller panel of patients and more time to address patients’ needs. It can be done. We just need the political will and to leverage technology to enhance - not eliminate - the patient doctor relationship. Trust is at the core of what we do - as you know! Trust takes time to build. Rapport takes time to develop. Doctors and patients want the same things. So let’s reinvent the system centering primary care. It’s about time
Stanford Medicine (at Stanford University) now has their own concierge internist group, and they continue to hire doctors for it. My usual internist (not concierge) is for all practical purposes unreachable now: no physical-exam appointments for the next three months; her next video appointments are December 29 or March 3; a simple MyHealth question to her asking whether we might reduce a medication given recent blood tests returned a message from a nurse saying to schedule a real appointment. I feel like I'm being pushed to concierge.
Let's be a little more honest about concierge medicine. A lot of it has to do with greed. Down here on the Gold Coast of Florida concierge internists. $2000 per patient in return for limiting themselves to 300 patients. Factoring in 40% overhead they've already made $360,000 before they see the first patient. Even though I have a number of severe medical issues I only see my internist once or twice a year so that would make that one very expensive visit. My wife is willing to pay that for her peace of mind but not me. And for that $2000 she first has to go through the practice' s nurse practitioner!
Clearly we have to make practicing medicine much more efficient with reliable dictation and summarizing systems as well as physician extenders-nurse practitioners etc. in the meantime I guess I have to go to the emergency room or one of the immedia centers when I need some help
This, this, a thousand times this!!! I could have written this, word for word. After 30 years in big system primary care, ending with two years as Medical director with 180 direct reports, I was pretty fried. I’ve been saying for decades that investment in primary care would come back many times over, but all we got were higher productivity goals and meaningful use BS. I left town (non-compete, you know) and joined a DPC.
It’s absolutely wonderful - 500 patients, hour long visits, direct contact via email/text, and though I do work part of every day in some capacity, it’s focused on helping people, not jumping through Epic hoops to support billing. I know my patients at paying far less for my care, for labs, etc than they would if they use their insurance (generally high deductible) and we have time to really cover all that needs to be covered each and every visit.
I have felt guilty about removing myself from the “public pool” but the work I do now is very fulfilling for me and patients are gobsmacked by the care we are able to provide for a really low rate (less than $100/month on average).
I no longer suffer as much moral injury at work, I know I can do what patients need and deserve. Yes I make a bit less and have far fewer “benefits”, but at this point of my career, it’s kept me going with a renewed sense of enthusiasm and joy for job. Best thing that’s happened in my career, it’s the way ALL primary care should be done, and if there had been more support, incentives, etc in the past 20-30 years, we could have had enough docs going in to this most rewarding ‘specialty’ to ensure we all would enjoy the same professional satisfaction.
Apparently the underlying message here is that we need to produce more doctors, especially PCPs / IM docs, and give them more freedom and less bureaucracy.
Concierge works largely because each doc sees far fewer patients. It's good for the patients who can afford it and for the doctors who practice it. That works great for wealthy patients but it puts up a velvet rope in front of everyone else.
We need real solutions for the whole population.
Adam, do you think delegating to PAs, NPs and AI is the answer?
I think it would be so interesting and good for our country to allow direct care types of arrangements to scale alongside our current system. One way to allow that, and address the issue of “taking from the public pool” would be to make it possible for doctors to link their Medicare/Medicaid participation to the entity. This would allow DPC docs to work at times taking hospital call or moonlighting shifts.
But for these groups to really scale we will need to lose the CON and Stark laws that prevent new and doctor owned facilities from opening.
I’m not sure that the direct pay subscription model necessarily leads to over testing. Many DPCs include common tests and services in the fee, so docs save money by not doing those test that aren’t needed. Plus for tests that aren’t included- patients have to pay someone else. For similar reasons, these models encourage less over use of specialists as well. I think on balance incentives are better.
Concierge medicine is the free market at work. I offer a service at a price that compensates me as I wish and willing buyers purchase it if it meets their hopes. Private and government insurance are accommodated, the buyer pays the shortfall in the subscription fee. It’s a very good arrangement that is working well for many doctors and patients. But it won’t scale to people who can’t or won’t pay the subscription fee, and it doesn’t apply to acute care or specialist care. I’m all for it but there are lots of other hills to climb.
1. You could close your practice for a while until things calm down.
2. I saw you're a hospital attending, I assume with house staff. But until the hospitalists came to our area in PA around 2000 all the PCP docs took care of their patients in the hospital and ER. I held out until maybe 10 years before I quit in 2017 and went to office only. That kind of practice was a killer with calls all the time and really long hours. But I loved it. You felt like a real doctor. I did close my practice after a while even though it doesn't seem to be in the M.D. nature to do that. But overdoing it gets dangerous.
Thank you so much for this piece. As a DPC doc for 10 years, I also appreciate your distinction between concierge and DPC. I don't think DPC is without flaws, but I do have some thoughts about the over testing. In my experience, I have noticed that the model itself seems to draw patients with very rigid expectations / 'demands'. Combine that with the early days of practice, trying to make rent every month and feeling pressure to please your 'customers', it definitely did influence how I practiced and led to giving in to things I did not think were necessary. However, over time, as I built stronger connections, more trust and more confidence, those interactions started to change. I spend much of my time talking to patients why something is not necessary and potentially harmful, and patients started to listen and make more thoughtful decisions, which I believe has lowered the rates of over testing compared to if I practiced in a high volume setting. I believe that DPC has allowed that shift to happen. I also credit sensible medicine and all the wonderfully nuanced discussions I've been reading over the years. So again, thank you!
Well articulated. As a patient, I am frustrated with the move to membership models. Take menopause for example, many doctors now have concierge membership models. I don’t need or want much of what is offered. I would just like to pay a fair fee for 30-60 minutes with the doctor.
After reading your post, Adam, I continued to think about the following and felt compelled to share my thoughts: For the past several decades, my brothers and I have helped countless lose and yes, maintain weight loss. We are seasoned, data driven and devoted. We lighten the physician's load. Now, in addition, I support many on The Arc of Life: when diagnosed with disease, when living with a spouse with dementia, when grieving one of life's many losses or "sitting with" and guiding a family while a life ends. Physicians collaborating with us are so relieved to do so, while for many, it does not cross their minds. Perhaps referring to skilled, loving professionals, who deal with the inevitable, time-consuming conditions (overweight and decline) for support and management - and building a trusted outsourcing partnership- could save our precious physicians from the exhausting experiences associated with the practice of medicine in a country overcome by preventable illness and aging. Just a thought...
This post left me nearly in tears because you are simply acknowledging your own humanity. That’s incredibly hard to do. In my surgical residency, this was unheard of. To show vulnerability was frowned upon or even ridiculed. Kudos for expressing what many of us feel but are often afraid to admit. The direct care folks are onto something- I too ended up becoming a patient of a direct care practice because I could never actually talk to my doctor who I suspect was also inundated.
My $150/mo direct primary care practice might seem expensive but the goal was to order fewer tests, spend more time with the patient, use fewer medications, and theoretically place more emphasis upstream of screening, i.e., prevention.
It's not perfect and it attracts a different crowd of patients. Some don't believe in health insurance, some can't afford it.
I have as many patients who are on $20/mo plans as $150 plans. Some haven't been able to pay in a few months. And I love that. Because I wasn't able to do this with Medicare - it's not allowed to render services without collecting copays.
I got a hand MRI for $350 when it was quoted at $2,500 through insurance. I coordinate care for my patients who is temporarily in the Philippines.
My patients can switch jobs, insurance companies, countries, or gender - they'll never lose me as a doctor.
As soon as mainstream healthcare puts the emphasis back on the patient-doctor relationship I'll jump right back into my own UCLA and Kaiser Permanente gigs.
I agree entirely. I have observed a few conscientious, rightly motivated colleagues who have set up DPC practices, and it has been a revelation. They are pricing at levels (~$80/mo for adults) that are not a big reach for the average American, and they are set free to practice good medicine for their patients, whom they can genuinely get to know and partner with. Unlike concierge practices, which make the physician beholden to the patient--and thus easily lead to overtesting and overmedicalization, DPC with ~700pts in one's panel allow the physician margin and freedom from third parties to help the patient AVOID undue medicalization. It allows the physician to develop referral relationships in which the specialist gives counsel to the PCP, who can help the patient integrate what is possible into what fits the patient's particular vocation. And it seems to me evident that it saves the system a lot of $, or at least diverts money that would go to overhead/third parties toward time between patient and clinician. Not to mention it allows physicians to chart in rational ways rather than to please billers. AND it allows doctors to see poorer patients and not charge them, or charge them a reduced rate at their discretion (practices that are illegal if one takes federal insurance).
Having heard me comment about this for years, my son just quit his job as an accountant and is working to develop a company that helps PCPs set up and run DPC practices that are focused on the patient's health (not on selling miracle cures or cosmetics or trying to live forever), and network with one another to practice and publicly promote good medicine. Imagine a world where at a cost of <$1000/yr/person, patients have PCPs who know them and have time to respond to them, and patients trust those PCPs enough to let them determine how to appeal to and then make use of specialists' care. If DPC numbers grow, there will be growing political will to change laws so that employers can offer policies that focus on DPC. There will be political will to innovate with giving medicaid patients DPC vouchers, etc. May a thousand flowers bloom in this area.
Thanks Farr!
Adam - I manage my own DPC / direct primary care practice in Washington DC. The demand for doctors who a) have time to address the nuances of people’s complex bio-psycho-social and medical issues and b) aren’t burned out and crispy with frustration with the demands on our time is vast. Yes we doctors generally a well paid bunch compared to other professions. But the commodity patients value most (and the thing I need most to care for myself and others) is TIME. We need to scale this concept in the US and allow every American (not just wealthy ones) unfettered access to a “primary care medical home” where doctors have a smaller panel of patients and more time to address patients’ needs. It can be done. We just need the political will and to leverage technology to enhance - not eliminate - the patient doctor relationship. Trust is at the core of what we do - as you know! Trust takes time to build. Rapport takes time to develop. Doctors and patients want the same things. So let’s reinvent the system centering primary care. It’s about time
Also - I should have said - thank you for this excellent post. I always appreciate your balanced perspective and open mind. It’s refreshing.
Stanford Medicine (at Stanford University) now has their own concierge internist group, and they continue to hire doctors for it. My usual internist (not concierge) is for all practical purposes unreachable now: no physical-exam appointments for the next three months; her next video appointments are December 29 or March 3; a simple MyHealth question to her asking whether we might reduce a medication given recent blood tests returned a message from a nurse saying to schedule a real appointment. I feel like I'm being pushed to concierge.
Appalling.
Let's be a little more honest about concierge medicine. A lot of it has to do with greed. Down here on the Gold Coast of Florida concierge internists. $2000 per patient in return for limiting themselves to 300 patients. Factoring in 40% overhead they've already made $360,000 before they see the first patient. Even though I have a number of severe medical issues I only see my internist once or twice a year so that would make that one very expensive visit. My wife is willing to pay that for her peace of mind but not me. And for that $2000 she first has to go through the practice' s nurse practitioner!
Clearly we have to make practicing medicine much more efficient with reliable dictation and summarizing systems as well as physician extenders-nurse practitioners etc. in the meantime I guess I have to go to the emergency room or one of the immedia centers when I need some help
Unfortunately, the emergency room is not a step up. It is painful for all.
This, this, a thousand times this!!! I could have written this, word for word. After 30 years in big system primary care, ending with two years as Medical director with 180 direct reports, I was pretty fried. I’ve been saying for decades that investment in primary care would come back many times over, but all we got were higher productivity goals and meaningful use BS. I left town (non-compete, you know) and joined a DPC.
It’s absolutely wonderful - 500 patients, hour long visits, direct contact via email/text, and though I do work part of every day in some capacity, it’s focused on helping people, not jumping through Epic hoops to support billing. I know my patients at paying far less for my care, for labs, etc than they would if they use their insurance (generally high deductible) and we have time to really cover all that needs to be covered each and every visit.
I have felt guilty about removing myself from the “public pool” but the work I do now is very fulfilling for me and patients are gobsmacked by the care we are able to provide for a really low rate (less than $100/month on average).
I no longer suffer as much moral injury at work, I know I can do what patients need and deserve. Yes I make a bit less and have far fewer “benefits”, but at this point of my career, it’s kept me going with a renewed sense of enthusiasm and joy for job. Best thing that’s happened in my career, it’s the way ALL primary care should be done, and if there had been more support, incentives, etc in the past 20-30 years, we could have had enough docs going in to this most rewarding ‘specialty’ to ensure we all would enjoy the same professional satisfaction.
Apparently the underlying message here is that we need to produce more doctors, especially PCPs / IM docs, and give them more freedom and less bureaucracy.
Concierge works largely because each doc sees far fewer patients. It's good for the patients who can afford it and for the doctors who practice it. That works great for wealthy patients but it puts up a velvet rope in front of everyone else.
We need real solutions for the whole population.
Adam, do you think delegating to PAs, NPs and AI is the answer?
I think they can only be part of the solution.
"Only be part of the solution" I think is the the right take.
Adam
Car mechanics will soon make more.
I really like my car mechanic.
They might deserve to make more.
I think it would be so interesting and good for our country to allow direct care types of arrangements to scale alongside our current system. One way to allow that, and address the issue of “taking from the public pool” would be to make it possible for doctors to link their Medicare/Medicaid participation to the entity. This would allow DPC docs to work at times taking hospital call or moonlighting shifts.
But for these groups to really scale we will need to lose the CON and Stark laws that prevent new and doctor owned facilities from opening.
I’m not sure that the direct pay subscription model necessarily leads to over testing. Many DPCs include common tests and services in the fee, so docs save money by not doing those test that aren’t needed. Plus for tests that aren’t included- patients have to pay someone else. For similar reasons, these models encourage less over use of specialists as well. I think on balance incentives are better.
Concierge medicine is the free market at work. I offer a service at a price that compensates me as I wish and willing buyers purchase it if it meets their hopes. Private and government insurance are accommodated, the buyer pays the shortfall in the subscription fee. It’s a very good arrangement that is working well for many doctors and patients. But it won’t scale to people who can’t or won’t pay the subscription fee, and it doesn’t apply to acute care or specialist care. I’m all for it but there are lots of other hills to climb.
You are so right and it’s such a travesty. And yet, you are just the one to be a primary care doctor. You are so good at it