Friday, August 29, 2014

More On Direct Patient Care

Plain directness can go a long way.

Anthony K. Tjam. “Have the Courage to be Direct,” HBR Blog Network, 2012

Healthcare providers are discovering strategic opportunities with large employers that are self-insured, but they need to be willing to partner more directly with payers and employers.

Phillip Betbeze, "Targeting Self-Insured Populations, " Health Leaders Media, August 27. 2014

I keep running across examples of “direct” patient care.

• Formation of organizations touting “direct primary care.”

• Self-funded corporations contracting “directly” for concierge and ambulatory surgical services.

• Independent “direct pay” providers bypassing 3rd party government and health plan middlemen.

• Physicians striking out and signing “direct contracts” with local businesses to provide comprehensive “direct primary care” to employees.

What does it all mean?

I suspect:

One, "being direct" is borne out of frustration with the current complex regulatory system, which seems to drive costs higher ever passing day.

Two, "being direct" is a bold attempt by businesses and providers to cut costs by cutting to the chase of health care matters by KISS (Keep it simple, stupid!),

Three, "being direct" exemplifies the American philosophy of “disruptive innovation,” i.e., there is more than one way to skin a cat by making things simpler, more direct, more convenient, more bundled, and less specialized.

I came across this direct way of doing things while interviewing “direct pay” concierge physicians and directors of ambulatory surgery centers for my book Direct Pay Independent Practices: Medicine and Surgery ( Amazon, Kindle book, $9.97).

Kindle books or e-books, by the way, are another example, of “directness" of bypassing traditional publishers by dealing directly with authors online.

If you give the matter any thought at all, you will realize “direct online care,” in the form of virtual medicine or telemedicine, has the potential of cutting out many health care middlemen.

Walmart and GE now directly contract for hip and knee replacements by contracting directly with health systems rather than going through health plans – it is simpler, more direct, and far less costly.

In Oklahoma City, many self-funded corporations and even public or government health agencies save money by sending patients directly to the Surgery Center of Oklahoma for routine surgeries for ambulatory patients.

In Wichita, Kansas, concierge physicians contract directly with local businesses for bundled primary care services. New corporate-provider partnerships are cropping up everywhere to simplify relationships and decrease costs, complications, and regulations of doing health care business.

Partnerships are replacing partisanship. Cooperation is replacing confrontation. And physicians and surgeons are learning the fundamental rule of health care nailing, "If you have a health care nail to hit, hit it on the head." Or, as Ben Franklin observed, "For want of a nail the shoe was lost; for want of a shoe the horse was lost; for want of a horse the rider was lost."

Thursday, August 28, 2014

Everything You Ever Wanted to Know about Direct Pay Independent Practice But Were Afraid to Ask

Ask, and it shall be given to you; seek and ye shall find; knock, and it shall be opened unto you.

Matthew 7:7

Because of a book David Racer and I wrote about direct pay medicine, Direct Pay Independent Practice: Medicine and Surgery, I am often asked about the current state of the direct pay medicine.

As a retired pathologist, health reform commentator, and bystander, I am not directly involved in the movement, so I am not the person to ask.

The people to ask are those actively engaged in organizing the Free Market Medical Association with members in all 50 states, organizations consulting in making the transition from traditional practices now driven by 3rd party payments – MD-VIP, Special Docs, Signature MD, and Access Health, and Jeffrey Bendix, a senior editor of Medical Economics, who has just written a comprehensive article on the subject : "Direct Pay: A Promising Model with Challenges, Medical Economics, August 21, 2014.

The statistics I am about to share with you are from his article.

• What types are direct pay practices are now operational?

1. The first is a straight cash model. Patients pay out-of-pocket, Sometimes the practice will give the patient a superbill that the patient can submit to his or her insurance company for reimbursement.

2 Under the second model patients pay a monthly fee to be included in a physician’s panel. The fee covers unlimited office visits and 24/7 access to the physician, including via text or e-mail. In most cases it also includes whatever in-office procedures and tests the physician offers, although some practices charge extra for these.

3. The third form, generally known as concierge medicine, includes a monthly or annual fee. Patient receives services such as 24/7 access by telephone or e-mail, a comprehensive annual physical exam, and no-waiting appointments. Some practices maintain contracts with insurance companies but most disengage from 3rd patients.

How long does it take to transition from a traditional practice to a direct pay practice?

Three to six months.

What specialties participate in direct primary care?

Sixty percent are internists, but family physicians also are switching to concierge practices, along with certain specialties, like psychiatry and certain surgical specialties, especially surgeons operating in direct pay ambulatory surgery centers. Many surgeons also accept direct pay discounts.

What incomes can direct pay physicians expect?

Less than $100,000, 33%; $100,000 to $200,000, 40%; $200,000 to $300,000, 14%; $300,000 to $400,000, 5%; over $400,000, 8%.

What are the average ages of direct pay physicians?

Under 30, 13%; 40 to 49, 32%; 50 to 59, 45%, over 60, 10%.

What are the average monthly subscriptions charged to patients?

Under $50,11%; $51 to $100, 14%; $101 to $135, 31%; $135 to $180; over $180. 36%.

What are the challenges involved ?

The challenges are (loss of loyal patients, criticism by colleagues and policy makers) and economic (loss of income during transition, lack of guaranteed success, no certainty direct pay movement will catch on, though some are predicting a 10% to 15% annual growth rate; and bureaucratic hassles from government and insurers while making the transition).

Read our book, Direct Pay Independent Practice Medicine and Surgery (Kindle book., $9.97) and Medical Economics article for details).

My book features interviews with 12 participants in the direct pay movement – their experiences and their expectations

Pre-Labor Day Lull and Health Care Reform Sleepers

Come Labor Day, the political campaigns begin in earnest.

At issue will be:

• Foreign policy decisions (Should we bomb ISIS in Syria?).

• Ukraine v. Russia (What should we do, if anything?),

• Obama end-runs around Congress on immigration and climate change regulations( Can the president do what he wants to do?).

• The state of the economy (What’s real – 4.5% growth in 2nd quarter or 1.5% project for all of 2014).

• ObamaCare ( Are premium hikes and health plan cancellations and switches worth the 5% drop in number of uninsured?)
According to Real Clear Politics polls on Senate and Government races without tossups (9 seats are too close to call), the political races shape up like this ( pundits are hedging their bets whether midterms will be a sweeping wave election or a mere GOP ripple),

Senate: 52 Republicans, 48 Democrats
Governors: 29 Republicans, 21 Democrats

For the moment, ObamaCare is dormant, but there are these big time sleepers.

• How much will double digit health care premium increases influence Red States Senate elections?

• Will health plan cancellations and forced switches to other health plans anger voters?

• Would a GOP Senate with vote for repeal really mean anything in view of certain Obama veto?

Only one thing is certain, after Labor Day, America will awaken from its temporary political slumber over matters of foreign affairs disarray, domestic economy troubles, and ObamaCare controversies.
Richard L. Reece, MD, now have 2 Kindle E-books available on Amazon.

The books are:

1. Direct Pay Independent Practice: Medicine and Surgery, $9.97

2. Understanding ObamaCare: Travails of Implementation, Notes of Health Reform Watcher, $3.99

In addition these books are available in paperback or hardcover:

Health Reform Maze; A Blueprint for Physician Practices

Innovation-Driven Health Care: 34 Concepts for Transformation

Obama, Doctors, and Health Reform

A Managed Care Memoir

And Who Shall Care for the Sick?

Wednesday, August 27, 2014

Key Health Care Reform Phrases and Issues

Communication – the human connection – is key personal and career success.

Paul J. Meyer (1928-2009), Texas Philanthropist and Founder of Success Motivation Instituute

Programmers tell me the key to online success are certain key words and phrases.
With this in mind, I revisited my 3650 blogs composed over the last seven years, and these three blogs popped to the top.

"Health Reform, Women Physicians, and the Doctor Shortages"

Jun 13, 2011 7640 page views

"Texas and the Future of Health Reform in America"

Jul 1, 2012 4710 page views

"Health Reform, Primary Care Shortages, and the Coming Political Crisis"
Mar 21, 2011 3991 page views

If you so desire, you may read these blogs by clicking on titles, which are blue and underlined.
What do these three blogs share in common?

1. They all contain the phase “Health Reform".

2. They were all published after the Patient Protection and Affordable Care Act, the ACA or ObamaCare, passed on March 23, 2010.

3. They all address three hot health care reform issues – women, Texans, and for primary care physicians.

That these three issues should rise to the top should not surprise.

• Women physicians because half of graduates of medical school are now women. The AMA now has 67,000 women members. Women now dominate primary care and the specialties of obstetrics and gynecology and dermatology. Women are more likely to be employed. Women in general practice shorter hours and retire earlier. And by doing so, contribute indirectly to t doctor shortages.

• Primary care shortages are topic number one in health care education and policy circles. Primary care physicians comprise only one-third of American physicians, yet they are the entry point for care for Medicaid and Medicare patients and for those millions of previously uninsured slated to enter the health system in the next three years.

• Texas, because of its physician-friendly environment, its robust business climate, its malpractice reform laws, its low cost of living, its relative shortage of doctors, its low taxes and lack of a state income tax, has become a magnet and destination of physicians from other parts of the U.S. and foreign physicians.

It is self-evident why readers are attracted to these three blogs. My other blogs featuring women physicians, primary care physicians, and Texas medicine have also been heavy draws. I invite you to read the three blogs listed above by entering their titles in the search box on the upper left on each Medinnovation blog – where health reform, medical innovation, and physicians practices meet.

Health Reform and The New England Journal of Medicine’s Agenda

Everybody has an health care and health reform agenda.


I avidly read each issue of the New England Journal of Medicine. The Journal is the world’s most prestigious medical journal. Each issue features meticulously edited scientific and general articles.

In recent years, the Journal has contained a Perspective section. The section precedes original articles, editorials, special reports, and correspondence.

The Perspective section features comprehensive pieces on reform and health care issues of the day.

In reading the Journal, I am aware of its hidden agenda – to advance the causes of government and global health care and health reform without, of course, being overtly political about the agenda. Its articles on health reform invariably have multiple authorship for government agencies and academic institutions , voluminous data, charts and graphs, multiple references, and content evaluating top-down government or academic reform.

Rarely do the articles reflect the point of view of independent practitioners. There is nothing wrong with this agenda. It simply reflects a nearly universally held world view in government and academic circles, as opposed to bottom-individual physician practice point of view, which more often than not, looks askance at ObamaCare.

To show what I mean, consider the titles and sources of authorship in the six articles in August 28 issue.

One, in Perspective, “A VA Exit Strategy,” by William Weeks, MD, and David Auerbach, Ph.D., from the Dartmouth Institute of Health Policy and Clinical Practice and RAND, Boston.

Two, in Perspective, “Reforming the Financing and Governance of GME G.R. Wilensky and D.M Berwick, co-chairs of the Institute of Medicine Commmittee on the Governance and Financing of of Graduate Medical Education, with 19 members of the Committee.

Three, in Perspective, “ Innovation in Medical Education,” David Asch MD and Debra Weinstein, MD, from Center of Health Care Innovation, Pennsylvania School of Medicine, Wharton School, Department of Medicine, Massachusetts General Hospital, Partners Health Care System, and Harvard Medical School.

Four, in Perspective, “Updating Cost-Effectiveness The Curious Resilience of the $50,000-per-QALY Threshold,” (QALY stands for Quality –Adjusted life-year), Peter Newmann, Sc.D., Joshua Cohen, PhD, and Mllton Weinstein, phD, The Center for the Evaluation of Value and Risk in Health, Tufts University, and Department of Health Policy and Management, Harvard School of Public Health.

Five, in Health Law, Ethics, and Human Rights Section, “Money, Sex, and Religion – The Supreme Court’s ACA Sequel,” George Annas, JD, Theodore Ruger, JD, and Jennifer Ruger, PhD. Department of Health Law, Bioethics, and Human Rights, Boston University, Pennsylvania School of Law and Leonard Davis Institute of Health Economics.

Six, Special Report, “Health Reform and Changes in Health Insurance Coverage in 2014,” Benjamin Sommers, MD, and five others, Office of the Assistant Secretary for Planning and Evaluation, HHS, and Department of Health Policy and Management, Harvard School of Public Health.

I will not get into the details of these articles. Suffice it to say, the authors view health reform from the top-down government and academia perspective. Most question but favor national health reform, e.g. the last article notes “These results are consistent with studies of previous insurance expansions that have shown that gains in coverage can lead to rapid improvements in access.” One graph shows the number of uninsured have declined from 20.5% to 16.3% since 2012.