Direct Primary Care – The Best Healthcare Delivery Strategy

1. Direct Primary Care – The Best Healthcare Delivery Strategy Missouri Rural Health Conference August 22, 2019

2. Objectives After the completion of this session those in attendance will have a better understanding of the following: • Concepts of Direct Primary Care • Advantages of Direct Primary Care • Limitations of Direct Primary Care

3. What is Expected During a Traditional Physician Office Visit?

4. When was the Last Time you Saw This?

5. Fee for Service/Insurance Based Practice • Overworked providers • Episodic focused • Long wait times • Opportunity costs • Short visit duration • Distracted by unnecessary documentation

6. Simple Math A primary care physician with a panel of 2,000 patients would need to spend an estimated 17.4 hours per day in order to provide recommended acute, chronic and preventive care to their patients.

7. Concierge and Direct Primary Care-Similar but Completely Different • Both improve quality of care for patients • Both improve physician experience/pay • Concierge has much smaller panel • Direct Primary Care improves access for low income/uninsured • Workforce improved instead of compromised Direct Primary Care

8. Key Differences Between Conciergeand Direct Primary Care? • Generally affordable for the average person • Can be successful in rural and poor communities • Can lower out of pocket costs vs. increase • Panel size is optimal vs. too small • Practices by definition NEVER file insurance

9. Factors Driving Direct Primary Care • The Affordable Care Act • Cultural shifts • Primary care provider shortages and more insured patients • Technology

10. The Affordable Care Act’s Individual Insurance Mandate • Direct primary care arrangements must be paired with low-cost health insurance plans that cover more expensive medical services, such as hospital stays, surgeries, and multi-course treatments. • According to a 2018 ValuePenguin analysis of health insurance plans across the United States, the average 21-year-old American pays $167 per month for a catastrophic plan and $201 per month for a bronze plan through the ACA exchange.

11. Cultural Shifts • Millennials and Gen Z expect responsive service • Emerging technology – texting, face time etc. • Opportunity costs – It is all about me

12. Primary Care Provider Shortages & More Insured Patients • According to the American Association of Medical Colleges, the United States faces a shortfall of anywhere from 12,500 to 31,000 primary care physicians by 2025. • People with health insurance are more likely to use primary care providers, this shortage is exacerbated by the dramatic (10 million plus) rise in the number of insured Americans. • Contributing to the rise of so-called mid-level practitioners, such as nurse practitioners (NPs), physician assistants (PAs) and assistant physicians (APs

13. Technology and Direct Primary Care • Fee for Service model • The patient must be seen to generate payment • Direct Primary Care • Technology-enabled access to providers – patients’ ability to call, text, exchange pictures, and video conference outside of the office

14. Direct Primary Care Aligns People and Incentives • Predictable monthly revenue allows for population-based care management • Allows providers more time with their patients • Allows for improved continuity of care • Better work environment and improved satisfaction • Investing more in primary care reduces overall costs

15. The Direct Primary Care Quadruple AIM • Increased Quality • Increased Access • Improved Cost • Improved Patient Experience

16. Why the need for Direct Primary Care? • Will practices be able to remain independent • Uncertainty about viability of solo practice • Increasing overhead costs • RUC not working for improved reimbursement • Burnout-insurance makes MDs “box checking gophers”

17. What is Primary Care? • Comprehensive primary care and prevention services • Direct agreement and relationship between patient and provider • Monthly fee and payor agnostic • No service billing • Not part of an insurance of health plan • Defined in the Affordable Care Act ( ACA1301 (a) (3)

18. Advantages of Primary Care • Increased access for patients • Better continuity of care • More attentive, personalized service • Less overhead & greater simplicity for providers • Improved image & reputation for providers and health systems

19. From the Patient’s Point of View Traditional Primary Care • Your physician works for? – Their hospital system employer... Average Panel 1,500-4,000 patients/ doctor • 7 minute appointment time • Fees and service defined as ‘office visit’ • Poor access • Quotas for referrals for tests/specialists? – Keep Direct Primary Care • The physician works for patient • The patient/physician relationship is restored • Health and well being is the top priority • Reduced number of total patients • Appointments last as long as necessary • • Preventive, acute, and chronic medical care when you need them, as often as you need them • 24/7/365 access by technology • Same day/next day appointments

20. Direct Primary Care Income Projections per Month and Year (Pediatric dependents: 1 monthly fee up to 10 dependents)

21. Disadvantages of Direct Primary Care • Needs to be paired with low-cost insurance for ACA compliance • Traditional insurance usually doesn’t cover membership cost • Ancillary cost such as labs and radiology may not be part of the membership • Unreasonable patient expectations • Thin coverage in many areas

22. American Academy of Family Physicians Response to Direct Primary Care • "The AAFP supports the physician and patient choice to, respectively, provide and receive health care in any ethical health care delivery system mode, including the DPC practice setting," says the policy. It notes that the model is structured to "emphasize and prioritize" the physician/patient relationship to improve health outcomes and lower costs and is consistent with the AAFP's advocacy of both the patient-centered medical home and a blended payment model.

23. Questions?

24. Additional Resources • https://www.aafp.org/dam/AAFP/documents/practice_management/payment/DirectPrimaryCare • Forrest, B.R. Physician’s Practice Pearl 12/7/11 New Primary Care Models Can Change the Way You Practice • Pofeldt, E. Medical Economics “The Rise of Direct Primary Care” 4/10/16 • Bendix, J. Medical Economics “Fighting Back for Independence” 8/25/15 • Lankford, K. Kiplingers “Pay Cash for your Healthcare” 2/15 • Sprey, E. Physicians Practice “New Practice Models are Gaining Acceptance” 9/14 • Forrest, B. Physicians Practice Pearl “New Primary Care Models Can Change the Way You Practice Medicine” 12/11 • Forrest, B. Medical Economics Cover Story “Cutting Edge” 5/25/11 • Mescia, T. Weekly Standard “Cash for Doctors Revisited” 4/11 • Mescia, T. Weekly Standard Cover Story “Cash for Doctors” 5/23/10 • Morgan, Lewis. Medical Economics Cover Story “Keeping it Simple” 1/22/10 • Forrest, B. Physicians Practice. July 2008. “Cash and Carry Healthcare Still Works.” • Forrest, B. Family Practice Management. June 2007. “Breaking Even on 4 Patients per Day.” • Forrest, B. Physicians Practice. June 2007. “Cash and Carry Health Care.” • Backer, L. Family Practice Management. February 2006. “2500 Cash Paying Patients and Growing” • Forrest, B. NC Medical Journal May 2005. Innovations in Primary Care. “The Access Healthcare

25. For Additional Information Tania Sharp, MHA Regional Executive Director Nuehealth Missouri Integrated Provider Network Heartland Physician Corporation 1405 Crown Drive Kirksville, MO 63501 (660) 956-4385 hpctsharp@gmail.com Jim Tune, MBA, SSBB Regional Vice President Nuehealth Missouri Integrated Provider Network 3208 Lemone Industrial Blvd. Columbia, MO 65201 (573) 499-6540 june@nuehealth.com