Jacqueline Fellows, for HealthLeaders Media , August 27, 2015
A new model of primary care avoids traditional insurance headaches— has shown how a $45 investment prevented $200,000 of healthcare costs—and is gaining momentum among physicians, patients, and payers.
Despite the move to transform the healthcare system to one that rewards value over volume, most reimbursement is still based on how many patients a doctor sees. The constant churn can lead to physician burnout, which the country can’t afford because in ten years there will be shortfall of at least 12,500 primary care physicians.
This is neither shocking nor news, but some PCPs are pinning their hopes on the direct primary care (DPC) model as a way to survive healthcare’s transformation.
DPC is similar to the concierge model in that patients pay a monthly fee in exchange for more access to their physician. Appointment times are kept without much waiting and patient visits are longer. Patients have 24/7 access to their doctor through phone, email, and text.
But that is where the similarities end. Concierge practices can be expensive with some annual fees reaching $6,000. DPC practices charge a monthly fee, usually a sliding scale depending on the age of the patient. Concierge physicians also accept traditional insurance. A DPC physician does not.
|Zubin Damania, MD|
The no-insurance rule is a radical idea that has some physicians scratching their heads, but others, such as Zubin Damania, MD, founder of Las Vegas–based TurnTable Health, believe DPC has the ability to improve patient care and physician satisfaction. “We are attracting younger patients,” he says, noting that the average age of TurnTable Health’s 300 DPC patients is 35 years old. “We have a minimum 30-minute visit.”
Damania is also known as ZdoggMD, an alter ego who raps about some of hospital’s biggest headaches, such as readmissions. He puts a humorous spin on sobering topics, but he is serious about changing patient health in Las Vegas. “It’s some of the worst healthcare in the nation,” he says. “Las Vegas tends to attract a transient kind of group. There are amazing physicians here, but it is one of the most challenging environments. I was horrified and terrified and when I came here, but I fell in love with it. There is something about this city… people here want change. Las Vegas is about reinvention.”
TurnTable Health is not exclusively a DPC practice. The city’s culinary union contracts with TurnTable Health so that its members have a place to go for care. And TurnTable was an option under the [failing] Nevada Health Co-op, which was set up for Nevada’s health insurance exchange. The Co-op announced this week that it would cease operations next year due to “market conditions” and it’s not clear how that will affect TurnTable, which has 1,500 Co-Op patients.
The mix of health insurance, self-pay patients, and the handful of small businesses that use TurnTable Health for health coverage is a not a one-off idea limited to Las Vegas. Iora Health, based in Cambridge, Massachusetts, and led by founder Rushika Fernandopulle, MD, is deploying its version of healthcare in several states.
Iora and TurnTable are also partners. Damania describes the relationship as supportive. “We provide the building, patient acquisition, and they (Iora) provide the staff, electronic health record, and clinical day to day operations.”
|Rushika Fernandopulle, MD|
Healthcare’s ‘Lack of Courage’
In addition to the clinic in Las Vega, Iora has clinics in five other states. Fernandopulle is an adamant patient advocate, viewing traditional health insurance as a nonstarter for innovating healthcare practices. But, he’s a realist, and rather than keep insurers completely out of the loop of care, he says they have to be part of the solution, but on his terms. For example, instead of submitting codes for care delivered, Iora charges insurers a flat fee.
“I think what we have in healthcare is a lack of courage,” says Fernandopulle. “I think there are a lot of us who realize that the payment model for primary care is silly. It doesn’t allow us to do the right thing. Every other industry in the world, the sellers of the service decide how they want to get paid and the buyers decide if they want to take it or not.”
Some insurers are taking the plunge with Iora. Tufts Health Plan, which has more than 1 million members, is scheduled to open two Boston-area primary clinics with Iora next month. The clinics are specifically designed for its Medicare and managed Medicaid members.
$45 of Prevention Saves $200,000 of Care
The reason that a model like Iora can take care of older patients, like the ones it will cater to in its newest clinics, and younger ones, like the ones in Las Vegas, is because it steps outside of the diagnostic box where fee-for-service medicine lives.
The protocols are evidenced-based, but since traditional health coverage is not a revenue stream, it is also not a barrier. And physicians employ whatever they need to do for a patient. For example, Damania says his practice gives patients $8 pedometers to start them walking. Fernandopulle once bought a $45 iPod shuffle from eBay for a patient who would leave in the middle of dialysis because of anxiety. The iPod was loaded with the patient’s favorite music. The result?
“In six months, zero ER admissions; [the patient] sat through dialysis every time,” says Fernandopulle. “This is a $45 iPod that solved $200,000 of healthcare costs. Why does no one else do it? There’s no CPT code for ‘Buy iPod on eBay,’ there’s no CPT code for ‘Spend an hour to download music on said iPod.’ But in our practice, it doesn’t matter. It’s the right thing to do for that patient. We do it for the patient.”