Posts Tagged concierge care
Happy doctors seeing fewer patients and making more money — what’s not to like? According to author David Von Drehle’s article “Medicine Gets Personal” in Time Magazine, Dec 29/Jan 5, the results are “intriguing”.
The story is about Qliance Health in Seattle founded by two doctors who were dissatisfied with fee-for-service medicine and all the associated paperwork. So, they developed a model of care where the patient pays $65/month and receives all the primary care they need. And, as a twist, they also agree to see Medicaid patients for the same cash amount (the details of the arrangement were not stated in the article). Of course, insurance and medicaid pay for all other services like tests, x-rays, drugs, hospitalizations and specialists.
The doctors are happy because they have less oversight from insurance, don’t have to collect any data to prove they are delivering quality care, get steady income, treat patients over the phone to minimize visits, and are able to “run” their own business with no boss. For the libertarian-minded physician it’s nirvana.
Piece-work is indeed a hard life as physicians and many in the garment industry know. A monthly salary is much easier on the worker. And, the salary model is not new in terms of primary medical care. The physicians working for the National Health Service (NHS) in the UK have had this system since WWII. However, the NHS found it was necessary to add financial incentives to get the doctors to do enough work. And, they found it necessary to monitor quality since quality slips without oversight.
So, this “Direct Primary Care” is not new in the world. In fact, it may be an important part of an Accountable Care Organization (ACO) as being tried the US. But, physicians need to realize they need to be part of a large organization to ensure quality care. The future for primary care is to be an employee, not a mom-and-pop store. Most of doctor’s patients work as employees, is that so bad?
$65 per month would be too much to pay for poor quality care (the cost of poor care is always too high!) So what does “Direct Primary Care” need to do for patients and payers to be confident quality care is being delivered?
- Measure and report quality in a transparent way — like on the office website. And, keep it updated.
- Deliver patient-centered care and prove it. Survey patient’s expectations and record whether the expectations are met with office visits.
- Report quality indicators other doctors must do like for diabetes, hypertension and smoking.
- Report primary care specific indicators regarding the most common diagnoses — skin conditions, joint pains and respiratory infections.
- Take a financial stake in what is prescribed or ordered. Pay some fraction of the cost of all medications prescribed and all tests ordered. They need to have some “skin in the game”. (So there is a connection to the larger world of health care cost — ordering a $1000 MRI scan for every ache and pain must have some consequence).
ER doctors never ask the question but often think: “Why did you call an ambulance for a sore throat?!” The trip costs at least $1000 and stands a chance of not being covered by insurance. The ambulance crew feels bad they don’t have a more appropriate option but if you call an ambulance — you get an ambulance.
Kaiser Health News reports the South Metro ambulance company in a suburb of Denver Colorado is trying a new service. An ambulance that is basically an ER in a box. Equipped with lab tests, bandages, sutures and a few medications they go to a home to treat a problem rather than transport a person to the ER. It costs about $500 — at this point, it is something insurance will not cover.
Here are two extremes:
- A single parent picks up their child from a family member after working 2 jobs at fast food restaurants. The parent just got the jobs after 3 months of being unemployed. The primary care doctor’s office is closed and the parent is expected at work in about 7 hours. But, the child has a fever and a sore throat. The bus they usually catch to go to the hospital does not run after 8 PM. The parent calls an ambulance.
- A woman drops a martini glass and cuts her finger. Her husband thinks she needs stitches but he has some after hours stock trading to do before bed. He tells the butler to call an ambulance and get the problem resolved.
The first case is common for Medicaid families. No resources, no car, and not much to lose by calling an ambulance. But, something to gain by not missing time at a new job and it helps the child on both counts. The ambulance and ER visit may cost Medicaid over $1000. But, during the day a visit to primary care might only cost $50.
The second case is crying for concierge care. The family has the cash to pay for someone to come to the house and put a few stitches in a finger. But, instead the problem clogs up the ER that should be dealing with heart attacks and car wrecks. Again, if the problem happened earlier in the day a primary care office or urgent care clinic could have solved the problem.
One could see Medicaid having a fleet of mobile treatment units just to limit the financial losses in the ER. Actually, a good idea. Both cases might have solved their problems by taking a taxi to an urgent care clinic — if one was open.
Will the “ER in a box” find a place? — at least a place where someone will pay them? The idea leans toward the concierge model. No insurance is going to pay for an ambulance when a taxi will work. No insurance company will pay extra just for the convenience of one patient.
Nice idea, but it’s not likely to fly financially.