In Episode 12, Dr Roussel interviews Dr Doug Farrago about DPC allowing doctors to be true to themselves and true to the profession. A seasoned blogger, book author and speaker, Dr Farrago sees DPC as the only way that DPC doctors can be authentic amidst the harsh realities of present third-party care.
[01:58] Dr Farrago’s inspiration to start writing
[03:28] How Dr Farrago’s writing about unhealthy influences in primary care aims to help doctors be true to themselves
[05:23] How authentic medicine is feasible in an age of industrialized care
[06:31] How Dr Doug sees DPC as connecting doctors back to the roots of medicine
[07:43] If everyone in the country had a DPC doctor…
[08:30] DPC is our only hope…
[09:06] How Dr Doug sees DPC as being able to help doctors with burnout
[10:23] Dr Doug’s book
[12:20] Dr Doug’s thoughts on the competition for DPC doctors
One of the major difficulties in our healthcare system is the primary care shortage. Many medical students and residents are loathe to enter/remain in primary care due to heavy workload, poor reimbursement rates and high burnout rate. In most other successful healthcare systems, there is no primary care shortage because nearly 70-80% of doctors are primary care doctors. In contrast, in the US, fewer than 50% of doctors enter primary care, and the number is decreasing each year. This is all changing with DPC, which offers a way for doctors to sustainably enter the field of primary care and remain in it for life. In this episode, Dr Roussel talks with Dr Karl Hanson, a DPC doctor in Kenner, LA about his talks with medical students and residents on the joys of DPC. DPC, he notes, offers the opportunity for young doctors to enter primary care and find a sustainable and enjoyable work environment.
[01:31] Dr Hanson explains his motivation to convert his fee-for-service practice to a DPC practice.
[02:18] How Dr Hanson got involved with speaking to medical students and residents about DPC
[05:02] Why medical training gives little attention to healthcare administration and finance
[06:40] Whether medical school faculty support DPC
[08:07] Ways Dr Hanson has offered to help medical students and residents learn more about DPC
[12:02] How Dr Hanson addresses the issue of income security and student debt for young/potential DPC doctors
[14:43] Dr Hanson’s experience with DPC’s reception by medical school faculty
[16:58] Resources for medical students and residents to learn more about DPC
Dr Karl Hanson is a DPC doctor at Infinity Health in Kenner, LA. In addition to being a doctor, he delivers talks to medical students and residents around the country on DPC and how it can not only reverse the primary care shortage but also lead to a more satisfying and sustainable life for doctors.
What initially started as a frustration with health insurance eventually spawned a national movement to restore primary care. In 1997 Dr Garrison Bliss said good-bye to health insurance, starting a direct pay practice in the Seattle, WA area. While this initial clinic was out of the price range for many families, his experience forming deeper relationships and quality care led him to expand his practice model to be well within the price range of every-day people. This new model became known as direct primary care. It involved a low-cost monthly fee for comprehensive primary care. While regarded with skepticism by many, the model has grown rapidly over the years since its beginning and has been responsible for a grassroots movement to restore primary care from the ground up.
In the interview, Dr Roussel interviews Dr Bliss about the origins of his motivation to pioneer the direct primary care model, including a frustration with insurance-based care that made it difficult for him to provide the quality of care he felt he could provide. While a couple of his colleagues formed a concierge practice charging $1000 a month per patient, he wanted his practice to be accessible to every-day people. As a result, he founded Qliance in 2007. Since then, the direct primary care movement has exploded from a few doctors in the late 1990s to thousands of doctors. The reason for the growth of the movement is clear, says Dr Bliss, doctors and patients are tired of caregiving arrangements dictated to them by insurance companies. As a result, they are flocking to the DPC model in droves, improving the relationship between doctors and patients. This improved doctor patient relationship is what drives the DPC movement and what will ultimately be responsible for its success, says Dr Bliss, but it will ultimately depend on the motivation of grass roots activists (both doctors and patients) who have seen the model succeed to keep the movement going and push it into the mainstream.
[3:54] Why Dr Bliss decided to start an insurance-free primary care practice.
[4:55] Dr Bliss discussion of trying to do ‘concierge’ affordably
[7:15] How and why Dr Bliss converted Seattle Medical Associates to a direct primary care practice, Qliance
[14:20] How has Dr Bliss viewed the evolution of the direct primary care movement
[18:33] Where does Dr Bliss see the tipping point where direct primary care becomes mainstream
[25:31] How can the direct primary care movement keep up its momentum?
[29:30] What happened to Dr Bliss when the insurance commissioner threatened to shut his practice down
Dr Garrison Bliss is an internist in Seattle, WA. In 1997, he started Seattle Medical Associates, a membership-based insurance-free practice. His positive experience providing primary care outside of health insurance led him to found Qliance, the nation’s first low-cost direct primary care practice. He is regarded by many as the founder of the direct primary care model and continues to speak around the country to doctors, lawmakers, companies, and patients about the beauty of direct primary care.
“The smallest minority on earth is the individual. Those who deny individual rights cannot claim to be defenders of minorities.”
Dr Josh Umbehr is a one-of-a-kind doctor. “Fearless” as some have described him, he ventured in 2010 to start an insurance-free, cash-based practice straight out of residency. Now, his clinic, AtlasMD, has a handful of physicians and services thousands of patients in the Wichita, KS area. Moreover, he has developed an electronic health record designed specifically for DPC doctors and provides free consulting for doctors interested in starting their own DPC practice and his clinic has served as spearhead for the nation for a new model of primary care.
In this episode, Dr Umbehr—who’s become a well-known voice in the DPC movement—discusses his motivation to start a DPC practice at a time when the number of DPC doctors were in the single digits. Inspired by Ayn Rand’s Atlas Shrugged, he found a direct relationship to be a more empowering way of delivering healthcare, one which better upholds individual liberty. When doctors and patients ‘shrug off’ insurance companies, he notes, they break free from the tendency to be treated as mere cog’s in a machine and find themselves free to make decisions directly between each other. While a great tool, Umbehr says, insurance should be used only for catastrophic events like hospitalizations, cancer care, hospice and critical illness. When insurance starts covering every day events, it not only creates un-needed work of mediating between another party but also undermines the liberty of the two more responsible parties: the doctor and the patient. In the interview Dr Umbehr cogently defend of DPC as the way to make healthcare not only more efficient but also make doctors and patients happier.
[2:36] When did AtlasMD start?
[4:19] Where Dr Umbehr got the idea to start a DPC practice?
[5:54] How did AtlasMD go about figuring out what to do with few models to follow?
[8:26] How does ‘First Do No Harm’ apply to direct primary care and the AtlasMD model?
[15:15] How has troubleshooting helped AtlasMD be a better practice?
[15:43] How did AtlasMD build an electronic health record?
[18:48] What would Dr Umbehr recommend to medical students, residents or practicing physicians who are interested in direct primary care?
Dr Josh Umbehr is a family physician who completed his medical school and residency in KS. He started the AtlasMD clinic in 2010. He has spoken on direct primary care on Fox News, Hannity and many other venues and speaks regularly at conferences around the country on the importance of keeping primary care direct and free from involvement of government or insurance.
As a new model of healthcare delivery, DPC entails a unique set of legal challenges. DPC practices often find themselves charting new legal territory as they provide innovative care in a profession whose regulatory laws trace their roots back decades, if not centuries. DPC law is a new area and without much legal precedent, leading many doctors and even lawyers to shy away. But as noted by Dr Phil Eskew, lawyer, family physician and founder of DPC Frontier website, sailing the un-sailed seas of new legal scenarios need not be frightening.
The most common legal question that Dr Eskew is asked regarding DPC law deals with the Medicare opt out process. According to Medicare laws, it is illegal to charge a patient for a service that is already paid for by Medicare, so unless a physician ‘opts out’ of Medicare, he or she runs the risk of ‘double dipping’ if he or she charges a patient for a DPC contract that includes services that could be reimbursed by Medicare. Should the physician opt out, this prevents him or her from moonlighting under any employer paid by Medicare. According to Dr Eskew, there are several ways that DPC physicians can opt out and still moonlight, all of which he describes in his website here. DPC physicians can also avoid violating Medicare laws by charging a “fee for non-covered services,” which concierge doctors have traditionally justified with the provision of newsletters, but as Dr Eskew notes, it’s difficult if not if not impossible to justify to the government that everything in a DPC contract is not covered by Medicare.
Another common legal issue arising in DPC law is HIPAA compliance. While there is still some debate in the legal community about whether DPC practices are considered a “covered entity” that must abide by HIPAA compliance standards, there are steps a practice can take to be in compliance with HIPAA which Dr Eskew details in his website. Also, for ensuring compliance of electronic health records (EHR) software, there are many free EHRs as well as several low-cost EHRs that meet HIPAA compliance encryption standards. Finally, for practices who sign a business associate agreement (BAA) with Google, communication on Google core apps is considered to meet HIPAA level of encryption.
Finally, for those who practice DPC in states without DPC laws (see which ones have these here), DPC can run the risk of violating rules of the state insurance commissioner. If a DPC practice fails to set appropriate limits to what services can be provided by the annual or monthly, then it can become liable to scrutiny by insurance regulatory bodies for failing to appropriately pool risk (i.e. offering services on which it can’t deliver). Per Dr Eskew, risk of violating insurance laws can be avoided by clear patient contracts detailing exactly what services are being offered. Areas where practices can get into trouble, he says, include not placing a cap on panel size or offering unlimited visits without a clear indication for the visit. By detailing exactly what can be offered, a practice makes clear that it can deliver on what is promised.
In sum, DPC law, while young, does present unique legal challenges. But with thoughtful preparation, these hurdles can be overcome. Brave pioneers like Dr Eskew and others have helped offer support along the way. He’s even started a website where he gives away as much legal advice as he can to DPC doctors. Certainly charting new legal territory can be daunting, but there’s help out there. Besides, for primary care doctors, what’s the alternative?
[02:41] What led Dr Eskew to enter medicine and DPC in particular?
[04:48] Dr Eskew provides an overview of legal barriers to opening a DPC practice.
[06:26] Dr Eskew provides the Medicare opt out requirements.
[07:25] Dr Eskew discusses moonlighting options for opted out physicians.
[08:37] Dr Eskew describes the ‘fee-for-non covered’ services.
[09:49] Dr Eskew discusses relevancy of HIPAA to DPC law.
[12:33] Dr Eskew talks about how DPC doctors should go about finding EHRs with regards to HIPAA compliance.
[13:49] How insurance laws do or don’t apply to a DPC practices.
Dr Phil Eskew is a family physician, DPC doctor, lawyer and DPC legal expert. Prior to graduating from medical school in 2012, Dr Eskew graduated from West Virginia University College of Law in 2008. He is now the VP of Clinical Development and General Counsel at Proactive MD, a company focused on helping employers design, staff, run and monitor onsite health and wellness centers. He is also the VP of Clinical Development and General Counsel at the Heartland Institute, a non-profit think tank devoted to discovering , developing and promoting free-market solutions to social and economic problems.
Direct Primary Care has been criticized by some naysayers as a luxury only available to the wealthy, but for Dr Ryan Nuehofel, this has been anything but the case for his practice. Self-termed a ‘concierge safety-net clinic,’ NueCare has provided care to many underserved patients via Direct Primary Care arrangements. In this episode Dr Ryan Nuehofel, founder of NueCare discusses his motivation for starting a Direct Primary Care practice and how he has been able to serve a predominately underserved population by going direct. Contrary to popular belief, many of his patients, though considered underserved, get far more attention and service due to the fact that they pay for services outside of insurance or Medicaid.
[01:27] Could you tell us about your Direct Primary Care Practice?
[01:51] What kind of population does Dr Neuhofel’s clinic serve?
[05:21] What challenges has Dr Nuehofel dealt with when dealing with underserved patients.
[08:48] Has Dr Nuehofel ever had to resort to collections?
[09:55] Where Dr Nuehofel got the idea to start a Direct Primary Care practice?
[12:18] How did Dr Nuehofel go about finding a location, hiring staff and getting legal help?
[14:37] Administrative hassle of a fee-for-service practice versus a Direct Primary Care practice.
[15:25] Dr Nuehofel’s response to criticisms of Direct Primary Care being for the wealthy.
Dr Ryan Neuhofel is a Direct Primary Care doctor and the founder of NeuCare in Lawrence, KS. In addition to being a Direct Primary Care doctor, he is among the founding members of the Direct Primary Care Alliance, a grassroots organization devoted to supporting Direct Primary Care doctors through support, education and advocacy, and a a national advocate for the Direct Primary Care movement.
“What’s scarier to you: Being in a career that you spend time, money and energy to do and not be able to do it the way you want to for the next 20 years or taking a couple of years where it may be rough, you may have to take a loan out, you may have to moonlight, to end up coming out on the other side practicing medicine the way you always envisioned and that made you apply to med school in the first place?”
To embark on one’s own as a direct care doc can be daunting these days, especially when one considers the challenges that must be faced. This is the question Dr Jeff Gold posed to himself when thinking about leaving his nearly decade-old successful practice owned by a local hospital system and starting his own direct care practice. In some way or another, every direct care doctor faces the question when deciding on the model.
In addition to “just” caring for patients, there’s business planning, marketing, regulatory hurdles and, not-to-mention, financing. After four years of medical school and three years of residency, it would seem at first thought that such matters are best outsourced to administrators. After all, we trained to be doctors didn’t we? Not administrators.
Like most other young primary care doctors straight out of residency, Dr Gold took this path, starting a practice under the management of a major hospital system. But after traveling that path he came to realize that this was not what he went to medical school for. Having to see up to twenty patients per day, take time from patient care to fill in insurance codes, and see patients in office for reimbursement, he, like many other primary care doctors, felt like the system of insurance-based care got in the way of caring for his patients. So he made the jump to direct care .
While daunting at first, the decision has allowed him the opportunity to practice medicine with a freedom and joy that he’s never experienced. While at times the challenge of running a business and having to market oneself can be daunting, he notes, being able to help his patients when they need it and how they need it is priceless. This is why Dr Gold embarked on the “road less traveled,” and he has “not regretted it one iota.”
[1:21] Dr Gold talks about his direct care practice.
[02:17] Where Dr Gold’s practice is located.
[03:01] What kind of demographic population Gold Direct Care serves.
[06:42] How long did it take from Dr Gold’s decision to start a direct care practice to starting his practice.
[10:05] What hurdles Dr Gold faced transitioning to direct care .
[13:30] Particular moments during a day’s work that motivate Dr Gold.
[16:55] Many direct care doctors recount similar experiences of being inspired by the model.
[19:14] Dr Gold offers to host other medical students, residents and doctors.
The US healthcare system is failing us. Prices our increasing far beyond our ability to pay, yet health outcomes are far below those of other countries with developed healthcare systems. Many solutions have been posed, yet the one that is shown to be effective has yet to fully take hold: Direct Primary Care.
In this episode Dr Roussel discusses the current healthcare crisis, where we are and how we got there. Moreover, he explains why DPC is the answer to the crisis. Finally, he responds to certain criticisms of DPC that have been leveled by critics of the model, many of whom are financial stakeholders with a vested interest in maintaining the status quo.
[2:07] Purpose of the Direct Primary Care Podcast is to be a resource for those interested in Direct Primary Care—particularly those on the fringe, those who are interested in the model but don’t quite see how it would work in the mainstream.
[2:10] The podcast is not just for doctors but also those in the insurance industry, health administration, policy makers and economists.
[2:44] Our discussion will deal with Direct Primary Care only—not concierge, not other models for healthcare delivery
[3:00] What is Direct Primary Care?
Full access primary care
Generally monthly or annual fee
Low cost (<$100/month)
[3:49]Direct Primary Care doesn’t cover insurance, not labs, meds, imaging or specialist visits.
[4:00] My interest in Direct Primary Care
I learned aboutDirect Primary Care as a medical student.
My motivation going into medical school was to practice straight up general medicine, making use of my training to help every day folks with every day problems.
[4:30] On the hospital wards and in clinic, I would witness residents and attendings having to see 15-20 or even 30 patients per day, many of them coming in with limited primary care access.
I did not think that I could practice primary care without burning out.
[4:45] Initially, thought of becoming a specialist, as 99% of my class does, or just staying out of clinical medicine, perhaps going into academia or industry.
[4:55] Towards the end of my third year of medical school, I learned about a new model being pioneered in Seattle by Dr Garrison Bliss.
It involved a low cost monthly fee in exchange for all-access primary care.
[5:02] Just being able to see a few patients per day—maybe up to five or six—while having the flexibility to help many more over the phone and email would allow me to be the doctor I went to medical school to be.
[05:22] So I decided to go into primary care, choosing to go into internal medicine residency with primary care track at a a Harvard Medical School affiliated program.
[05:30] There I had the opportunity along the way to spend time in Direct Primary Care clinics and be mentored by Dr Garrison Bliss, Dr Josh Umbehr, and Dr Jeff Gold. I also had the opportunity to meet many more Direct Primary Care doctors atDirect Primary Care Summits.
[06:10] My current Direct Primary Care practice is in Louisiana.
[06:34] Healthcare is now in a state of crisis.
[06:44] It’s riddled in debt.
[07:02] There is a huge shortage of primary care doctors.
[07:12] Physician burnout/satisfaction is rampant.
[07;22] The insurance model in healthcare is outdated.
[07:30] Healthcare services have expanded virtually exponentially in the past fifty years since health insurance was rolled out in the 1950’s and 1960’s.
[08:20] Health insurance has continued to cover virtually all of healthcare needs, even as healthcare services have come to include not only catastrophic events but also every day services—eg preventative care, regular management of chronic diseases.
[08:40] Rates have consequently increased dramatically to the point that premiums are on average not affordable, and the cost is only increasing.
[08:55] It’s as if car insurance expanded to cover all car repairs—oil change, tire change, battery replacement, etc—or homeowners insurance covered replacing a heater or an AC or a new paint job. Of course the cost of the premium would go up.
[09:19] For insurance to be affordable it needs to cover rare events, not common ones. Otherwise it’s not pooling risk, it’s just pooling money.
[09:22] Then insurance becomes not insurance but an financier, like one would pay a car dealership for unlimited repairs or apple for AppleCarePlan.
[09:33] And if we want to talk about financing models for healthcare, that’s well and good.
[09:43] But if we are going to talk about subscription type plans for healthcare, which I think is the way to go, then who better to provide the subscription service then the doctor. Why outsource financing when it’s not necessary?
[10:01] Direct Primary Care as the answer
[10:12] Direct Primary Care lowers overall cost of care by 30-40%.
No third parties for most services
Doctors available any time
Continuity of care
Less need for duplication
Less legal risk because of patient rapport. Not just overall cost for the system less but also for the individual
[11:07] Direct Primary Care fee can be paired with HD health plan, which is much cheaper.
[12:04] Doctor patient relationship has been nearly third party free for 2,000 years. Only in the age of managed care has insurance come to be the responsible party for paying for medical expenses.
[12:27] Hospital growth is a modern trend due to third party payment
[12:40] Unfounded criticisms against Direct Primary Care
[12:53] 1. Unfounded Criticism #1.It will reduce the number of primary care doctors
Actually, the reason so few enter the field is because of the stress of burnout, low pay, etc
Can encourage new med students, residents to enter the field, and can keep other doctors from retiring
[13:33] We have the physician staffing right now to provide Direct Primary Care to everyone.
[14:30] 2. Unfounded Criticism #2. It’s going to harm patient care because doctor’s aren’t regulated/connected/integrated, etc.
Data doesn’t support this and it’s empirically untrue.
[15:19] 3. Unfounded Criticism #3. It’s financially unfeasible for the underserved.
This happens to be empirically untrue: Ryan Neuhofel, Josh Umbehr, many others
There’s nothing against helping people pay their fee.
[16:00] Direct Primary Care doesn’t solve the need for insurance, but it reduces the cost of it and what the plan needd to cover.
Dr Landon Roussel is a Direct Primary Care doctor who lives in Baton Rouge, Louisiana. He founded the Direct Primary Care podcast in 2016 as a way to support the Direct Primary Care movement as it continues to resolve the healthcare crisis from a grassroots level, one doctor-patient relationship at a time.
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