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Direct care model eliminates many sources of physician stress


Many of the most common challenges in medicine can be addressed through alternative practice models.

For years, Medical Economics has been one of the few medical magazines I receive that I read cover-to-cover as soon as it arrives in my mailbox. I’ve always been interested in the business aspects of medicine and especially eager to read practical solutions to challenges that physicians face in being fairly compensated for our labor.

But since I changed my practice from a traditional insurance-based practice five years ago to a direct primary care (DPC) model, I find myself reading the journal with a different viewpoint. Rather than poring over the articles seeking solutions to the latest billing and coding challenge, I find myself recognizing the ways in which DPC solves so many of problems that physicians face in the practice of medicine.

The cover article of the January 2021 issue, “2021’s Top Challenges Facing Physicians” was a particularly poignant example. As I paged through the article, I realized that I had overcome every single challenge listed simply by changing to a direct care model.

Challenge #1: Administrative burdens and paperwork

According to the article, a 2020 American Medical Association survey found that 86% of physician respondents were significantly burdened by prior authorizations, a process by which physicians must justify medications or tests ordered to the insurance company to have payment approved. Although I no longer bill insurance for my services, I do have patients who require prior authorizations for medication and tests. But with a smaller panel size (most DPC practices cap at 600-700 patients), I have far more time to complete these tasks. I can also often bypass the need for prior authorizations for drugs that are generic or inexpensive, either by providing the patient with a price estimate from a service like GoodRx.com and advising them to pay cash (sometimes less expensive than an insurance copay!) or by dispensing the medication from my low-cost, in-house dispensary.

While I’d be lying if I said that direct care had eliminated every bit of administrative work in my office day, I have cut my workload to the bare bones required to run a practice. Most importantly, by opting out of billing Medicare and insurance, I am no longer required to collect and submit “quality data” just to be paid for an office visit for a patient.

While the article suggests that one solution to managing the stress of “value-based reporting” is to hire a scribe or invest in an EHR that automatically reports data, these services can be costly. By opting out of an insurance payer model, I don’t need to pay an extra assistant to gather data, and I can use a physician friendly EHR that costs just $300 per month. And by keeping my overhead low, I can pass on my savings to patients by offering an affordable rate for care.

Challenge #2: Getting paid and seeing enough patients

Having spent enough hours studying E/M coding to write a book teaching doctors how to code for maximum efficiency, I’m almost embarrassed to admit that I haven’t even looked at the new E/M coding system. Since I no longer submit codes to insurance companies, this is just not something that I need to know. And while experts say that the new E/M codes are “much simpler,” doctors must still invest time and energy into learning a new system. Also, they must take the time to document exactly the right bullet points to ensure that an insurance auditor credits them for the work they put in, something that often takes longer than the actual office visit. This documentation time is slashed when doctors write office notes for themselves and their colleagues, and not for the insurance company. My office notes are short, succinct, and free of the pages of meaningless jargon many modern EHR systems produce.

Direct care docs also don’t need to worry about payer reimbursement for virtual visits with patients. Even before COVID19, many direct care practices were already communicating with patients by phone, video, email, and text. When the pandemic struck, doctors had the infrastructure in place to seamlessly transition patients to virtual visits.

Challenge #3: Physician burnout and autonomy

For the first time in history, more physicians are employed than own their own practices. While corporate ownership can alleviate certain stressors from the practice of medicine, the trade-off is often a loss of physician autonomy, which can lead to burnout. One way to bring back physician autonomy is through self-ownership, and direct care is a simple practice model achievable with minimal business know-how. Direct care provides not only autonomy but flexibility in work hours, something that women physicians especially value. For example, in my practice, I see patients Tuesdays through Thursdays, and I reserve Mondays and Fridays for practice management, self-care, and to pursue interests outside of the day-to-day practice of medicine.

Challenge #5: Hiring and maintaining clinical staff

When I worked in a traditional insurance model, I had six staff members – two in the front for scheduling, two clinical assistants in the back, and one office manager, not to mention outside billing staff. Having many staff members is not only expensive but can lead to a lack of accountability and personality conflicts. Most direct care practices have no more than one or two staff members—and some micro-practices have no staff members, with the physician taking on all office responsibilities. My preference is to have one right-hand staff member who manages all the clerical duties of the office. This frees me up to perform all the clinical responsibilities – the part of medicine that I like the best. I take my own vital signs, give my own injections, and even do my own blood draws—a skill I initially feared but with practice, has become one of my favorite parts of my job. Having fewer staff members lowers overhead costs but also leads to greater empowerment and accountability amongst your team—and far less drama in the office.

Challenge #6: EHR usability

I’ve worked with at least seven different electronic health records over the last twenty years and became the master of ‘work-arounds’ in all of them. What a pleasure to have an EHR that actually works for me as a physician! Since direct care physicians don’t have to submit data to third-parties, they are free to choose the system that works best for them, whether it be paper charts, word documents, or a simple electronic system designed for direct care practices, like the one I use.

Challenge #7: Increased competition

Since my patients pay me by a monthly membership, not by the visit, I have no fear of competition from telemedicine clinics or urgent cares. This also removes the stress of the occasional no-show patient—I’m still getting paid whether the patient comes into the office or not. Regarding competition from my fellow physicians, at least once a week I receive an email or phone call from a physician interested in converting to a direct care model, and I’m thrilled to help. Because even if these physicians work in my community, there is no real fear of competition. After all, with a shortage of primary care in my area, most direct pare practices like mine rapidly become full. As more direct care practices open, awareness of the model increases, increasing patient volumes for everyone. 

Challenge #8: Transitioning to value-based care model

In a direct care model, patients pay for their own care, so they decide if they are receiving the value they expect, rather than an insurance company or government entity. The model incentivizes physicians to be accountable directly to patients, seeking our patients’ best interest above the financial profits of a third-party payer. By involving patients in all aspects of their treatment plan, including the way their healthcare dollars are being spent, direct care empowers patients to be a true partner in decision-making for their healthcare. As patients become more involved in this decision-making, they become more engaged and take more responsibility for their health, which should have a positive benefit on the entire healthcare system.

While direct care eliminates many of the challenges that physicians face, it certainly is not free of all stressors. In my next blog, I’ll address some of the unique challenges in the direct care model, and ways to overcome them.

Rebekah Bernard MD is a family physician in Fort Myers, FL, and the author of Patients at Risk: The Rise of the Nurse Practitioner and Physician Assistant in Healthcare.

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