A Big Change
In 2012, after 18 years of working in the American health care system, I realized something: I didn't like my boss. Instead of working for my patients, I found that I was spending more and more of my time and energy trying to please my real boss: insurance companies, government agencies, and anyone else who could tie their strings around me. As much as I loved being a doctor, I found that I no longer liked my work. Far too little of it actually centered around the people I had committed to serve.
So, in September of 2012 I left my job, my life's work, and my security behind and started something totally different.
On February 5, of 2013 (after many delays and much hair-pulling) I opened the doors of this new practice, the first "Direct Primary Care" practice in the Augusta area.
"Direct Primary Care" refers to care that is old-fashioned: the doctor takes care of the patient, and the patient pays the doctor. It gets rid of the usual middlemen who control health care: the insurance companies, hospitals, and government agencies. The doctor works directly for the patient, which makes a big difference.
But instead of paying for each visit or procedure, as is done in the rest of health care, the doctor is paid a flat monthly fee by the patient. This means that the doctor is no longer motivated to do more procedures or stay overwhelmingly busy (as I was in my previous practice). In truth, it is this difference that makes the biggest difference in the kind of care I give.
Direct vs. Concierge Care
While direct care practices are becoming more and more common, there were practices with a very similar payment structure known as "concierge" practices. While the basic concept is the same, a flat monthly payment instead of paying for visits/procedures with insurance, there are some important differences:
- Direct care practices are less expensive, charging under $100/month, while concierge practices can cost much more.
- Concierge practices tend focus on premium services, like extended office visits, extra procedures, and "executive" lab panels done on a regular basis, while direct care practices focus on efficiency, communication, and prevention.
In short, concierge practices take the "first-class cabin" approach to care: offering a pampered experience to a small number of people who can afford it. Direct care, on the other hand, focuses on reaching more people with affordable care.
My Philosophy of Care
Direct care, to my delight, allows me to practice a type of medicine that is much more consistent with my philosophy of care, which is:
- The patient is the center of care, not the doctor.
- Never prescribe an unnecessary medicine - one that doesn't reduce a person's risk of serious problems or doesn't significantly improve their quality of life. If I can't explain to a person why I am prescribing a drug, I shouldn't prescribe it.
- Never order a test that doesn't help make a decision. Too many tests are done "just to know," without any clear goal (in reality, many are done because the insurance companies pay for them). I believe that tests are done either to understand a person's risk factors, to make a treatment decision, or to improve their quality of life.
- Communication is at the center of care, not drugs or tests. The more I listen to people, the more I know them; and the more I know them, the better care I can give. Of equal importance: the more my patients know me, the more they trust me; and the more they trust me, the more they will let me help them stay healthy or get healthy.
There is nothing more personal than health care. In my office, people expose their weakness, vulnerability, and do something that many of us (me included) struggle to do: ask for help. I think this is best done in a setting that is personal and inviting, not cold and clinical. I believe the best care happens not between doctor and patient, but between two human beings, both of whom know their weaknesses and limits. My job is not to give care to people, but to share my experience, knowledge, and expertise so my patients can know how to care for themselves.
The result of this approach?
- My office looks more like a house than a doctor's office.
- My patients spend more time on a comfy couch than in the exam room.
- We take the time to chat with people about their lives and tell them about ours.
- I keep my guitar (which I've played since I was 10 years old) in my office, sometimes even playing it for my patients if they want.
- My logo expresses this philosophy of care, as an open door.
- We do our best to speak English, not that strange secret doctor language with its Latin, Greek, and all of those codes.
From Theory to Reality
With over a year's experience in the practice, I can say that things are working! We've steadily grown to over 450 patients, patient satisfaction is very high, and I am enjoying being a doctor more than I ever have. Here are some of the big changes that are real, not theoretical:
- Patients continue to tell me how much they love having a doctor who gives them his time and attention.
- Accessibility is the greatest thing we offer, talking with people on the phone, answering questions electronically, and frequently using a phrase rarely heard at a doctor's office: "Come on in now and we can see you."
- We continue to have practically no wait time in the office (unless people come in early for appointments!), giving patients the ability to leave the doctor's office 10 minutes after coming in!
- We spend a lot of our time trying to save our patients money. We do this by:
- Searching for the lowest cost on medications
- Helping patients avoid the emergency room whenever possible. We do not tell our patients: "in case of emergency, please dial 911;" we actually help our patients decide if it is a true emergency (which it often isn't).
- Getting discounts on labs, immunizations, other services, and passing those prices along to our patients (with minimal mark-up).
- Keeping a list of inexpensive x-ray providers and medical supplies that we pass along to our patients.
- We keep the office as non-doctorish as possible. We treat our patients like people, not the reverse. We greatly enjoy the chance to chat, laugh, and share the lives of the people who honor us by choosing our practice.
- When lab or x-ray results come to our office, we send an actual copy of the results, not just the cryptic word that "everything is OK."
Things to Come...
So where is this all going? What is the ultimate goal of the practice? Since there were many surprises in the first year of practice, I anticipate more surprises to follow. But I do feel like the future looks bright for the practice, and perhaps for the rest of the system should more practices like mine emerge. I really believe this is better care: care that is patient-centered; care that is more fun for the doctors and nurses; care that focuses on quality, not quantity; care that tries to save money, not spend it; care that tries to prevent disease, avoiding expense and suffering that could be avoided; care that won't bankrupt our country.
Here is my vision for the future of my practice:
- An efficient office, with organized patient records.
- Patients with full access to their records.
- Patients who have the information and resources to take better care of themselves.
- Other types of providers, including dieticians, mental health professionals, exercise specialists, social workers, pharmacists - all focused on helping patients in their areas of expertise.
- Education resources, including an online library of articles and videos, as well as a series of classes with the aim of teaching people how to eat better, exercise, raise kids better, take care of their diabetes, or whatever else we can think of.
- Each person having a care plan - a list of care they are due for in the future based on their medical situation, their family history, and their lifestyle choices.
- Pairing our care with a reduced-cost high-deductible plan so people can have money for care when things go bad, and a team who does everything possible to prevent them from ever needing to use that money.
I think this is not just a dream. I really think this is a much better way to do care. I am sure that once you've experienced this type of care your whole concept of what health care should be will radically change. You will never again be satisfied with the old way.
Expect more from your doctor.