How Direct Primary Care Benefits Patients With Chronic Conditions

January 6th, 2017 by 2 Comments

By Katherine Restrepo

Anybody who is in the business of selling the idea of direct primary care (DPC) to patients, employers, or politicians can anticipate the usual pushback that will arise in any Q and A format. “Why would I want to pay twice for health care?” “Are these doctors just cherry-picking patients?” “Is this health care delivery model just for the wealthy?” It’s nice that physicians are able to spend more time with their patients, but won’t a smaller patient panel exacerbate the physician shortage problem?” “If DPC is so great, why isn’t there more data to prove it?”

It couldn’t be more predictable. Really.

For those who need a quick explanation of direct primary care, it works like a health care gym membership. In exchange for a membership fee (the industry average monthly payment ranges from $25 to $85), patients have access to around-the-clock primary health care. They can even schedule same-day appointments and longer office visits with their doctors as needed. A major reason why monthly fees are affordable for the masses is because many DPC practices follow a micro-practice philosophy in which most resources focus on patient care. By opting out of insurance contracts and accompanied claims personnel, a DPC practice can sustain itself while devoting just one-third of revenues towards overhead.

So, how about those DPC myths? Let’s tackle the skepticism that DPC physicians have a vested interest in cherry-picking healthy patients to ensure lucrative business.

Dr. James Breen, co-founder of Vitral Family Medicine, a direct primary care practice located in Greensboro, NC, is one of many providers I’ve interviewed on the cherry-picking sticking point. He turns this notion on its head by providing an example of how DPC provides fast access to care for patients who need lots of medical attention. One of his current patients, a 50-year old male, initially scheduled a visit with an insurance-based primary care practice to be seen for complaints of blurry vision and was referred to an ophthalmologist. He left his specialist appointment without a diagnosis.

Dissatisfied, the patient decided to see what Vitral Family Medicine had to offer. At his initial assessment, he was diagnosed with diabetes for the first time in his life. His blood sugars read above 500. “It’s pivotal moments like these where DPC doctors can get back to the heart of doctoring,” says Breen.

The practice coordinated prescriptions for a glucometer, diabetic testing devices, and insulin. That same evening, the patient and his wife picked up these supplies at a nearby pharmacy after work and proceeded to spend two hours learning about effective diabetes management in his direct primary care doctor’s office; everything from administering insulin to checking blood sugar levels.

“For the first two weeks, we were in daily communication with him, either by phone or our electronic portal. As he improved, we were able to space out our communications. Now a few months into treatment, he is doing exceptionally well and we’re excited to anticipate the improvement in his quarterly labs for glucose control,” said Breen.

When asked about how DPC compares to the conventional health care system regarding access to care and treatment for medically needy patients, Breen expressed that the conventional system’s insurance demands and limited patient interaction make it difficult for physicians to practice to their full capabilities.

“I don’t want this to be a matter of ‘oh, we’re better diagnosticians or anything. It goes beyond that. We’re talking about a system of care. The processes of care in most conventional practices are unwieldy and make it difficult to allot the kind of high-touch and timely care that we were able to provide in this case.”

Anecdotes like this one matter for the purpose of dismantling the perception that DPC providers avoid dealing with complex patients. However, while qualitative stories are indeed important, the argument goes that if DPC is to ever become mainstream, more quantitative data is needed. The US health system has an obsession with patient treatment process measures and data-driven evidence based medicine.

Fortunately, large-scale DPC organizations like Paladina Health have compelling numbers suggesting that patients who are chronically ill find that direct care is more beneficial compared to accessing care in the traditional health system.

Union County, a self-insured employer located outside of Charlotte, has contracted with Paladina to offer its workers an additional health benefit option to seek direct primary care at Paladina’s near-site clinic. I’ve written about how the local government saved $1.28 million on health care claims in one year when board-certified physicians provided care for 44 percent of Union County’s 2,000 covered lives. This is what can happen when primary care physicians opt out of insurance-contracts. Less paperwork means more time to spend with patients as needed to effectively prevent at-risk health conditions or manage comorbidities. More time means better access which yields fewer specialist referrals, unnecessary hospital admissions, and emergency room visits. Studies show that in the traditional system of care, 43 percent of physicians spend more than one-third of their day on data entry and other administrative tasks. Other surveys say primary care physicians spend upwards of 50 percent of a patient’s office visit on the computer. 87 percent of surveyed physicians feel professional burnout due to these administrative demands.

The calculated savings is equivalent to the difference between the average per employee per month (PEPM) cost that consists of both medical and prescription claims incurred by employees who subscribe only to their consumer-driven health plan and those who choose to access care at Paladina’s clinic alongside their consumer-driven plan. That $1.28 million comes out to an average savings of over $260 per employee per month.

What do we know about that “44 percent” patient population? The end-of-year results indicate the following:

  • Based on in-person office visits, 59 percent of Paladina members have at least one chronic illness, while 35 percent are diagnosed with multiple – the leading diseases being high blood pressure and hyperlipidemia.
  • Of the 55 percent of Paladina members who have moderate to severe chronic conditions, over 90 percent of them are defined as being heavily engaged with their health care. Paladina defines “engagement” as having at least one in-person office visit per year at the near-site clinic. Patients with more than 3 chronic conditions averaged more than 5 visits in one year, while those with more than 1 chronic illness averaged over 3 visits.
  • Paladina members with more than one chronic condition cost on average 28 percent less than the control group enrolled in Union County’s consumer-driven health plan.

Although control group data is not available at this juncture to compare the number of average annual in-office visits for chronically ill patients with Paladina’s statistics, it’s important to point out that Paladina’s patient population, including those who have complex medical needs, are voluntarily electing direct care. DPC attracts these patients because this method of health care encourages them to feel more empowered over their health care. The evidence also tells us that patients realize the value direct care has to offer and can make good medical decisions for themselves.

Katherine Restrepo is the Director of Healthcare policy at the John Locke Foundation. The Georgia Public Policy Foundation, an independent think tank that proposes market-oriented approaches to public policy to improve the lives of Georgians. Nothing written here is to be construed as necessarily reflecting the views of the Georgia Public Policy Foundation or as an attempt to aid or hinder the passage of any bill before the U.S. Congress or the Georgia Legislature.

© Georgia Public Policy Foundation (January 6, 2017). Permission to reprint in whole or in part is hereby granted, provided the author and her affiliations are cited.

2 thoughts on “How Direct Primary Care Benefits Patients With Chronic Conditions

  1. Palladia Health may not be a “large scale” DPC plan. A patient panel of about 700 is roughly what DPC advocates target for a two-physician DOC practice.

    More importantly, a year’s experience at Palladia Health is certainly not large enough to generate reliable comparative data about DPC cost savings. From this article and the two others by Ms Restropo linked within, and giving her account the benefit of every doubt as to whether it is fair and accurate as far as it goes, we can infer that Palladia has about 725 members whose costs are compared to roughly 1250 other Union County employees who chose other means of receiving primary case. We can also compute a per person cost to the county for the year in question as being about $3750 for those in Palladia and $6000 for those not in Palladia, and a total bill for the county of about $10,000,000.

    The problem is that this sample size so small that even a single outlier case may well have swayed these results dramatically. Switching a single patient with a million dollars in medical expenses from the DPC roster to the non-DPC roster would wipe away every penny of those savings. Well over one percent of patients have claim rates over $50,000 in a given year, over twenty people on the two Union county rosters Restropo compares; these have an average of over $100,000 in claims per annum. Million dollar case are not that rare. The right cherry left unpicked, a single adverse selection by a county employee looking at a long hospital stay and deciding to take the $750 HSA that Union County offers to those who decline DPC, a bit of bad luck here and good luck there, these can make all the difference in a small pool.

    As this study is insufficiently granular as to the eliminate the risk of these kinds of distortions, Ms Restopo’s argument is nowhere near proven and, despite her protestations, barely advances her argument beyond the anecdotal level.

  2. Sorry, Ms. Restropo. No control data, no validity. Here’s why.

    About 1.2% of all insureds have high claim rates (> $50,000), with an average claim rate for these people of over $110,000. That’s two dozen people in the combined Union County groups. If these people happen to split 2-1 away from the DPC option, that itself would explain over two-thirds of the savings observed.

    Any enrollee who expected significantly high claims in the coming year would have been certain to max out their $2750 out-of-pocket expense cap, and thus would have had no financial incentive to elect the DPC option.

    In fact, any enrollee who expected substantial expenses would apparently have had a significant financial incentive to AVOID the DPC option, as the DPC apparently contributes $750 to an HSA for those who do not elect DPC.

    There is, therefore, very good reason to suspect that however unhealthy the DPC cohort might be, the non-DPC cohort is likely to be even less healthy. This is why a controlled study is absolutely essential.

    Failing a larger and better controlled study, may I propose that Ms. Restropo come up with a list of the twenty-five highest Union County individual claim rates for the year of study and show how those claim rates were divided between the DPC and non-DPC insureds.

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