Direct primary care

[AtlasMD]

Direct primary care continues to grow and getting great press.

http://time.com/3643841/medicine-gets-personal/

What do you think?

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[Dharma]

The driving insight here is that primary care and specialized care have two very different missions. Americans need more of the first so they’ll need less of the second. And each requires a different business model. Primary care should be paid for directly, because that’s the easiest and most efficient way to purchase a service that everyone should be buying and using. By contrast, specialty care and hospitalizations–which would be covered by traditional insurance–are expenses we all prefer to avoid. Car insurance doesn’t cover oil changes, and homeowners’ insurance doesn’t cover house paint. So why should insurance pay for your annual checkup or your kid’s strep swab?

This.

 

[midweststudent1]

Direct primary care continues to grow and getting great press.

http://time.com/3643841/medicine-gets-personal/

What do you think?

I heard you speak a couple months ago at my school, and it was one of the best presentations I've ever heard. I will be seriously considering doing DPC myself after I graduate.

Thanks for being a trailblazer. I think a lot more will be following in your footsteps

 

[AtlasMD]

Oh wow--that's awesome!

Thanks!

 

[KLycos]

very exciting! I love how DPC continues to snowball in interest.

 

[AtlasMD]

Snowball indeed! We're working with students, residents, physicians, employers, insurance companies and state gov'ts to advance the growth of DPC.

And i think its growing b/c we're always asking how we can put the patient first.

 

[aspdoc200990]

AtlasMD,

I saw a post of yours from a while back in a different thread where you said that the DPC model fits with some specialists. I think it was in response to someone who was contemplating retraining in a FM residency. Just curious if you could elaborate on that a little. Is it for specialists after a primary care residency, or would it work for a specialty like neurology where you only do an internship then straight to specialty?

Thanks for the optimism you provide, it is much appreciated

 

[AtlasMD]

Fantastic question! I'm actually working with a pediatric neurologist, and endocrinologist, and a gynecologist to design their direct care model.I have also worked with the dermatologist and a psychologist in the recent past.

I believe this can work for nearly all outpatient specialties.The underlying principles of improved efficiency, decreased bureaucracy, savings on medications/labs/imaging/pathology etc. are universal to many specialties.

I would be happy to answer any specific questions how we could work for your practice model. Neurology is essentially chronic care like family medicine so I can see a lot of similarities.

 

[olivarynucleus]

Direct primary care continues to grow and getting great press.

http://time.com/3643841/medicine-gets-personal/

What do you think?

I have a few questions, How long does it take you to build up to a patient base of around 600 patients? How many patients do you see a day. and how do patients feel about direct primary care? The only thing that worries me about this is patient over using services and coming in very often, (though I doubt this is likely.) Honestly, I think DPC is a wonderful idea and I am considering primary care now because of it. I am considering IM for residency and hospitalist work. With the 7 on,7 off schedule, I could probably work full time while working to build the practice.


I also wonder what it would take for the government to start placing ridiculous regulation on DPC, because after all, most primary care practices use to be similar to DPC.

 

[VA Hopeful Dr]

I have a few questions, How long does it take you to build up to a patient base of around 600 patients? How many patients do you see a day. and how do patients feel about direct primary care? The only thing that worries me about this is patient over using services and coming in very often, (though I doubt this is likely.) Honestly, I think DPC is a wonderful idea and I am considering primary care now because of it. I am considering IM for residency and hospitalist work. With the 7 on,7 off schedule, I could probably work full time while working to build the practice.


I also wonder what it would take for the government to start placing ridiculous regulation on DPC, because after all, most primary care practices use to be similar to DPC.

The average I've heard (since I'm not at 600 yet) is 18-24 months. That's with a cold start. If you have a regular practice for a year or two before that, I bet it would be much faster - I bet BD could fill a DPC in a few weeks if he so chose.

The majority of patients won't overuse it. I tell all of mine that I'm there for them 24/7, they have my cell phone number for any after hours issue. So far, they have all said some variation of "I don't want to bother you" and then I have to explain that its what they're paying me for. You'll of course probably end up with a few worriers. My plan with them is to essentially set up weekly appointments where they can bring up all of their concerns. That should cut down on phone calls if it becomes an issue.

 

[AtlasMD]

I have a few questions, How long does it take you to build up to a patient base of around 600 patients? How many patients do you see a day. and how do patients feel about direct primary care? The only thing that worries me about this is patient over using services and coming in very often, (though I doubt this is likely.) Honestly, I think DPC is a wonderful idea and I am considering primary care now because of it. I am considering IM for residency and hospitalist work. With the 7 on,7 off schedule, I could probably work full time while working to build the practice.


I also wonder what it would take for the government to start placing ridiculous regulation on DPC, because after all, most primary care practices use to be similar to DPC.

Thanks olivarynucleas

How long to fill up - really depends but primarily you get back what you put in. The docs that commit to the process the most are by far the most successful. the MOST important step is to have a GOOD business model -- one that SELLS ITSELF. After that, the rest is much easier. A converting practice that is low cost/high value can pre-enroll 50-300 (10%) of their pt panel which is awesome. A startup that is priced correctly and working with ins to help employers can also expect to add 50 pts a month roughly.

Abuse - we've never fired anyone for abusing the model - we just set boundaries. We have fired people for being rude. Sorry but homie don't play that game.

Gov't would have to try really hard to regulate this, since every doc doing this is VERY aware that they just left a broken system. Plus, they don't pay us - so they have very little leverage.

 

[Ericslv]

Direct primary care continues to grow and getting great press.

http://time.com/3643841/medicine-gets-personal/

What do you think?

Can some one in a DPC clinic carry about 800 patients and charge about 65 to 70 per month? Will be successful? After overhead would they be able to net about 300 to 360K per year and see about 6 to 10 pts per day?

This is my goal. Is it possible? How long would it take to get about 800 patient?

I think medlion (a dpc group) carries about 1000 patients.

 

[AtlasMD]

Hi, i've had a direct care practice for 5 years now and we're up to 5 doctors (www.atlas.md/wichita). We charge $10/50/75/100 per patient/month for 600 patients. Our average revenue is $50/pt/mo x 600 pts x 12 mo = 360k/yr - 30% overhead = 200-240k/doctor/year salary.

Good growth is about 40-60 patients per month - but many doctor work on pre-enrolling patients so that they can have 100-200 patients ready on day one.

We've just released a free 12 chapter curriculum for direct care at www.atlas.md/stater

Feel free to contact me directly anytime either by email or cell. [email protected] and C 316.734.8096

 

[alberrito]

Dr Atlas
This is most likely a stupid question but are you saying under the PDC model a patient pays just $50/month and can come in to get a CXR, ultrasound, blood works, procedures and drug re-fills as much as he likes?

Do you have a recording of you presentation on youtube or the web? really interested in listening to it. Thanks!

 

[AtlasMD]

not a problem at all! happy to help!

To clarify - the membership is for unlimited visits, no copays, all office procedures for free which include ekgs, holter, dexa (in house), ultrasound, spirometry, rapid streps, cryothereapy, lesion removal, minor surgical procedures, joint injections, biopsies etc.

Services like wholesale medicines, lab tests, xrays/CT/MRI, pathology etc are at an additional fee to the membership but at wholesale costs. You can download our prices for meds, labs, imaging, etc at www.atlas.md/starter.

And you're always welcome to ask any question and/or email/call me. we love educating about DPC.
Josh
[email protected]
C 316.734.8096

 

[VA Hopeful Dr]

Dr Atlas
This is most likely a stupid question but are you saying under the PDC model a patient pays just $50/month and can come in to get a CXR, ultrasound, blood works, procedures and drug re-fills as much as he likes?

Do you have a recording of you presentation on youtube or the web? really interested in listening to it. Thanks!

There is a great series of podcasts on itunes that I enjoyed when getting started in my practice.

https://itunes.apple.com/us/podcast/atlas-md/id674138661?mt=2

 

[DoctwoB]

not a problem at all! happy to help!

To clarify - the membership is for unlimited visits, no copays, all office procedures for free which include ekgs, holter, dexa (in house), ultrasound, spirometry, rapid streps, cryothereapy, lesion removal, minor surgical procedures, joint injections, biopsies etc.

Services like wholesale medicines, lab tests, xrays/CT/MRI, pathology etc are at an additional fee to the membership but at wholesale costs. You can download our prices for meds, labs, imaging, etc at www.atlas.md/starter.

And you're always welcome to ask any question and/or email/call me. we love educating about DPC.
Josh
[email protected]
C 316.734.8096

You briefly discussed this in the Time article, but how does one get around the statistic that DPC physicians have a patient panel of ~1/3 the size of a typical PCP? I understand that some factors like avoiding burnout and longer primary care careers can help compensate for this, but surely not by a factor of 3. While solutions exist like increasing medical school enrollment, increasing primary care spots, and reducing the number of IM/peds grads going into fellowships by increasing the attractiveness of primary care, these are all long term solutions. If DPC is widely adopted, in the short term, how would we manage such a shortage of PCPs?

 

[AtlasMD]

thanks!

 

[AtlasMD]

If DPC is widely adopted, in the short term, how would we manage such a shortage of PCPs?

this is a great question! maybe one of my favorites - will dpc cause a physician shortage?

is there a physician shortage? or do we have a problem with physician efficiency? Is the problem the # of doctors we have? or the # of bureaucrats? Are we having problems seeing patients? or managing red tape?

the fact is we have plenty of doctors. they are only projecting the shortage to be 50-130k physicians by 2025. https://www.aamc.org/newsroom/reporter/december2013/363844/word.html

The study below says that 22% of a docs time is wasted doing paperwork (hahaha yeah, just 22%) BUT if you had JUST that time back, multiplied across the work force it would be equal to 165k physicians ADDED back to the workforce.
http://ideas.time.com/2013/07/02/the-epidemic-of-disillusioned-doctors/

so all of the other things (decreased burnout, increased primary care participation, etc) are all fantastic - but nothing will fix the issue, like improved efficiency.

And that's exactly what DPC does. And depending on the mix of patients, a direct care doc could flex up to 800 (maybe a 1000).

Thoughts?

 

[VA Hopeful Dr]

this is a great question! maybe one of my favorites - will dpc cause a physician shortage?

is there a physician shortage? or do we have a problem with physician efficiency? Is the problem the # of doctors we have? or the # of bureaucrats? Are we having problems seeing patients? or managing red tape?

the fact is we have plenty of doctors. they are only projecting the shortage to be 50-130k physicians by 2025. https://www.aamc.org/newsroom/reporter/december2013/363844/word.html

The study below says that 22% of a docs time is wasted doing paperwork (hahaha yeah, just 22%) BUT if you had JUST that time back, multiplied across the work force it would be equal to 165k physicians ADDED back to the workforce.
http://ideas.time.com/2013/07/02/the-epidemic-of-disillusioned-doctors/

so all of the other things (decreased burnout, increased primary care participation, etc) are all fantastic - but nothing will fix the issue, like improved efficiency.

And that's exactly what DPC does. And depending on the mix of patients, a direct care doc could flex up to 800 (maybe a 1000).

Thoughts?

The biggest factor that I think about often (as I sit in one now) is the massive expansion of urgent care centers. My middlin' sized southern city has 15 that I can think of off the top of my head. Every other patient I see says some variety of "I called my PCP and they told me to come here".

Josh, how often do you send your patients to urgent care? I'm going out on a limb and guessing somewhere between never and never. In my location alone, getting rid of even half of the urgent cares would free up close to 25 family doctors.

 

[septoplasty]

Loving this thread, thanks for the insight! I'm a PGY-3 looking at all of the possibilities, unfortunately our program has a high "retention" rate at base pay of $165k a year working 5 days a week, no call etc. which the PD promotes and essentially everyone just blindly follows. A few of us have caught on and are always willing to learn.

x2 on that youtube video!

 

[alberrito]

There are many valuable information and discussions going on in this thread.
@AtlasMD if you don't mind can you create a thread describing a typical work day for you? Thanks!

 

[AtlasMD]

Sure!

 

[Ericslv]

this is a great question! maybe one of my favorites - will dpc cause a physician shortage?

is there a physician shortage? or do we have a problem with physician efficiency? Is the problem the # of doctors we have? or the # of bureaucrats? Are we having problems seeing patients? or managing red tape?

the fact is we have plenty of doctors. they are only projecting the shortage to be 50-130k physicians by 2025. https://www.aamc.org/newsroom/reporter/december2013/363844/word.html

The study below says that 22% of a docs time is wasted doing paperwork (hahaha yeah, just 22%) BUT if you had JUST that time back, multiplied across the work force it would be equal to 165k physicians ADDED back to the workforce.
http://ideas.time.com/2013/07/02/the-epidemic-of-disillusioned-doctors/

so all of the other things (decreased burnout, increased primary care participation, etc) are all fantastic - but nothing will fix the issue, like improved efficiency.

And that's exactly what DPC does. And depending on the mix of patients, a direct care doc could flex up to 800 (maybe a 1000).

Thoughts?

What do you mean by mix of patient? I don't want to make 200 to 240K. I want to make 300 to 360K. (to those who don't feel comfortable talking money and number and feel I'm being greedy please understand this is how I feel and we don't have to agree. I respect your choice please respect mine).

So, that means I need about 800 patients. How I get there? It seems it will take at least 3 years. Can this be done in any population or size city? MOST IMPORTANT how do you pick your patients? Do turn the difficult ones away? I don't really want to carry 800 chronic really sick patients. That would burn me out.

 

[AtlasMD]

What do you mean by mix of patient? I don't want to make 200 to 240K. I want to make 300 to 360K. (to those who don't feel comfortable talking money and number and feel I'm being greedy please understand this is how I feel and we don't have to agree. I respect your choice please respect mine).

So, that means I need about 800 patients. How I get there? It seems it will take at least 3 years. Can this be done in any population or size city? MOST IMPORTANT how do you pick your patients? Do turn the difficult ones away? I don't really want to carry 800 chronic really sick patients. That would burn me out.

Mix of patient - ages and price levels. 300 medicare pts at $100/mo = 600 pts at $50/mo.

Don't be ashamed about wanting to make money - as long as you're making it right. by providing a VALUE for your patients.

we cap at 600 pts currently - but we're busy with consulting, software, students, traveling for lectures etc....and we can still do our 600 pts. If you saw 800 pts, that would be another $120k/year.

Sick patients are great! They need you - which means they stay with you - which means you're valuable to them. A gym could say we want 1000 customers that never come in (just think how much we'll save if no one ever use our equipment, it wont' break). but if no one ever comes to the gym - why would they keep paying for the membership?

Managing the chronically ill and doing it well is how you'll grow your skill and reputation is a good physician.

 

[Lawgiver]

Oh wow--that's awesome!

Thanks!

which books have you read on being a salesman?

 

[deleted87716]

which books have you read on being a salesman?

Take a look at this thread: http://forums.studentdoctor.net/threads/good-reads-on-how-to-run-a-practice.1148358/

 

[Lawgiver]

Take a look at this thread: http://forums.studentdoctor.net/threads/good-reads-on-how-to-run-a-practice.1148358/

Charles Koch. oh lawd no!

 

[VA Hopeful Dr]

Charles Koch. oh lawd no!

That was actually the first book on that list I read. It's a very good read.

But that's cool, ignore it because of who wrote it. That'll serve you well.

 

[AtlasMD]

Agreed. If you only read the books from people who you like you'll limit your opportunity to learn and grown. I may disagree with Warren Buffett but I can admit that he's successful.

 

[AtlasMD]

which books have you read on being a salesman?

the single best book on the topic is Dale Carnegie's how to win friends and influence people.

others i like are:
start with why by simon sinek - brilliant!
10x rule byt Grant Cardone
traction by gabriel weinburg
street smarts by norm brodsky
the charisma myth
contagous by jonah berger

 

[Blue Cohosh]

Many thanks to those DPC advocates here for your generosity in answering questions. I have few:

How does DPC work with Medicare? What about HSAs?

If you don't work with Medicare, have you found that this affects your patient panel? Are you seeing many folks age 65+?

Lastly, anyone doing full spectrum FM ( w/OB) as DPC and making it work?

Apologies if the above have been asked/answered before, I've read through most of the posts on here and have not found answers to these.

 

[VA Hopeful Dr]

Many thanks to those DPC advocates here for your generosity in answering questions. I have few:

How does DPC work with Medicare? What about HSAs?

If you don't work with Medicare, have you found that this affects your patient panel? Are you seeing many folks age 65+?

Lastly, anyone doing full spectrum FM ( w/OB) as DPC and making it work?

Apologies if the above have been asked/answered before, I've read through most of the posts on here and have not found answers to these.

As of now, you can't be a medicare provider and see medicare in a DPC. I expect that to change, but we're not there yet.

Its a very very rare 65+ patient who doesn't have medicare.

Adding inpatient care wouldn't be all that hard. I thought about it, but I'd have to cover 5 hospitals and that's just not worth it.

 

[VenturaResident]

I work in an area with many undocumented immigrants, primarily farmworkers who aren't going to wind up with Medicare for the most part. These are among the folks I worry about being able to afford participation in a a DPC practice, but for those who could afford DPC it could be a great fit for primary care needs.

 

[VA Hopeful Dr]

I work in an area with many undocumented immigrants, primarily farmworkers who aren't going to wind up with Medicare for the most part. These are among the folks I worry about being able to afford participation in a a DPC practice, but for those who could afford DPC it could be a great fit for primary care needs.

There are certainly work-arounds for most problems. Its the nice thing about any type of private practice - since us doctors make the rules, we can decide if we want to change them. If BD, Atlas, or I decide we want to see a patient for free, we can. Personally, I'd love to reach a point where I can afford to see a decent number of patients for either free or, more likely, significantly reduced costs (mainly because if its free, people tend to not value it).

That all said, I don't think any of us want to see a system where there is only a single option for how we obtain healthcare.

 

[AtlasMD]

Many thanks to those DPC advocates here for your generosity in answering questions. I have few:

How does DPC work with Medicare? What about HSAs?

If you don't work with Medicare, have you found that this affects your patient panel? Are you seeing many folks age 65+?

Lastly, anyone doing full spectrum FM ( w/OB) as DPC and making it work?

Apologies if the above have been asked/answered before, I've read through most of the posts on here and have not found answers to these.

thanks for the questions and happy to help.

Medicare – yes and no. Yes a physician can take Medicare patients if they opt out of Medicare. No position does not have to opt out of Medicare if they do not want to take Medicare patients in their direct care practice.

Yet many practices are seeing a range of Medicare patients. Some are 30 to 50% Medicare and others are less so. I think it depends mostly on how you advertise and if you are converting an existing practice with a high Medicare population in an area with very few doctors accepting Medicare patients.

I don't know very many practices doing obstetrics as part of their direct care model. Technically it can work because the cost savings there are still very significant. However difficult more so because doing obstetrics alongside a family practice is difficult. The obstetric patients want you to be there when they are delivering. And your non-obstetric patients don't like the disruption to your schedule.

Always happy to answer any questions.

 

[Merely]

Wait so back to the money issue...is it possible to make 500k+ in this model? I know some pp fm docs are able to do that and was wondering the economics/feasibility of doing that with this system?

 

[NurWollen]

Wait so back to the money issue...is it possible to make 500k+ in this model? I know some pp fm docs are able to do that and was wondering the economics/feasibility of doing that with this system?

Why are you so specifically fixated on the $500k+ number?

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[Merely]

Why are you so specifically fixated on the $500k+ number?

Sent from my SM-G930V using SDN mobile

Bscause that's attainable in other fields so I always like to explore what's possible in fm

 

[HipsterLorax]

Bscause that's attainable in other fields so I always like to explore what's possible in fm

Other fields like ENT, ortho, neusurg, plastics, etc.?? You realize how different those are than FM, right? Figure out what you want to do with your life then work out the numbers.

 

[Merely]

Other fields like ENT, ortho, neusurg, plastics, etc.?? You realize how different those are than FM, right? Figure out what you want to do with your life then work out the numbers.

You're right they are different but I don't thinks it's fair to undervalue fm like that. Fm provides an immense value to patients when done correctly so if a doctor wants to be paid dollars similar to other high paying fields for providing value it's not unreasonable.

 

[VA Hopeful Dr]

Wait so back to the money issue...is it possible to make 500k+ in this model? I know some pp fm docs are able to do that and was wondering the economics/feasibility of doing that with this system?

Its possible, though fairly difficult to achieve. 2 basic ways to get there:

1. Either see more patients or charge more per patient. Once I'm at capacity, I'll be bringing in right around 200k with my 600 patients at $50/month. Up that to $100/month and increase to 800 patients and I'd be making 600k.

2. If you're successful enough, hire additional docs on salary. If I add 1 doctor, the only real additional cost to me beyond salary is malpractice. The difference between what they bring in and that amount can go into my pocket if I so choose.

You do have other options as well. Moonlighting, cash-based stuff like cosmetics, and so on but those aren't unique to DPC so I'm ignoring them.

 

[Merely]

Its possible, though fairly difficult to achieve. 2 basic ways to get there:

1. Either see more patients or charge more per patient. Once I'm at capacity, I'll be bringing in right around 200k with my 600 patients at $50/month. Up that to $100/month and increase to 800 patients and I'd be making 600k.

2. If you're successful enough, hire additional docs on salary. If I add 1 doctor, the only real additional cost to me beyond salary is malpractice. The difference between what they bring in and that amount can go into my pocket if I so choose.

You do have other options as well. Moonlighting, cash-based stuff like cosmetics, and so on but those aren't unique to DPC so I'm ignoring them.

Thank you for the insight, out of curiosity why don't you up your price to 80 or something since 50 seems really low?

 

[deleted480308]

Thank you for the insight, out of curiosity why don't you up your price to 80 or something since 50 seems really low?

I'm assuming because they started recently and are not at capacity yet. It might just be benevolence though

 

[deleted87716]

$50 does seem a bit low. If somebody can afford $50, they can probably afford $80, and you'd increase your income by >$200,000 (effectively doubling it).

 

[HipsterLorax]

Correct me if I'm wrong but the core value of DPC is not necessarily to make more money, but to avoid the beaurocracy and patient load that a traditional practice has to deal with. I'm guessing prices are low in order to appeal to a broader patient base and not just the upper-middleclass+. If you want to make 500k+ do concierge medicine and cater to the rich. Or open a medspa and cater to the rich. Or go into investment banking.

 

[deleted480308]

Correct me if I'm wrong but the core value of DPC is not necessarily to make more money, but to avoid the beaurocracy and patient load that a traditional practice has to deal with. I'm guessing prices are low in order to appeal to a broader patient base and not just the upper-middleclass+. If you want to make 500k+ do concierge medicine and cater to the rich. Or open a medspa and cater to the rich. Or go into investment banking.

i think it's wrong to assume freedom from interference and making a lot of money are somehow mutually exclusive

 

[VA Hopeful Dr]

Thank you for the insight, out of curiosity why don't you up your price to 80 or something since 50 seems really low?

Honestly? Because I'm following AtlasMD and that's what they charge. Plus, cost of living here is similar to Kansas so it works. If I was somewhere more expensive I might charge more. Plus, it works.

 

[Merely]

Correct me if I'm wrong but the core value of DPC is not necessarily to make more money, but to avoid the beaurocracy and patient load that a traditional practice has to deal with. I'm guessing prices are low in order to appeal to a broader patient base and not just the upper-middleclass+. If you want to make 500k+ do concierge medicine and cater to the rich. Or open a medspa and cater to the rich. Or go into investment banking.

Lol no one said the core value of DPC was about money? We were just discussing the various possibilities so people can make their own educated decisions.

 

[HipsterLorax]

i think it's wrong to assume freedom from interference and making a lot of money are somehow mutually exclusive

Wasn't assuming that at all, but that doesn't change the fact that if you're intending to make 500k+ you're going to have to serve the wealthy and that shouldn't be confused with what DPC is.