AtlasMD

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I'm curious if FP residents who are exploring their options are familiar with insurance free direct primary care pracrtices.

I started a dpc practice straight out of residency and i would never go back. I see an average of 5 people per day and make 200k plus....but best of all, i don't have to mess with insurance.

Our practice: $10-100/pt/mo based on age for unlimited visits, no copays, all procedures in office are free, and access to our wholesale medicines and labs for up 95% savings. Then we can take all of that value back to their insurance and lower their premiums by 30-60%!

Its a great model for doctors and patients but i'm curious why more doctors aren't aware of DPC.
 
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I'm curious if FP residents who are exploring their options are familiar with insurance free direct primary care pracrtices.

I started a dpc practice straight out of residency and i would never go back. I see an average of 5 people per day and make 200k plus....but best of all, i don't have to mess with insurance.

Our practice: $10-100/pt/mo based on age for unlimited visits, no copays, all procedures in office are free, and access to our wholesale medicines and labs for up 95% savings. Then we can take all of that value back to their insurance and lower their premiums by 30-60%!

Its a great model for doctors and patients but i'm curious why more doctors aren't aware of DPC.
The only DPC I ever read of was your practice in a forum off SDN a few months back. I am more curious to know what lead you to come up with this model plan? Seems like a bold move. How did insurance companies react? With ACA in the horizon and people getting penalized for not having a health care plan, how do your patients fit in? Does your practice also do prenatal/obstetrical care?
 
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I've followed your posts here and read your articles online. The only thing I've heard from my attendings is them refer to it as concierge care, which obviously implies youre catering to the rich. I have also been told directly to my face that it will not work as a model. Not saying I believe this, just echoing what I've heard from attendings.
 
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I'm curious if FP residents who are exploring their options are familiar with insurance free direct primary care pracrtices.

I started a dpc practice straight out of residency and i would never go back. I see an average of 5 people per day and make 200k plus....but best of all, i don't have to mess with insurance.

Our practice: $10-100/pt/mo based on age for unlimited visits, no copays, all procedures in office are free, and access to our wholesale medicines and labs for up 95% savings. Then we can take all of that value back to their insurance and lower their premiums by 30-60%!

Its a great model for doctors and patients but i'm curious why more doctors aren't aware of DPC.

I'm quite aware of the model, and would love to do it, but there are a few things hampering it.

1. I have absolutely no financial "reserves" to get a practice started
2. I have bills to pay, immediately.


Those are the big ones. If not for that, I would LOVE to do it.
 
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VenusinFurs

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I mean, I'm guessing the patients would still have to have insurance for things like hospital admissions. Also, let's say you put a Mirena in some one. Them suckers are like $850- would you bill insurance for that?

It would work probably in the end work out to be cheaper for the patient. In the past 6 months I've had to pay close to $200 out of pocket, and as a healthy young person I'm guessing I would pay much less than that per month in this model. Some insurances (mine included) only cover certain types of office visits and I'm stuck having to pay for others, such as walk in care visits.
 
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Blue Dog

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I mean, I'm guessing the patients would still have to have insurance for things like hospital admissions. Also, let's say you put a Mirena in some one. Them suckers are like $850- would you bill insurance for that?
Mirena can stay in for five years. That's $14/month. Sure, you need to have the cash up front, but it's not unaffordable.
 
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AtlasMD

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The only DPC I ever read of was your practice in a forum off SDN a few months back. I am more curious to know what lead you to come up with this model plan? Seems like a bold move. How did insurance companies react? With ACA in the horizon and people getting penalized for not having a health care plan, how do your patients fit in? Does your practice also do prenatal/obstetrical care?
Sorry for the delayed response, holidays :)

Thanks for your interest and i'm happy to answer anything. For a really comprehensive article, check out http://www.theobjectivestandard.com/issues/2013-fall/dr-josh-umbehr-on-concierge-medicine-revolution.asp

What lead us to come up with this: I could see as a pre-med, med student and resident that practicing doctors were burning out on insurance based practice and i didn't want to hate my patients a few years after training like so many others. Plus, insurance just never made sense for family medicine....after all you don't have care insurance for gasoline....insurance is meant for catastrophic costs/loss, not for daily expenses. And yes, primary care is/can be affordable.

Bold move - you're telling me :) we started straight of residency with no patients and a dream!

Insurance companies - at first didn't see the value but now they do, in large part b/c we made them 100% profit several times on large groups over the course of a 12 month cycle b/c the employees didn't have to file ins claims to get care. Now they are starting to work WITH us to accept our fees towards deductibles (based only on our invoice, no coding) and to lower premiums.

ACA - despite what many people think/say, the ACA will drive the development of direct care practices like never before. If you don't have insurance and pay the fines, then we are the most affordable option available. If you do get exchange based insurance, your premiums/deductibles are going to be high and there's no coverage until you meet your deductible = we're the most cost effective option available.

OB - we don't but it would be a great model!

sorry to be short but i know that its hard to read long answers on forums.
 
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I've followed your posts here and read your articles online. The only thing I've heard from my attendings is them refer to it as concierge care, which obviously implies youre catering to the rich. I have also been told directly to my face that it will not work as a model. Not saying I believe this, just echoing what I've heard from attendings.
Hi Smokemont, thanks for following my posts. Concierge = Direct Care = Family medicine (when done right). Basically its all different buzzwords for affordable care. Sure there's some concierge docs who have very high prices but they are the exception now a days. Just look at our prices and tell me that we're catering to the rich :) $10/mo/child for unlimited care?

Attendings - haha yeah they told me that too! ;-) not to harp on attendings b/c they're good people, but they aren't in academic medicine b/c they are so business savy. Everyone told me this wouldn't work, and i respect that they were being honest. But now that we've been open 3+ years and are growing faster than ever expected, i think its safe to say they are wrong.

Again, Our practice: $10-100/pt/mo based on age for unlimited visits, no copays, all procedures in office are free, and access to our wholesale medicines and labs for up 95% savings. Then we can take all of that value back to their insurance and lower their premiums by 30-60%. Now ask your attendings what they would think of a model like that and if its affordable. And yes, the doctor makes good money in this model too. An avg of $50/pt/mo x 600 pt = 360k/yr - 30% overhead = 200-240k/yr seeing 5 pts/day on avg.
 
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1. I have absolutely no financial "reserves" to get a practice started
2. I have bills to pay, immediately.
Thanks! Very fair questions and i think typical of most physicians, which is why its so important to answer it.

Yes, many physicians would find it very difficult to put a full stop on their income to start up something new. 3 years ago when DPC wasn't really known, we had to pound it out to educate patients, doctors and employers about the benefits. Now that its really gaining traction with recognition in the WSJ etc, AND with the pressure of health reform baring down on everyone, the market has never been so ready for a solution.

I really do believe that it doesn't take much to open a practice like this in terms of extra expense (ie office perks and amenities).

Option 1) convert your practice - if you have a panel of 2k+ pts, then you could convert in the course of 2-3 months and be full or nearly full by day 1. Say your start date was 1/1/14, you'd send out invoices that day and have money in your account by the end of the week. If you're not pre-enrolling enough patients, you can push the start date back.

Option 2) talk with a large employer or several small employers. You only need about 200 employees to have 500+ pts when you include families. Our model helps employers lower insurance premiums by 30-60% so they are thrilled to learn about this. You'd basically pre-enroll with these employees so that you'd have a full panel right away to minimize any out of pocket cost or loss revenue.

thats the short explanation but happy to expand if you'd like.
 
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I mean, I'm guessing the patients would still have to have insurance for things like hospital admissions. Also, let's say you put a Mirena in some one. Them suckers are like $850- would you bill insurance for that?

It would work probably in the end work out to be cheaper for the patient. In the past 6 months I've had to pay close to $200 out of pocket, and as a healthy young person I'm guessing I would pay much less than that per month in this model. Some insurances (mine included) only cover certain types of office visits and I'm stuck having to pay for others, such as walk in care visits.
Hospital fees - yes, we're a Family Practice office so we do all that we can for you, but can't be your surgeon or your hospitalist, if thats what you need. Of course its our job to keep you out of the hospital when possible.

Mirena - yes, some things are expensive so we work with our patients for the most cost effective option for them. We don't get Mirena's at much of a discount but the procedure is free at least.

But at least the patients still get unlimited visits, no copays, free procedures, access to our wholesale meds/labs and negotiated discounts on imaging for about 80%. If they don't have insurance, this is the most cost effective care and if they do have insurance we can help decrease their premiums to save more than our services cost.
 

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Have you considered approaching residency programs and offering to do a lecture about DPC, both in general terms and specifics about your clinic? I knew about this as a resident, but only because I read these forums. I would think most programs would love to have you.
 
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Have you considered approaching residency programs and offering to do a lecture about DPC, both in general terms and specifics about your clinic? I knew about this as a resident, but only because I read these forums. I would think most programs would love to have you.
yes, we've spoken with a number of residents/residencies as well as medical students. We're happy to speak to any group who will have us. feel free to email me direct at [email protected]
 

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I'm not a FM resident but I've discovered the direct patient care model several years ago. That's what has made me consider getting back into medicine and retraining in FM. The big obstacle to me (other than matching after having done some GS time)? I cannot imagine how I could manage to get started in such a practice just after residency. My student loan debt is a huge burden, and I'm really hesitant to take on more debt. I don't have the cash to invest up front. I'm 100% down with this model and think it needs to ramp up fast or the statists in government will seek to make one condition of getting a license to practice medicine that it be mandatory to accept medicare/medicaid- especially the "medicare for all" crowd.
 
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xenotype

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The big obstacle to me (other than matching after having done some GS time)? I cannot imagine how I could manage to get started in such a practice just after residency. My student loan debt is a huge burden, and I'm really hesitant to take on more debt. I don't have the cash to invest up front.
I think the typical plan is get a partner and work hospitalist/community ED/urgent care temp while building the practice. Money for those is good, and schedule so you can cross cover with the partner.
 
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Do you think such a practice model is sustainable for pediatrics? Or do you need the higher paying adult members as well?
 
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I think the typical plan is get a partner and work hospitalist/community ED/urgent care temp while building the practice. Money for those is good, and schedule so you can cross cover with the partner.
yes, moonlighting is an excellent option you getting started. But do not forget that you can start patients and working with employers prior to your launch date. It is very reasonable that you could start with several hundred patients day one so that you have immediate cash flow. Employers are increasingly receptive to the direct care model.
 
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Do you think such a practice model is sustainable for pediatrics? Or do you need the higher paying adult members as well?
absolutely and feel free to email me direct at [email protected] if you would like to discuss this. In part it depends on what the pediatrician to earn for income. We typically base our math on the family physician making $200-240,000 per year (after overhead expenses). for this income, a pediatrician would need to charge either $25/mo/pt for 1200 pts or $20/pt/mo for 1500 pts. however I have spoken with many pediatricians should be happy with something closer to the 150k income. I would be happy to help however I can.
 
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I'm not a FM resident but I've discovered the direct patient care model several years ago. That's what has made me consider getting back into medicine and retraining in FM. The big obstacle to me (other than matching after having done some GS time)? I cannot imagine how I could manage to get started in such a practice just after residency. My student loan debt is a huge burden, and I'm really hesitant to take on more debt. I don't have the cash to invest up front. I'm 100% down with this model and think it needs to ramp up fast or the statists in government will seek to make one condition of getting a license to practice medicine that it be mandatory to accept medicare/medicaid- especially the "medicare for all" crowd.
what is your training right now? You do not have to be family medicine to be successful in direct care models. It works equally well for all kinds of specialist. Not to sound like a broken record, but we are working with more more employers monthly are looking for doctors doing models like this. In fact we are talking with one employer who has 8000 employees in one location. This would mean approximately 20,000 patients and up to 40 physicians. Please feel free to contact me directly and I would be happy to keep you informed of employers near you who are looking for physicians.
 
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So do you stay in the office all day waiting for the 5 patients to come in? I imagine the visits are probably longer than in a typical insurance based model. Still, seems like a lot of down time...
 

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So do you stay in the office all day waiting for the 5 patients to come in? I imagine the visits are probably longer than in a typical insurance based model. Still, seems like a lot of down time...
I see 5 patients before my second cup of coffee. ;)

Seriously, though, if I spent a full day (8 hours) in the office, I'd expect to see at least 8-10 patients, even in a "concierge" model.
 
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So do you stay in the office all day waiting for the 5 patients to come in? I imagine the visits are probably longer than in a typical insurance based model. Still, seems like a lot of down time...
I keep busy running the busy, consulting w docs ( gratis), making software, etc. Plus pt calls, emails Etc.

A DPC who was able to focus on just the practice could have a slightly higher pt panel to increase revenue.
 
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I see 5 patients before my second cup of coffee. ;)

Seriously, though, if I spent a full day (8 hours) in the office, I'd expect to see at least 8-10 patients, even in a "concierge" model.
The important thing is a balanced model. We have busier days and slower days. Plus, too many patients = busier after hours and weekends.
 

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Do you think that an urgent care center or walkin clinic could be done with a cash only model?
 
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Do you think that an urgent care center or walkin clinic could be done with a cash only model?
I assume you mean a simple standalone cash clinic and not a membership model like direct primary care. absolutely, that would be a very successful model if designed well and priced appropriately. The 10 most common things seen and urgent care are very simple to manage, do not take a lot of time or diagnostic equipment, and people are usually willing to pay for an answer quickly. If you price to between 50 and $75 a visit I think you could manage a very successful practice
 

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Sorry, couple more questions- Do your docs see your patients when admitted to the hospital, or hand off to hospitalist?

Are you tracking quality metrics? I see this as a likely area for attack by statists who will make the claim that DPC practices don't provide the same quality of care.
 
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Our doctors don't see patients in the hospital even though one was a Hospitalist. We are focused on out patient care. But it would be possible.

Yes we track some metrics but not as well as we will be able to. We are finalizing lab integration and such to streamline that process. But always the goal is to more data tracking to prove the value.
 

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Do you work on weekends? Holidays? How many weeks of vacation do you take? Is it better to go solo or with a partner?
 
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As a medical student who is about to enter a FM residency in a few short months, threads like this one are a breath of fresh air. I love family medicine, but I have become increasingly weary of the administration/insurance/paperwork nightmare that is modern medicine. I hate not being able to look at my patients because of the damn computer. Often its like, " Sorry i can't talk to you about you because I have to finish typing all this stuff about you"

I have found myself often thinking that there has to be a better way......
 

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Do you think that an urgent care center or walkin clinic could be done with a cash only model?
Most of the Urgent Cares that I know off have, at the very least, an X-ray and a CT-Scan. Some also have an U/S. We see cases similar to the ER. Off course, we transfer to the ER any acute MIs, Stokes, PEs, or life-threatening conditions. Would a cash model work, may be if priced coorectly (not less than $150$-250) per visit.

Now if by "urgent care" you mean those "minute clinics" that are staffed by NPs and see mostly URIs, UTIs, and ear infections all day (no CP or abd pain or complex work-ups), then a $50 per visit model would be OK.
 
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Do you work on weekends? Holidays? How many weeks of vacation do you take? Is it better to go solo or with a partner?
We take 2 weeks of vacation typically per year. Usually not more than 1 week at a time though. We are available on holidays but we don't keep the clinic open. Usually we take Wed-Friday off for Thanksgiving and 12/23-12/26 for Christmas.

Solo is ok but its always nice to have other peers with you for a variety of reasons.

Anything else i can answer for you?
 
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As a medical student who is about to enter a FM residency in a few short months, threads like this one are a breath of fresh air. I love family medicine, but I have become increasingly weary of the administration/insurance/paperwork nightmare that is modern medicine. I hate not being able to look at my patients because of the damn computer. Often its like, " Sorry i can't talk to you about you because I have to finish typing all this stuff about you"

I have found myself often thinking that there has to be a better way......
Hi and thanks for the support and kind words. There's absolutely a better way. I truly believe DPC will change the face of medicine for the better. Its a win for everyone, patients, doctors, employers and insurance companies. I love practicing medicine this way and other docs who are transitioning are finding their love for medicine all over again.

Don't let people who don't know about DPC tell you it can't work. Please feel free to contact me directly, [email protected] If i can be of any help, just let me know.

Best!
 
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I'm curious if FP residents who are exploring their options are familiar with insurance free direct primary care pracrtices.

I started a dpc practice straight out of residency and i would never go back. I see an average of 5 people per day and make 200k plus....but best of all, i don't have to mess with insurance.

Our practice: $10-100/pt/mo based on age for unlimited visits, no copays, all procedures in office are free, and access to our wholesale medicines and labs for up 95% savings. Then we can take all of that value back to their insurance and lower their premiums by 30-60%!

Its a great model for doctors and patients but i'm curious why more doctors aren't aware of DPC.
So am I missing the business model or is this based solely on just a "membership" fee? Can you give a breakdown of your patient panel? This is intriguing.
 
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So am I missing the business model or is this based solely on just a "membership" fee? Can you give a breakdown of your patient panel? This is intriguing.
Happy to clarify. Yes the model is to not take any insurance and only charge the monthly membership for unlimited visits, no copays, free procedures and access to our wholesale medicines/labs for up to 95% savings. This in turn helps them to get insurance that is 30-60% cheaper. We limited our panel size to 600 patients per doctor but thats enough to keep our prices low and our income high.

We charge $10-100/mo/patient based on age only.

questions?
 

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I followed Rob Lamberts' blog for a while, not sure that's you or not.

I understood the direct pay model to depend on the catastrophic coverage insurance policies that I now understand to be not really legal any more under the ACA.

So are you still able to save your patients money if they get insurance that is good enough to avoid the uninsured penalty, assuming people are following the spirit vs. the currently disputed law of the ACA?

I'm also interested in how much work you have to do to get deals with labs & pharm. Is that somebody's job, other than you?

Thanks.
 

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Seriously considering fam medicine because I believe in DPC so much. I've signed up for a longitudinal fam med rotation 3rd year and I really think I'm going to love it.
 

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I understood the direct pay model to depend on the catastrophic coverage insurance policies that I now understand to be not really legal any more under the ACA.
It's my understanding that the ACA actually permits direct-care practices to be marketed on the exchanges in conjunction with insurance that basically covers the stuff that the direct-care practice wouldn't cover. I've seen those policies described as "wrap-around" policies, and I think they actually cover a bit more than the traditional "catastrophic" coverage. The combination of the direct-care practice plus the right wrap-around policy would be considered the equivalent of an approved insurance policy under the ACA (which is why they'd be allowed to be marketed via exchanges.

I'd be interested to know if AtlasMD does anything like this or knows of a practice that does.
 

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It's my understanding that the ACA actually permits direct-care practices to be marketed on the exchanges in conjunction with insurance that basically covers the stuff that the direct-care practice wouldn't cover. I've seen those policies described as "wrap-around" policies, and I think they actually cover a bit more than the traditional "catastrophic" coverage. The combination of the direct-care practice plus the right wrap-around policy would be considered the equivalent of an approved insurance policy under the ACA (which is why they'd be allowed to be marketed via exchanges.

I'd be interested to know if AtlasMD does anything like this or knows of a practice that does.
http://www.dpcare.org/health_reform
 

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Thanks--that's exactly what I was thinking of. I wonder if any direct-care practice has actually done this. (Interestingly, a fairly large number of the web links on the list of direct-care practices are either broken or link to practices that appear not to do direct care anymore.)

AtlasMD has mentioned a few times something about insurance companies offering his patients lower rates, so I'm curious if he has put together one of these "bundles" or if he's doing something else.
 

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http://qliance.com/medical-services/

Listed under the WA exchange. Currently you need to have some kind of a critical mass to get this kind of deal, but I see no reason why a conglomerate of independent DPC practices couldn't do the same. The hard part is that it takes a very forward looking insurance company, which there are few of.
 
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Seriously considering fam medicine because I believe in DPC so much. I've signed up for a longitudinal fam med rotation 3rd year and I really think I'm going to love it.
Congratulations!!! Family medicine is a blast especially when free of ins red tape. You're welcome to contact me directly for anything or do a rotation w us. 316.734.8096 [email protected]
 
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Thanks blue dog! Exactly right w the link.

Yes we are working directly w ins and have been for 3.5 years to decrease cost of ins by 30-60%.

To answer the question about negotiating med and lab prices. We have national pricing w quest and working on labcorb so docs don't have to haggle. Meds are from andameds.com and prices are clearly listed and simple.
 

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I'm a huge DPC fan by the way, but just as an aside, cutting red tape doesn't always mean better care.

Searching through the DPC directory on their website, I went to one family physician website which says he orders Mammograms for all patients starting at 30 y/o. Almost makes me want to start a 'gofundme' thing to send the guy to an Evidence Based Medicine conference...
 
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I'm a huge DPC fan by the way, but just as an aside, cutting red tape doesn't always mean better care.

Searching through the DPC directory on their website, I went to one family physician website which says he orders Mammograms for all patients starting at 30 y/o. Almost makes me want to start a 'gofundme' thing to send the guy to an Evidence Based Medicine conference...
That's just bad medicine regardless of the model but I agree w you completely.
 

Silent Cool

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Hi Smokemont, thanks for following my posts. Concierge = Direct Care = Family medicine (when done right). Basically its all different buzzwords for affordable care. Sure there's some concierge docs who have very high prices but they are the exception now a days. Just look at our prices and tell me that we're catering to the rich :) $10/mo/child for unlimited care?

Attendings - haha yeah they told me that too! ;-) not to harp on attendings b/c they're good people, but they aren't in academic medicine b/c they are so business savy. Everyone told me this wouldn't work, and i respect that they were being honest. But now that we've been open 3+ years and are growing faster than ever expected, i think its safe to say they are wrong.

Again, Our practice: $10-100/pt/mo based on age for unlimited visits, no copays, all procedures in office are free, and access to our wholesale medicines and labs for up 95% savings. Then we can take all of that value back to their insurance and lower their premiums by 30-60%. Now ask your attendings what they would think of a model like that and if its affordable. And yes, the doctor makes good money in this model too. An avg of $50/pt/mo x 600 pt = 360k/yr - 30% overhead = 200-240k/yr seeing 5 pts/day on avg.
So could you see 10 patients per day and make 400-500K? Or does it not quite work like that.
 
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AtlasMD

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So could you see 10 patients per day and make 400-500K? Or does it not quite work like that.
Not really. Bc that would mean more after hours calls, busier days, which means less time for emails and phone calls etc.
 

Silent Cool

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Not really. Bc that would mean more after hours calls, busier days, which means less time for emails and phone calls etc.
Gotcha. So a good chunk of your day is spent on admin, etc.., tasks, such that a realistic max patients per day might be like 5-6?
 
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AtlasMD

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Gotcha. So a good chunk of your day is spent on admin, etc.., tasks, such that a realistic max patients per day might be like 5-6?
Not necessarily but the model lives and dies on quality and if you enroll too many and quality suffers, patients will leave.
 

sb247

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Not necessarily but the model lives and dies on quality and if you enroll too many and quality suffers, patients will leave.
Total premed question here: is your site set up as a facilitator for clerkships? It would be great to spend a few weeks just observing your system (and it would help "spread the gospel" of dpc.


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AtlasMD

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Total premed question here: is your site set up as a facilitator for clerkships? It would be great to spend a few weeks just observing your system (and it would help "spread the gospel" of dpc.


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Indeed, we have med students and residents an docs visiting regularly.

Anything to spread the word :)