Concierge FP

[KLycos]

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I want to figure out what I can do as an MS2 to plan on making the best segue into this after residency. What can I do during medical school and beyond to streamline direct primary care in the future.

 

[xenotype]

Fair question but basic business sense can answer it. Small town likely = few/no doctors = high demand / low supply = opportunity. Maybe you charge less and take more patient. Or maybe you just make more bc the town knows that If they lose their doctors they'll risk losing their town.

Ie this would work beautifully.

Just a quick question, how many hours a week would you say you typically work all included with a full panel of ~600 patients?

 

[AtlasMD]

Just a quick question, how many hours a week would you say you typically work all included with a full panel of ~600 patients?

Normal office hours 9-5 M-F typically. I usually show up by 830 and leave by 530

 

[AtlasMD]

I want to figure out what I can do as an MS2 to plan on making the best segue into this after residency. What can I do during medical school and beyond to streamline direct primary care in the future.

Just get the best training you can. I'd recommend plenty of ER time, orthopedic, women's health, etc. always feel free to email me questions drjosh @ atlas.md

 

[Silent Cool]

Unlikely, as medical licensing is done at the state level.

It would also be politically imprudent, as it's unconstitutional (13th Amendment), and would accomplish nothing in terms of improving access by legislating doctors into bankruptcy.

Many people argued that Obamacare was fundamentally unconstitutional, and look where we are now. I believe that the state of MA already requires the acceptance of M&M for licensure there. I could see other states doing the same.

 

[AtlasMD]

Many people argued that Obamacare was fundamentally unconstitutional, and look where we are now. I believe that the state of MA already requires the acceptance of M&M for licensure there. I could see other states doing the same.

They can try but they'll see a huge backlash from providers.

Plus the pandora box of direct primary care has been opened. The savings are too great to ignore.

 

[deleted87716]

I believe that the state of MA already requires the acceptance of M&M for licensure there.

'Nuff said.

 

[xenotype]

Canada was single payer until a doc sued and won. Attempts to force medicare on everyone will assuredly fail in federal court.

 

[Silent Cool]

'Nuff said.

lol, that's funny. good find

😎

 

[Frank Nutter]

So question...

If the AtlasMD patients have "Unlimited access...Literally. After hours, weekends, holidays"...does this essentially mean no vacation, at all? What do you do if there is a wedding 1000 miles away, family death, personal illness?

 

[deleted480308]

Atlasmd will obviously give how it works for them but I'm assuming there is either A) aclause for emergencies/vaction B) multiple providers in the practice to cover or C) locum coverage arranged

 

[tony montana]

I'm glad you asked. I do NOT think you should start a traditional practice AT ALL. I started straight out of residency with zero patients in a town with NO "concierge" doctors. I added 300 patients in the first 9 months, brought on doc #2 at least two years ahead of schedule, at 32 months we have 1071 patients (as of today), i'm full, doc #2 has 500 pts and doc #3 started this week.

Believe me, its better to have no reputation and build it, then risk getting a bad reputation b/c of your work in a broken system.

Hi Atlas

How much would you say you spent in advertising (radio was most successful?) to achieve the 600 patient mark?

 

[VHADOC]

Apple and oranges. Most any insurance premium would also cover the child's medications, hospitalization, cancer treatment, etc. in addition to primary care.

Also, that $10/month for the child is based on at least one adult parent paying $50/month, as well. So, figure $60/month for two people. That's $720/year.

A typical healthy adult and healthy child would probably not pay that much in insurance co-pays for a couple of routine office visits per year apiece (the average), even if the adult had a physical with basic labs. By definition, AtlasMD's patients are a self-selected population who feel that he's providing them good value.If they didn't, they wouldn't be his patients. And, lots of people aren't his patients. 😉

Don't forget that most patients are (or should be) paying for high-deductible catastrophic insurance coverage on top of whatever they're paying you out-of-pocket for primary care.

This is a straw-man argument. The family also pays premiums. And likely an employer pays additional premiums.

This is Josh's argument: "my 2 cents - concierge family practice will grow to become the standard, drop the concierge, and will be the new "family medicine". Health reform will drive this b/c the current insurance based model (regardless of who resides in the oval office) is unsustainable and unaffordable."

Simply put, the average patient will need a spectrum of medical services through his/her lifetime. Each segment of the spectrum has a cost.

So Blue: are you arguing that the system that you are working in can cover the same amount of spectrum at the same or lower cost than a predominantly direct primary care model? If you don't mind, what is your office's approximate total billing for the following services:
-Annual physical for 35yo mother
-Well child visit for 5yo son
-One URI visit for each during the year
-One fall on wrist requiring x-ray for the 5yo?

According to Josh, his costs (to the family and employer) would be less than $800.

Sure, catastrophic spectrum coverage is also needed, but for primary care, whose is smaller?

 

[deleted87716]

If you don't mind, what is your office's approximate total billing for the following services:
-Annual physical for 35yo mother
-Well child visit for 5yo son
-One URI visit for each during the year
-One fall on wrist requiring x-ray for the 5yo?

According to Josh, his costs (to the family and employer) would be less than $800.

I pulled these prices directly off our self-pay price list.

Annual physical for 35 y/o mother = $145 (for the visit - 99395), $46 for routine labs (CBC, CMP, FLP). Total = $191.
Well child visit for 5 y/o son = $131 (99392)
One URI visit for each during the year = $82 x 2 (99213) = $164
One fall on wrist requiring x-ray for the 5 y/o = $82 (for the visit - 99213), $50 for the wrist x-ray.

Total = $618.

So, I guess mine is smaller. Wait, that didn't sound right...

 

[VHADOC]

One fall on wrist requiring x-ray for the 5 y/o = $82 (for the visit - 99213), $50 for the wrist x-ray.

Good deal. I don't know many family physicians these days willing to come to the office on any Sunday morning to look at the wrist of any of the 2500 patients on their panel. 👍

The reality is that most of them are putting their own needs before those of the public, no matter how they try to justify it. 👎

I'm not condemning them. I just think it's disingenuous to pretend that they are entirely noble. 😉

 

[deleted87716]

Good deal. I don't know many family physicians these days willing to come to the office on any Sunday morning to look at the wrist of any of the 2500 patients on their panel. 👍

You didn't mention Sunday previously, but for that we have a group-wide after-hours clinic with x-ray, so I wouldn't have to come in. Same prices for self-pay.

Self-pay prices are discounted from our standard fee schedule based on payment at the time of service.

 

[AtlasMD]

ha! i love hearing form other Ayn Rand fans! let me know how i can help! We're talking to more med schools all of the time. contact me direct anytime drjosh @ atlas.md

 

[AtlasMD]

"Hoping?" What do you imagine would stop you?

good point blue! nothing should stop them 🙂

 

[AtlasMD]

http://www.breitbart.com/system/wire/upiUPI-20130614-232724-6523

OK, so I went and read this article as mentioned above. I don't see how this type of practice is better than the FFS that we already have from the patient's perspective. From my perspective it sounds great as I get money up front without fussing with a billing service. But if the patient has Medicare, you pay $100 to this PCP every month in compensation for seeing the doctor. But the same patient sees me for free. In theory, you get more time with the doctor? I don't see it. I see patients with same day scheduling and don't rush anyone out the door. What am I missing?

i'm the doc from the article and happy to help answer any questions

Membership = unlimited visits, no copays, extended visits, free procedures etc.

Medicare patients can pay a significant amount out of pocket, are limited by what the gov't says they can have, spend a small fortune on meds, can't find doctors to give them enough time, etc.

In our practice, we dispense medicines and labs at wholesale pricing for up to a 95% savings. see http://atlas.md/blog/2013/06/you-cant-beat-our-prices-at-atlasmd/

 

[AtlasMD]

Just listened to it. "Do we have car insurance that buys gasoline, tires, oil changes" - great example that I would keep using since the public can relate. Thought you articulated your points and argued well. Keep pushin'.

thanks!!

 

[AtlasMD]

So question...

If the AtlasMD patients have "Unlimited access...Literally. After hours, weekends, holidays"...does this essentially mean no vacation, at all? What do you do if there is a wedding 1000 miles away, family death, personal illness?

sorry that i'm just now getting to some of these questions.

Yes its "unlimited" and our "contracts" clarify that we can't be available 100% of the time b/c of sick time, family needs, etc. Its never a problem with our patients b/c they know how hard we work.

This week, i'll travel out of town to speak to a medical school about our model so we sent a mass email to our patients and they responded with congrats and well wishes.

Very doable. Remember, its a small group of patients.

 

[AtlasMD]

Hi Atlas

How much would you say you spent in advertising (radio was most successful?) to achieve the 600 patient mark?

We spent about $2500/mo in radio for about 2 years. We added our second doc at month 10 and our third doc at month 32. We haven't advertised since february 4th 2013 and continue to grow at 50+ pts per month.

Yes, radio was OUR most successful medium but it may be harder in larger cities.

 

[AtlasMD]

I pulled these prices directly off our self-pay price list.

Annual physical for 35 y/o mother = $145 (for the visit - 99395), $46 for routine labs (CBC, CMP, FLP). Total = $191.
Well child visit for 5 y/o son = $131 (99392)
One URI visit for each during the year = $82 x 2 (99213) = $164
One fall on wrist requiring x-ray for the 5 y/o = $82 (for the visit - 99213), $50 for the wrist x-ray.

Total = $618.

So, I guess mine is smaller. Wait, that didn't sound right...

Unlimited visits for a child - $120/yr
Unlimited visits for an adult - $600/yr
No copays
Free: sutures, biopsies, cryotherapy, ekg, holter, spiro, dexa, UA, rapid streps, minor surgical procedures, audiometry
Xray - $20 cash, etc
Savings on insurance - Huge

thats the difference b/w cost and value.

Check in 1.... 🙂

 

[AtlasMD]

🙂 is designed be a high value low cost model.

The other factor not included in blues math is the cost of insurance premiums required for a standard practice.

 

[deleted87716]

not included in blues math is the cost of insurance premiums required for a standard practice.

The high cost of insurance (even high-deductible plans or those purchased in the insurance exchanges mandated by the ACA) will continue to be a problem for the forseeable future.

AtlasMD and those like him who venture into direct-pay practices are to be commended for offering the sort of variety and choice that is (IMO) characteristic of our great nation. There is no "one-size-fits-all" solution to the healthcare dilemma, nor will there ever be. Freedom FROM choice is no freedom at all.

 

[xenotype]

Have any of you read the Innovator's Prescription? It goes into a lot of alternative payment models in healthcare and is a really interesting read.

 

[AtlasMD]

freedom from choice is no freedom at all.

well said

 

[AtlasMD]

Have any of you read the Innovator's Prescription? It goes into a lot of alternative payment models in healthcare and is a really interesting read.

Yes, it's an interesting read.

 

[xenotype]

Yes, it's an interesting read.

Do you have any thoughts on how the author discusses separating business models into solution shops, VAPs, and networks with different payment systems for each? Also, any thoughts on the switch from intuitive to precision medicine and potentially how to incorporate midlevels into this type of practice?

 

[AtlasMD]

Do you have any thoughts on how the author discusses separating business models into solution shops, VAPs, and networks with different payment systems for each? Also, any thoughts on the switch from intuitive to precision medicine and potentially how to incorporate midlevels into this type of practice?

It's been too long since I read the book to respond intelligently to his specific comments/plans.

Of course though, I see significant value in new models with payment systems and value propositions that adjust accordingly.

I'm currently reading "Moneyball" and I love the parallels from old-style Medicine to new style medicine. Yes there's significant value in being more precise and accurate, or evidence-based, and what we do. Basically The goal is to always increase quality and decrease cost.

Mid levels will have a role to play, but ultimately I feel is limited. There's no way around the fact that the physicians assistant has less than 1/4 Of the training that I do.