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Category: Cost of Healthcare, Health Insurance

Is Primary Care Best Delivered ‘Directly’?

If we are ever going to get healthcare costs under control here in the U.S., it’s clear that we will have to get more Americans to develop relationships with primary care providers (PCPs).

A PCP is a family medicine, general practice, internal medicine or geriatrics doctor for adults, and a pediatrician for children.

The beauty of the PCP-patient relationship is that it often stretches over years, with the PCP handling the majority of the patient’s needs when he or she is sick or injured. Rather than specialists or other types of providers you see here and there as specific needs come up, the PCP gets time to develop insights into your health status over time. This includes keeping an eye on any long-term conditions you have. Patients who have good PCP relationships are less likely to have uncontrolled chronic conditions, tend to stay out of the hospital and even live longer.

PCP Supply and Demand

Historically, the American health insurance system has not done a good job of supporting PCPs. PCPs are often pushed to the bottom in terms of reimbursement even though what they are providing is critical day-to-day care for their patients. In fact, PCP pay lags far behind what other providers and specialists make. As a result, in an average year, only 12-15% of medical students indicate they want to become a PCP.

This lack of focus on primary care has led to a PCP shortage, which often forces PCPs to see and diagnose their patients in visits that are 10 minutes, max! Some PCPs may see 40, 50 or even 60 patients a day! This is not a recipe for good long-term health (or the sanity of the PCP!)

The future is not as bright as it could be, either. About half of the current PCP workforce is over age 55, and in the USA, we currently have only 225,000 of them to take care of some 330 million patients! That works out to 1 PCP for every 1,466 people. And, these are nationwide statistics – in some states, including Louisiana, PCPs are even scarcer – the state ranks 32nd out of 50 for PCP availability.

So, what can we do?

I’ve observed two solutions entering the marketplace, and one will be a long-term negative for patient care, in my opinion. The other is already boosting the fortunes of PCPs, offering them better support in helping their patients get – and stay – healthy.

What’s Direct Primary Care (A.K.A. Concierge Medicine)?

About 20 years ago, some docs in the Midwest were faced with needing to make expensive upgrades (like electronic medical records) to compete with larger clinics. They were also struggling to deal administratively with Medicare and multiple private health insurance companies. They were seeing so many patients they felt overwhelmed.

These enterprising docs decided to create a subscription care model to fit their practices as-is, essentially eliminating their participation in health insurance networks and drastically reducing their patient rolls. These models have come to be known as “Direct Primary Care,” or DPC. They are called “concierge medicine practices,” too.

DPC is pretty straightforward: Every month you pay your PCP a flat fee (your subscription to that practice), and you get care from that doc or other providers in his or her practice, typically without any additional payments – like copayments or coinsurance – for your visit.

DPC practices also buy common generic drugs in bulk, including some medicines that insurance companies don’t cover — like generic antibiotics or Sildenafil (you can look that one up yourself!) then sell them to their patients.

Their goal is administrative simplicity, up-front revenue, a lighter patient load and a more attentive relationship with patients without the burden of electronic reporting or having to interface with other docs, hospitals or insurance companies.

A DPC rep once told me they are trying to do things “the way it used to be, before the government or insurance companies got into healthcare.” (I didn’t bother him with the fact that Blue Cross and Blue Shield of Louisiana started back in 1934.)

On the positive side of DPC, I’ve seen plenty of small-practice PCPs in their late 50s or early 60s facing burnout from the traditional healthcare model. Migrating to DPC allowed them to stay in the game a little longer. With the shortage of PCPs, I believe that’s a good thing for all of us. I’d rather see a doc reduce his or her patient load from 3,000 to 500 patients and focus hard on them rather than leave practice entirely and deprive the healthcare space of ALL of his or her capabilities.

On the negative side, in this era of integrated care, the inability of a DPC practice to work with hospitals and other specialists, or to feed patient data electronically to the insurance company responsible for the care of that patient across ALL healthcare providers is a problem. This will damage the ability of that patient’s docs and insurance carrier to make sure that patient gets the best care, in the best setting, at the best time.

And, this would further strain the PCP shortage I mentioned earlier because not all the docs embracing DPC models are on the verge of quitting. If more docs go to this model, we at Blue Cross will need to find and recruit even more PCPs willing to take new patients and be reimbursed through us. Otherwise we won’t be able to make sure we have enough docs to treat all our members. Since we already have too few PCPs in Louisiana, that’s a challenge that would be pretty hard to overcome.

Insurance companies must manage a patient’s care across ALL providers, including specialists, pharmacy and hospital care. In other words, in this day and age, getting good PCP care is important, but it’s far from enough. You’ve seen me write about how good we’ve become at analyzing our data to predict when people are at risk of hospital stays or ER visits  and intervening BEFORE they get very sick.

If those predictive models are starved of data from DPC practices, they become much less effective, and patients are more at risk. And, we are not the only insurer doing more with data, so this could put a lot of patients at risk. In other words, in an era where healthcare data integration is CLEARLY proving its worth, DPC seeks to remove itself from those connections to “simplify healthcare.”

Money Talks
In addition, if you have health insurance, you are ALREADY PAYING for PCP care through your premiums. Subscribing to a DPC practice means you are essentially paying for your primary care twice.

And, the DPC practices do not typically provide comprehensive prescription coverage, specialty coverage, coverage for labs, imaging, physical therapy or hospital stays. So, this is clearly not a substitute for having comprehensive health insurance.
Carriers won’t charge you less because you subscribe to a DPC practice, nor will they help you pay the fees for membership.

“Well, Mike, if insurance companies aren’t pushing DCP practices, what’s their answer to getting more people engaged in primary care?”

The problems facing PCPs I illustrated at the beginning of this article have an integrated, wildly successfully solution that is lowering costs for healthcare consumers while better supporting PCPs and reimbursing them more for quality care. Believe me, you don’t want to miss THIS program!

Quality Blue: Better Outcomes, Lower Costs
That solution is Quality Blue. It’s really simple. PCPs need more money. Patients need to get well and stay on top of their chronic conditions. Insurance companies need to help keep prices down. One good way to do that is to keep people healthy and out of the hospital.

“But Mike, surely this Quality Blue program can’t do all that?”

It can! We’ve been running it for years now, and it is lowering costs with every PCP who jumps in. It’s improving the health of our members across the board. It’s keeping them out of the hospital. Yep, all of that!

How’s it work?

It starts with Blue Cross and participating PCPs securely exchanging data from electronic health records and claims data. This ensures that the doctors have a complete picture of their Blue Cross patients before their appointments, which allows them to spend the appointments directly addressing patients’ needs, not doing more paperwork. It also gives our dedicated nurses the information they need to support the doctors and patients in between visits.

With this information and support, the doctors can focus on keeping their patients healthy, rather than treating them only when they’re sick. In turn, we measure how well they control their patients’ chronic conditions, and we pay the doctors MORE as their patients’ health improves.

And, doctors in this Quality Blue program are knocking it out of the park.

There are more than 700 Quality Blue doctors around the state, and their patients have better and better health outcomes for chronic conditions like diabetes and high blood pressure. (If you look up your PCP on our website www.bcbsla.com and you see a Blue “Q” next to the name, you are already seeing a Quality Blue doctor.)

In fact, we’ve measured the impact for the last few years, and the patients seeing Quality Blue PCPs have:

  • A 26% improvement in diabetes care
  • A 46% improvement in hypertension (high blood pressure) care
  • A 13% improvement in vascular disease care
  • A 10% improvement in chronic kidney disease care

That’s comparing them to patients seeing other, non-Quality Blue doctors.

The Quality Blue doctors are holding the line on healthcare costs, too. By taking extra steps like working with Blue Cross to coordinate care, getting more eligible patients connected with our Care Management nurses and prescribing more generic drugs, they’re achieving savings. In our most recent Quality Blue program year, large physician groups enrolled saved an average 3.27% of their total cost of healthcare, with the most successful groups saving up to 12%!

DPC or Quality Blue?

Blue Cross is not the only health insurance company moving away from the old fee-for-service system, where we reimbursed providers for taking care of you only when you were sick.

Instead, we and other insurers are using programs like Quality Blue to reimburse docs for keeping their patients healthy and out of the hospital.

And before you start thinking about reaping the benefits of both programs… DPC doctors can’t join Quality Blue. And, most other insurers don’t let DPC practices in their programs like Quality Blue, either.

So, you can have one or the other, but not both.

One is already included in your premiums. The other is an extra cost to you.

So, is primary care best delivered “directly”?

Clearly, not for everyone.

Straight Talk is, think carefully before you double-pay for primary care coverage.

13 comments on “Is Primary Care Best Delivered ‘Directly’?

    • Michael Bertaut

      Melody! This is a good question. After I ran a quick search, I found most of the docs that list “pediatrics” as a specialty in our networks seem to have the “internal medicine Blue Q” on their name as well.

      So it appears you can find a pediatric doc who is a Quality Blue doc as well.

      Give it a try at http://www.bcbsla.com under “find a doctor”. You’ll see a Blue Q on their account if they are a Quality Blue doc.

      thanks..mrb

      Reply
  1. DPC Doc

    Wow! How misleading can you be. You didnt mention anything about the quality DPC provides in your article. You also didnt mention that for your BCBS population that fall in the medication donut hole, save even more with DPC. In fact that ends up paying for the DPC MEMBERSHIP. DPC ‘IS NOT’ Concierge medicine. Stop confusing the two. Concierge medicine has its place, but they do charge both a membership and bill the insurance company. In DPC, the doctor NEVER bills the insurance company nor collect a copay at each encounter. There is only one flat monthly fee which is usually no more than $100 a month. So its not double dipping as you suggest. And it may be true that a PCP is included in the premium, but if all you get is a total of 40 minutes a year with your doctor if you have diabetes, how effective can you really be compared to more than an hour of time and countless of other modalities to monitor a patients condition.

    All of the insurance companies do great things and BCBS is a bonafide leader in quality initiatives. Lets stop misleading the public and work together and provide real healthcare without diverging interests at the patients expense!

    Reply
    • Michael Bertaut

      DPC Doc!
      Thanks so much for your comments on our article. I’m sorry you found the material misleading, but rest assured, I have no doubt DPC practice doctors deliver quality care in their setting and I certainly know they care about the customers as much as any other doctor. And I did find your comments about DPC’s not billing insurance companies very confusing. We have many DPC practices who treat BCBSLA customers and file claims with us. And we are fine with that.

      I’m also not sure where your “40 minutes a year with your doctor” came from? I have close family members who are Type 2 and have 10-15 clinic visits a year or more. Maybe there is a benefit scheme out there I’m unaware of that doesn’t apply to us?

      I noticed you mentioned the Medicare Part D “donut hole” and Blue Cross members who save money on their drugs in the donut hole by doing business with your DPC practice. Let me say “thank you!” for any drugs you can deliver to patients who are subject to that zero coverage zone and save them money! It is much appreciated, but we don’t offer a Part D plan here in Louisiana to our 1.6m members. We do have a few thousand MA clients who might benefit from such a benefit. AGain, thanks!

      I absolutely agree that we all need to put the patient first, and partner to make sure they get the absolute best care. We believe that this will require going forward data connectivity and predictive modeling combined with lots of clinical interventions (our 200 clinicians stay VERY busy, even going with our members to doctor visits and helping them afford their meds) for maximum effectiveness in controlling chronic conditions AND using that data to intervene in social issues that drive poor health. Every single data point is critical now, since we are treating people who have no transportation, for example, and need us to send them a Lyft or an Uber. One simple example that we can glean if we have the correct data.

      AGain, I apologize if you found the article misleading. I’m not into attacking anyone (feel free to read any of my 150 + articles online at http://www.straighttalkla.com) and I was asked my opinion about DPC, concierge medicine, and the intersection of modern 3rd party payers and I gave it.

      Thanks for sharing yours with me!
      mrb

      Reply
      • DPC Doc

        If a doctor who claims to be part of a DPC model drops a claim with an insurance company, they are NOT a DPC doc they are a Concierge doctor. We must stop confusing the public that they are one in the same. DPC doctors DO NOT receive any payment from insurance companies. Your issue is the fact that in a DPC model it is difficult to extract health data. I agree that the direction of healthcare will incorporate more health data analytics, but we aren’t there yet. The data will be flawed until we have a reliable system that is able to acquire real data without the potential for manipulation. The software I use, “Atlas”, does track any metric I want. However, I decide what to track and ultimately responsible for its integrity as well. The nice thing is it has the capability to connect with wearable technology which has been a total deal maker. I am able to track my diabetic patients blood glucose every time they check it, or my hypertensive patient as well. I have nearly daily interactions in the corrective phase then monitor them in the maintenance phase without having to drag them into my office just to submit a billable visit. Almost every other EMR has stumbled in its own compliance loop hole to provide this.

        We can go round and round about this, but I would love to see BCBS embrace DPC. We are already shifting more and more cost on to the patient. This is one way to work together to give them more value. You should speak to our own Senator Cassidy for his own perspective on DPC. He is in favor of the premise and hopefully can be a way to provide for more covered lives in Louisiana that do not have access to affordable healthcare. See the following link from Senator Cassidy.
        https://www.cassidy.senate.gov/newsroom/press-releases/cassidy-unveils-new-ideas-to-make-health-care-affordable-again

        Thank you.

        Reply
  2. Karl N Hanson, MD

    Your article states that “the insurance company responsible for the care of that patient across ALL healthcare providers.” That is wrong. The insurance company is not responsible for ANY healthcare. The insurance company takes 20% of the premium collected for themselves and distributes compensation to those who actually deliver the healthcare. Insurers do no healthcare. The next sentence states “This will damage the ability of that patient’s docs and insurance carrier to make sure that patient gets the best care, in the best setting, at the best time.” Since the a priori is a falsehood, this conclusion is a double falsehood. BCBS has never made “sure” that my patients get the best care. BCBS has no positive influence over care.
    To continue the fear mongering you suggest “Otherwise we won’t be able to make sure we have enough docs to treat all our members” is false. I am a DPC doctor and I have plenty BCBS patients signed up with me and they get great care. And more…”in an era where healthcare data integration is CLEARLY proving its worth”…you mean in profits for carriers. The aggregate of data does not support your conclusion that spending hours on data mining has improved our health.
    Anyone reading this, listen to a REAL family medicine physician. Insurance red tape and Medicare regulations are killing primary care. The complex yet enjoyable act of taking care of a patient has been gummed up while the insurers are making confiscatory sums of money. Any reference to us Direct Primary Care model docs interfering with health care because we do not submit claims data is false. Does the patient want their private health information routinely sent to a financial institution such as an insurer? I think not. Doctors are not data clerks even though insurers wish us to be. In DPC, our allegiance is exclusively with the patient with no interference with third parties such as insurers, the way it should be. Yes, believe it or not, health care took place before insurance companies and Medicare existed. I would contend that insurers are partially responsible for high health care costs.
    Buy your high deductible policy to prevent exposure to catastrophic expenses (the reason for insurance) and join a DPC doctor’s practice. Get personal service and you can still use your health insurance benefits if needed.

    Reply
    • Michael Bertaut

      Dr. Hanson!
      Thanks so much for your comments on our DPC/Concierge article. I’ll try to address them one at a time for clarity’s sake.

      “insurers do no healthcare” was your first point. I would argue that our 200 clinicians, RN’s, Docs, Nutritionists, pharmacists, and the like who interact with our patient’s medical providers every single day, providing tons of information that those providers often do not have access to, are just as important to long term health, and dealing with chronic disease that any doctor whom you believe actually “practices medicine”. Our members get zero healthcare when they have a serious illness without the means to pay for the care they need. I find your view of us as a carrier as simply “someone who keeps 20% of your premiums” without delivering any value to our members as highly inaccurate. First of all, we haven’t operated on 20 points of gross margin in YEARS. 15% is more accurate. Second only 7% of that money in an average year runs our business. The rest is consumed by ACA fees, taxes, and sales costs we pass through for businesses. 90% of our clients come from company groups.
      Worth mentioning also that Our predicative models alone and the clinical integration they spawn are providing enough intervention data to help 100’s avoid acute care hospital stays. That is certainly a positive influence on care in my book. I’m sorry you haven’t experienced this but we are always looking for new providers to join our Quality Blue program and partner with us to maximize the care our patients can receive.

      WE don’t turn a profit on data integration. We are a not for profit carrier. We have no shareholders. There are no out-of-state interests skimming money off the top in our plan. Our members money is invested in Louisiana healthcare. We owe allegiance to no one except the folks who have a BCBSLA card in their pocket. In fact, last year we lowered rates significantly because of a change in tax policy. You don’t see anyone in the medical space nowadays doing with 15% less than the year before, but that was us in the individual market 2019.

      I don’t recall saying a single time in my article that DPC’s don’t delivery quality care. I’m simply making the point that without the connectivity we can’t make ALL the data available to providers who depend on us to do so. Your focus on “insurance company profits” does not apply here. You do realize that our small Blue plan pays around $300m every month in care for the people of Louisiana who cannot afford to pay for care otherwise? It’s clear that serious illness care is a no-go in this day and age without a 3rd party payer. That’s us.

      I think if you take the time to read more of the 150+ Straight Talk articles on our website, you’ll find I’m not a “fear monger” nor an unreasonable man. But I try to give my honest opinion on things in healthcare without criticizing any single person. I trust that you will find this as you read through.

      Thanks again for your comments. I would leave you with this notion: Not all health insurance companies are the same. Likewise, I’m sure not all DPC practices are exactly the same either.

      Reply
        • Michael Bertaut

          KimDalton!
          Thanks for the article on one of the multi-state Blue Plan’s tax status. I’m not sure what that has to do with us here at BCBSLA, since we pay taxes every year and run our entire payroll on just 7% of all premiums coming in. It’s also worth remembering that health insurance companies are under a federal mandate to spend at least 85% of all the premiums paid in by their largest clients on nothing but healthcare. Not salaries, bonuses, new buildings, or anything you might consider “overhead”. That’s 85% on nothing but healthcare. And if we fail to hit that standard over three years, we must issue rebates to the people who paid those premiums in. And the rebating is going on all over the place.
          I’m proud to say our Blue Plan is run on such low overhead that we’ve never broached the standard or had to pay rebates. But that’s always been the case here, and our commitment to directly passing as much premium as possible directly through to healthcare is strong and growing.
          Thanks for playing!…mrb

          Reply
  3. Siobahn Hruby MD

    DPC and Concierge are not the same, please do not propagate the confusion there.

    Great insurance does not equal great healthcare. A system that rewards doctors for data entry, faster visits, and sicker patients, will always distract the physician from their primary goals and eventually lead to physician burnout. You could not offer me enough money to go back to Fee For Service, my soul is not for sale.

    You’re right about double paying for primary care, which is why I steer many patients towards Healthshare plans instead.

    Reply
    • Michael Bertaut

      Siobahn Hruby!!
      Thanks so much for your comments. You’d be interested to know that there ARE DPC practices in our state who bill us for their patient’s services as well as collecting subscription and membership fees. I suspect they are in the minority, but they do exist and we have experience with them. It seems the “bright line” between DPC and concierge medicine is not always as bright in every situation, but we do have the advantage of seeing a very big picture because we are responsible for funding healthcare for 1.1 million people day in and day out.

      I would also caution against promoting Healthcare Sharing Ministries to your patients without making it CLEAR they are not insurance and are regulated in most states by nobody. I’m not demeaning the product itself, just advocating full disclosure to your patients when you recommend them.

      And I am in total agreement with you that the insurance industry as a whole has done a lousy job of supporting Primary Care docs, which is why we started Quality Blue Primary Care in the first place, to give PCP’s a chance to make lots more money while doing what they’ve wanted to do all along, improve the health and lives of their patients.

      Great stuff! Thanks for playing!…mrb

      Reply
  4. New doctor and a patient:

    Why would you volunteer to write it, you know it’s all bs. The whole article is like a communist propaganda. The writer obviously works for the company and he can’t possibly say anything good about DPC or he’ll get fired. The whole reason the whole health care is in this mess, is because of insurance. As a first year grad doctor who took insurance, reimbursement is $42 to 62$ for visit, 25$ co payment with $2000 deductible that most patients have, yes try to bring that patient back every week (or 15 times, good luck) And if you are a patient, next time i am getting prior autorization for your blood pressure or diabetes med, I’ll make you get that autorization. In fact we all as doctors should stop doing PAs, let patients do it. Be on the phone for hours and let a person with accounting degree tell you why he thinks you need another med, because yes,
    insurance wants whats best for you and will deny med that i as a doctor know better for you, and that’s why your pressure is better. They’ll drop that insurance like hot potato. isurance pays nothing to doctor while taking all from patients, higher co pays every year, higher deductible. And to all readers, just to undermine the whole false facts, the writer doesn’t even know the difference between Direct primary care and consearge medicine, how could he even possibly say anything else factually correct. At least you could have Googled what DPC is and copy pasted, not just make up #falsenews. Have fun replying to my answer and configuration on your new black granite building and a new record high salary for CEO. # insurancedeception #morefalsenews

    Reply
    • Michael Bertaut

      Hello “New Doctor and a Patient”
      I enjoyed your comment on my article on Direct Primary Care very much! Oddly enough, I did lots of research on DPC for the article, even sitting through a presentation by one of the larger national DPC presenters, so I’m sorry if you think I got it wrong. Of course you are entitled to your opinion, but there are a few things in your post that I found troubling.

      First of all, none of the restrictions you imagine on my opinions exist. BCBSLA has been remarkably supportive our our Straight Talk efforts, even when it points out things that we don’t do well. You’ll notice in this article (if you read it, that is) that I pointed out clearly that one of the reasons DPC exists is because I think insurance companies have not supported primary care docs as they should all along. AND that Quality Blue Primary care is our reaction to that fact. The 800+ primary care docs in Louisiana who participate consistently rate the program very highly and all the while it MAINTAINS that critical continuity of data that allows us to keep more people out of acute care situations both inpatient and at the ED. I would encourage you to read some more of the 150+ blog posts online at http://www.straighttalkla.com and enjoy the depth of my disagreement with the insurance and medical establishment on many topics.

      AND I believe there are several references in my article about how DPC is really good for some docs. Did you miss that?

      I can’t speak for all carriers, but as a long term cancer patient and chronic disease patient myself, I’ve never experienced prior authorization for blood pressure, cholesterol, or my (pre) diabetes meds. In fact, BCBSLA now sends many patients their chronic care meds at no charge whatsoever automatically. So you lost me there.

      Also you can rest assured, if you are on the phone with BCBSLA talking about a medical authorization of any type, you are either speaking to an RN, Doctor, or Pharmacist. Over 200 of them work for us and they are VERY busy.

      I’m not sure where our “new black granite building” is or our “record salary for our ceo” is (both nonsense) but I do know not all insurance companies behave the same. I can only assure you that our Blue Plan runs on VERY low overhead (7% of all premiums pay everyone’s salaries) and that we are committed to making Louisiana healthier and we can’t do that without a healthy primary care population.

      Thanks for playing!….mrb

      Reply

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