Healthcare Consumerism and the Move Toward Wellness

A Four-Part Series by Will Stabler

About This Series

I wrote this article series 2019 as consumerism was presumably taking hold in the healthcare industry. The series examines several potential models for a consumer-centric healthcare system.

Articles in This Series

Introduces the series and challenges assertions about consumerism in health care wile exploring what consumers want from the healthcare system and their personal health care.
 
Consumer Centric System #1: Empowering Consumers and Providers With Direct Primary Care
Explores one hypothetical model of what a true consumer-driven healthcare ecosystem might look like by putting the power into the hands of the players that have the least power in our current healthcare system—the patient and the provider.
 
This article asks the question: Can a healthcare system similar to the one we have now progress into giving consumers everything they want, while still staying financially viable?This model is a multiple-payer system in which we keep private health insurers and employers working together in the driver’s seat.
 
For this article our hypothetical model will be a national, single-payer health plan. Instead of directly looking at an existing model from another country, we will detail two proposals that are currently in the hopper here in the United States and how their particulars relate to consumers. 

Consumer-Centric System #1: Empowering Consumers and Providers With Direct Primary Care

By Will Stabler

First published on Jan 21, 2019

In the first article in this series, we looked at how we got to where we are currently at on the road to consumer-driven healthcare and what models of care are out there. In this article we will explore one hypothetical model of what a true consumer-driven healthcare ecosystem might look like by putting the power into the hands of the players that have the least power in our current healthcare system—the patient and the provider.

Healthcare Ecosystem #1: Direct Primary Care

Whatever names direct primary care (DPC) goes by, the model we are addressing is best defined as retainer-based healthcare services, an alternative to our currently prevalent fee-for-service and insurance-based models. In a DPC model, consumers pay a monthly, quarterly or annual fee to a provider or provider organization for primary and preventive care that includes routine office visits and services in the office, as well as lab work and sometimes diagnostics (such as x-rays). It generally does not cover specialists, multi-course treatments, hospitalization, surgery, prescription medication or emergency services.

So, let’s get our terminology straight, because there is some confusion over what people mean when they are referring to DPC. We are not addressing out-of-pocket care, or paying on a given day at the point of care for the services you receive, which is basically fee-for-service without insurance (although we will cover this in a later article). We will use the term direct primary care. The term “concierge care” is still used interchangeably for DPC, but the term generally has gained a negative connotation in this context—describing providers and provider organizations that are prohibitively expensive for most people.

The retainer provides the primary funding for the provider, and insurance is not usually accepted. DPC retainers are not legally considered health insurance by state and federal statutes. This includes the Affordable Care Act, so in order to meet the ACA’s individual mandate, DPC patients must also carry catastrophic or other low-cost health insurance plans that cover the more expensive medical services mentioned earlier that DPC does not cover.

We are not addressing out-of-pocket care, or paying on a given day at the point of care for the services you receive, which is basically fee-for-service without insurance (although we will cover this in a later article). We will use the term direct primary care. The term “concierge care” is still used interchangeably for DPC, but the term generally has gained a negative connotation in this context—describing providers and provider organizations that are prohibitively expensive for most people.

DPC is not a theoretical model for consumer-driven healthcare; it is in active use today. The Direct Primary Care Journal in 2017 estimated that there are from 500 to 600 DPC practices in the United States, and similarly in 2017, DPC expert Philip Eskew estimated the number to be 620 (Carlasare, 2018). The Direct Primary Care Coalition, a membership association that advocates for DPC policy positions, estimates that there are currently about 700 DPC practices in 48 states providing care to 250,000 American patients (https://www.dpcare.org).

Evaluating the direct Primary Care Model

For the purposes of evaluating DPC as a hypothetical consumer-centric healthcare system model, we are using the strict criteria that recognized DPC expert Philip M. Eskew, DO, JD, MBA, uses to allow a DPC organization to be included in his studies on DPC practice distribution and cost. The criteria are derived from “a comprehensive legal interpretation of 14 state laws passed to clarify DPC ‘business insurance’ regulatory questions and language from the Affordable Care Act describing mechanisms for DPC practices to participate in the insurance exchanges with ‘wraparound’ insurance products” (Eskew & Klink, 2015).

Eskew’s criteria define a DPC organization as one that:

  1. charges a periodic fee for services
  2. does not bill any third parties on a fee-for-service basis, and
  3. any per-visit charges are less than the monthly equivalent of the periodic fee

While there are some DPC providers who accept Medicare, Medicare Advantage and other insurance to a limited extent, our hypothetical model will be based on the above criteria.

Typical Costs of Direct Primary Care

Eskew’s frequently cited study, “Primary Care: Practice Distribution and Cost Across the Nation” identified 141 practices with 273 locations across 39 states. Of those, the study was able to find online pricing for 116 of the practices, and found that the average monthly cost of $93.26 (with a range from $26.67 to $562.50 per month). Of those that charged a one-time enrollment fee in addition to the monthly fee, the average for that fee was $78.39. About a quarter of DPCs charge a per-visit fee in addition to the retainer, which averaged $15.59. The “concierge” connotation we mentioned before might be well-deserved, since this study also found that practices that described themselves as “concierge” providers charged an average of $182.76, compared with an average of $77.36 for those who described themselves as “direct primary care” providers. (Eskew & Klink, 2015).

Overall, DPC arrangements, even when combined with high-deductible, catastrophic, or otherwise low-cost health plans, can be much more affordable than premium health plans, especially for healthier adults, or those not yet eligible for Medicare.

Looking at the Pros and Cons

For a consumer-centric healthcare model to work, the consumer cannot be the only one who is satisfied with the arrangement. In the DPC model, the healthcare provider also needs to be satisfied or it all falls apart. So, it is instructive to look at levels of physician satisfaction within the system that prevails today as a basis against which to compare the changes that would accompany a DPC model. A recent national survey of 8,774 physicians has found that many are unhappy, burned out and do not have the time for the most important part of their jobs—their patients. Many of them are so discouraged they are talking about quitting clinical work. The survey, titled, “2018 Survey of America’s Physicians: Practice Patterns and Perspectives” was conducted on behalf of The Physicians Foundation (Merrit Hawkins, 2018). Among its findings were:

  • 55 percent of physicians rate their morale as somewhat or very negative.
  • 78 percent of them sometimes, often or always experience feelings of burnout.
  • 80 percent of physicians say they are at full capacity or are overextended.
  • 46 percent plan to change career paths.
  • Physicians spend 23 percent of their time on non-clinical paperwork.
  • 79 percent of physicians indicate patient relationships are their greatest source of professional satisfaction.

There are elements of the DPC model that can help turn some of this around. In a DPC environment, doctors stop working for insurance companies and are free to focus on patients. They start working directly for patients as customers. Providers are not spending large amounts of their time on insurance compliance and billing, and submitting data to government programs. This not only cuts own on time spent away from patients, but it cuts down on overhead and some of the main sources of burnout as well.

For a consumer-centric healthcare model to work, the consumer cannot be the only one who is satisfied with the arrangement. In the DPC model, the healthcare provider also needs to be satisfied or it all falls apart.

In the Merritt Hawkins study cited above, 14.1% of physicians indicated they were practicing some form of DPC. The study authors pointed out the following benefits:

“By reducing or eliminating third party payers, private practice owners can limit overhead in their practices, no longer requiring large staffs to process third party payments. They also can regain clinical autonomy while spending more time per patient. Concierge/direct pay represents a path by which practice owners can remain independent and enjoy the rewards of the physician/patient relationship” (Merrit Hawkins, 2018).

So, the DPC model could provide one enormous benefit to the healthcare ecosystem and the move toward consumerism: better care arising from greater physician/patient contact and higher physician satisfaction. Providers can spend more time with patients listening, teaching, planning with the patient, and solving problems, which is especially valuable in preventive, wellness-oriented care, and care for patients with chronic conditions. This attentiveness can help with continuity of care. Studies show, for example, that when people with chronic conditions have a dedicated PCP, they are better able to manage their chronic conditions.

On the downside, arguments have been voiced that a burgeoning DPC model will contribute to the looming physician shortage in part because DPC practices tend to maintain lower patient counts. The authors of the Merritt Hawkins study noted this: “Physicians transitioning from traditional private practice to concierge/direct pay medicine usually maintain only about 25 percent of their patients. The migration of physicians to concierge/direct pay in these numbers would remove approximately 9,000 physicians from the workforce” (Merrit Hawkins, 2018).

This would only add to the projected shortage of between 42,600 and 121,300 physicians by the end of the next decade (HIS Markit Ltd, 2018). Proponents of DPC argue that some of the shortfall potentially caused by DPC would be offset by the use of other certified healthcare providers in the DPC model, such as physician assistants and advanced practice registered nurses, but the precise impact on the already worrisome shortage has not been adequately studied.

 

Uh-Oh. Where Does the Data Go?

One additional downside of the DPC model is that it results in little change in the current dispersal of health care data across a host of different unrelated (and potentially protective) provider sources. In fact, the portability of healthcare information and any progress we have made in electronic health record (EHR) interoperability may suffer in the direct care model. As someone who works in the health insurance industry and has advocated for EHR interoperability, I know that health insurers and the government are the engines pulling the industry toward interoperability. With them largely out of the picture in a hypothetically pure DPC system, interoperability could become a problem.

In a recent study of 15,000 physicians titled, “Medscape National Physician Burnout, Depression & Suicide Report 2019,” physicians were asked what the greatest sources of burnout are for them (Medscape, 2019). The following were the top three:

  • Too many bureaucratic tasks (e.g., charting/paperwork) (59 percent)
  • Spending too many hours at work (34 percent)
  • Increasing computerization of practice/EHRs (32 percent)

With EHRs and other documentation such a significant source of physician dissatisfaction, who in a DPC model would force physicians to use them?

Let’s pause a minute here to ensure we remain focused on the consumer. They are the point of all this. If this were truly a consumer-driven world of health care focused on wellness, people would expect to have complete access to all of their medical records. Not just static copies, but real, interactive versions. Everyone would have access on their phones to their complete medical records and medical knowledge that affects them.

Now, this requirement—this foundational shift—is not unique to the DPC model; it is in fact common across all consumer-focused models. But, this being the first model that we explore in detail, we will need to look at it as a basis for understanding a pre-requisite to success in any of the new models.

In a consumer-centric system, if I were on the road 2,000 miles away from home (as I often am) and needed treatment for something, or even preventive care, I would expect to be able to beam all of my medical records to whoever is providing care to me in that place, wherever it is. Then, when I beam it there, it should be able to “talk” to the medical records system on the other end, whatever it is. I would also expect appropriate data from my wearables and other health and fitness apps to be part of my medical record.

I can’t do any of that at the moment. For any hypothetical consumer-focused model of healthcare to succeed, including DPC, we need much improved use of patient data than we see in practice today.

As someone who works in the health insurance industry and has advocated for EHR interoperability, I know that health insurers and the government are the engines pulling the industry toward interoperability. With them largely out of the picture in a hypothetically pure DPC system, interoperability could become a problem.

In a report released in March 2017 and conducted for NEJM Catalyst, titled, “Care Redesign Survey: What Data Can Really Do for Health Care,” of nearly 700 healthcare executives, clinical leaders and clinicians, 72 percent listed lack of interoperability in healthcare information technology as the number one “biggest barrier” to better use of patient data. (Compton-Phillips, 2017)

In a recent study on innovation in health IT, researchers asked respondents to name the top areas in which innovation is needed most. Figure 1 below shows the top five areas for respondents, with health information exchange/interoperability topping the list. It is interesting to note that all of the rest of the top five are some of the most important issues that relate to consumer-driven healthcare.

Figure 1: Where is technology innovation needed most in healthcare?

Source: Technology Innovation in Healthcare Survey, HIMSS Media, August 2018

The reason why interoperability is so critical to creating a true consumer-driven healthcare ecosystem is because of the place where it can take us. In 2017, I published a series of articles titled, “The Long Road to Interoperability in Healthcare Information,” in which I wrote what that destination looks like: “The long road to interoperability eventually leads to a place where patients and providers are enabled to work as a team toward preventive medicine, wellness, and value-based care.” That is what a consumer-centric ecosystem looks like.

A little farther along in that same series I explain how getting to that destination provides benefits for all of the major stakeholders in the healthcare ecosystem—consumers, providers, health plans and the government:

“Interoperability is a place where patients have access to their full medical records and are working in decision-making partnerships with their healthcare providers. In this place, healthcare IT is seen as a tool for streamlining operations, creating practice efficiencies, reducing costs, and increasing face time between patients and their care providers, rather than being viewed as a hindrance.”

With health plans and some layers of government regulation out of the picture, and providers left with much less incentive (or pressure) to provide portable, interactive EHRs, consumers will have to be the ones to drive this forward, even though many DPC providers may resist it.

Because realizing all of these benefits and having true consumerism in healthcare will mean giving all patients access to working versions of their full medical records, patients should be insisting on it, and they should bring that pressure with their pocketbooks, as good consumers are supposed to do. In the current environment all consumers know is that they want this access—they do not care about the details of why it is not happening rapidly. It is not their problem.

CareMore Health System President/CEO Sachin H. Jain recently stated: “When we stop seeing ‘medical records’ as a competitive asset, we will have health information exchange. Health information exchange is a business and political problem, not a technical one. We put a man on the Moon in 1969. Surely, we could exchange health information in 2018 if we wanted to.”

He is right. Despite all of the hype surrounding the emergence of the consumer in the healthcare ecosystem, there will not be a true consumer disruption until we have meaningful health information exchange, and those things will not come to fruition until we manage to solve for interoperability. So, consumers must insist on this.

Summary

I want to reiterate some of the pros and cons of DPC for consumers and providers in order to summarize.

The following are some of the pros of DPC:

  • Providers spend more time with patients during visits, which can result in better shared decision making and better patient outcomes.
  • Healthcare providers become more accessible to patients, meaning patients have shorter wait times, not only during visits, but also in getting appointments and receiving results back on critical laboratory tests.
  • Out-of-pocket expenses may be lower.
  • Patients have increased communication with physicians via phone, email and text.

The following are some of the cons of DPC:

  • Providers may not make as much money as they do in the fee-for-service world at startup and it may take a significant amount of time before the direct-care model becomes profitable.
  • Single providers can become isolated from the rest of the medical world if they are not in a group.
  • Providers see less patients.
  • Less providers are available for the entire patient population.
  • Lack of individual consumer and population data.
  • Patients still must carry insurance for prescriptions, consultation with specialists, hospital services, and other non-routine medical care, requiring an additional monthly payment for healthcare coverage.

To recap, the role and stature of the health insurance industry would likely be significantly diminished in a pure form of this model, as would the role of government. The consumer’s preventive care and wellness needs might be better met, but the future of EHR interoperability—something that I personally always saw as essential to the industry’s future—might be threatened.

Health insurers are definitely not happy campers in this model for obvious reasons, since a main driver of DPC is cutting out the middleman, although it is difficult to see a scenario in which the health insurance industry does not have a role, given what is left uncovered in this model. However, the health insurer’s role, and the health insurance industry as a whole, would be significantly diminished if DPC were widespread.

Government regulators to some degree might not be happy either, because their oversight of quality metrics in medical care would be diminished. This creates the possibility that this currently small segment of the provider industry might come under greater regulatory control than it currently experiences if DPC was a major player, taking away one of its major selling points for providers.

An increasing number of employers are eyeing this model for their employees in order to save costs, part of which comes by cutting out the middleman. CHI Health, the Catholic Health Initiatives (CHI) division for Nebraska and southwest Iowa has made a move into this space. In 2017 CHI, launched a DPC clinic in Omaha with one salaried doctor and one advanced practice registered nurse. This DPC clinic primarily provides care for the health system’s employees—offered as an alternative to its employee PPO offering. During the first quarter of 2018, more than 1,100 of CHI’s 20,000 employees opted into the DPC offering. Early results show that in the first quarter, facility and specialist claims were cut about 20 percent from $488 to $387 per member per month, and outperformed other primary care settings in patient satisfaction (Porter, 2018).

The above example shows not only an employer seeing the advantages of DPC, but also a health system recognizing and seizing the opportunities in such a model. There is a trend toward hospitals decentralizing care, opening satellite facilities, paring down the acute care apparatus, and engaging in remote monitoring and telehealth (Wiler & Harish, 2018). If these trends continue, DPC could also become part of the evolution of hospitals and health systems.

Many aspects of DPC are consumer-centric, but it also brings many benefits for providers, and provides possible opportunities for employers, and health system providers. So, there is quite a bit of promise in DPC, but it can also come with much pain.

In the next article in this series, I will put employers and health insurers back in the driver’s seat to see how they can possibly be partners in a hypothetical consumer-centric model.

References

Carlasare, L. E. (2018) Defining the place of direct primary care in a value-based system. WMJ, 117(3), 106-110. Retrieved from https://www.ncbi.nlm.nih.gov/m/pubmed/30193018/.

Eskew, P.M. & Klink, K. (2015). Direct primary care: Practice distribution and cost across the nation. J Am Board Fam Med, 20(12), 1079-1083. doi10.3122jabfm.2016.06.140337.

IHS Markit Ltd. (2018). The complexities of physician supply and demand: Projections from 2016 to 2030. Prepared for the Association of American Medical Colleges. Retrieved from: https://aamc-black.global.ssl.fastly.net/production/media/filer_public/85/d7/85d7b689-f417-4ef0-97fb-ecc129836829/aamc_2018_workforce_projections_update_april_11_2018.pdf

Medscape. (2019). Medscape national physician burnout, depression & suicide report. Retrieved from: https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056

Merritt Hawkins. (2018). 2018 survey of America’s physicians: Practice patterns and perspectives. Commissioned by the Physicians Foundation. Retrieved from: https://physiciansfoundation.org/wp-content/uploads/2018/01/Biennial_Physician_Survey_2016.pdf

Porter, S. (2018) Direct primary care: A segue to direct-to-employer? Health Leaders. Retrieved from: https://www.healthleadersmedia.com/strategy/direct-primary-care-segue-direct-employer

Wiler, J.L., & Harish. N.R. (2017, December 20) Do hospitals still make sense? The case for decentralization of health care. NEJM Catalyst. Retrieved at https://catalyst.nejm.org/hospitals-case-decentralization-health-care/