More Patients Turning to ‘Direct Primary Care

Having quick access to a primary care doctor 24/7 is very appealing to Mick Lowderman, 56, who is married with two children, ages 10 and 8. He pays a monthly membership fee to AtlasMD, a direct primary care practice in Wichita, KS.
Primary care is built on the long-term relationship between clinicians and patients. A 10- to 15-minute patient visit doesn’t support that relationship, Sullivan says.
When Kevin Boyd, 64, fell on his stairs in Wichita and broke three ribs, he didn’t go the emergency room. Instead, he called Umbehr, who told him to come to his office. He referred Boyd nearby for an X-ray and dispensed pain medications at his office. The total cost was $70.
In contrast, the first time Boyd fell and broke his ribs, he had Blue Cross Blue Shield and drove himself to the ER, where he saw the ER doctor, a radiologist for an MRI, and got shots for his pain. The total bill was $14,000, and he paid $2,600.

“I don’t put off care the way I used to because of the money I save,” says Boyd, who joined AtlasMD in 2015.
For his monthly membership fee of $75, Boyd gets several benefits, including unlimited 24/7 access to Umbehr by text, email, or phone, extended same- or next-day office visits, and free diagnostic tests and office procedures, such as EKGs, DEXA scans, and body fat analysis. If Boyd gets really sick and needs a house call, or if he needs a phone consult when traveling, those are also included in the fee.
“It’s awesome that I can call or text Dr. Josh Umbehr when my children are sick and that I have a solution before they leave for school,” he says.
For example, when one child woke up coughing recently, Mick and his wife, Jennifer, contacted ‘Dr. Josh,’ who asked them to put her on the phone to hear her cough and then take a picture of her throat and text it to him.
“He prescribed an antibiotic, which we picked up at his office the same day.”
Umbehr is part of a growing movement of primary care doctors, including those in family, internal, and geriatric medicine, who want to practice more personalized comprehensive medicine without the burden of dealing with insurance in a traditional fee-for-service system. Most choose to not accept health insurance and charge patients a membership fee instead.
“When you look at direct primary care and other models that are cropping up, it points to our broken system that doctors don’t want to practice in and are looking for alternate solutions ― and so are patients,” says Erin Sullivan, PhD, research and curriculum director at the Center for Primary Care at Harvard Medical School.
Umbehr is in Kansas, one of 44 states that allow doctors to directly dispense medications with the exception of controlled substances. Boyd pays $2 and $3 for typically a 3-month supply of common generic medications that he can pick up at AtlasMD or have mailed to him.
Another way Umbehr saves patients money is through contracting with specialists who agree to give his patients discounted rates. For example, when Umbehr sent Boyd for an ultrasound of a possible blood clot in his leg, he was billed $120.
The popularity of these alternative models is growing. DPC Frontier, which tracks the number of direct primary care practices nationally, estimates there are 1,219 practices in 48 states and Washington, D.C. They range in size from solo practitioners to corporate, multisite direct primary care organizations with thousands of doctors, Sullivan says.
The American Academy of Family Physicians supports the direct primary care model “as a potentially powerful disruptor in the health care payment environment that has traditionally undervalued family medicine and comprehensive care,” the group says on its website.

But there are drawbacks and concerns to be aware of. For one, the monthly fee is in addition to any insurance for major medical problems. While many doctors and patients claim the direct care model results in better health outcomes, there are no studies proving that, according to an editorial in The Journal of the American Medical Association. Because it is a retainer operation, too, the model encourages doctors to target healthier patients, while others charge more for patients who have more needs.

As a premed student, I spent time in a brilliant surgeon’s practice who never figured out the business side of fee-for-service insurance with all the billing and coding. That was a peek into a bad business model. Josh Umbehr, MD, CEO of AtlasMD in Wichita, KS

The American College of Physicians, too, warned in its policy paper on the practice that the direct care model can “potentially exacerbate racial, ethnic and socioeconomic disparities in health care and impose too high a cost burden on some lower-income patients.”
Umbehr chose to establish a direct primary care practice right out of residency. “As a premed student, I spent time in a brilliant surgeon’s practice who never figured out the business side of fee-for-service insurance with all the billing and coding. That was a peek into a bad business model.”

While the membership payment model in concierge medicine appealed to him, “we wanted an affordable version for the masses.” Concierge primary care practices offer similar outpatient services and amenities to members but typically charge higher membership fees, and many also bill insurers.
Direct primary care practices charge an average monthly fee of $78, while concierge practices charge an average monthly fee of $183.00. Umbehr also saves money on overhead with no front office or administrative staff and one registered nurse for each of AtlasMD’s five doctors. “There’s a good chance one of us will answer the phone,” he says
Umbehr limits his patient volume to 700, compared to a typical “in-network” primary care doctor who sees 2,500-3,000 patients total. This allows him to see five to six patients a day instead of 20 or more seen in a typical primary care office.

Lowderman and Boyd say that Umbehr can take care of most of their health care needs, including minor office procedures that don’t require anesthesia or sedation. If needed, they will pay cash for a specialist or use their major-medical insurance plan if something more serious happens. Major-medical plans, sometimes also called catastrophic insurance, will cover things like trauma care, emergency surgeries, and more. They feature low monthly premiums and high deductibles.
Lowderman, who has 12 employees in his pest control business, pays AtlasMD $50 per employee monthly to provide primary care services to them. Because he also gets customized major medical insurance through AtlasMD, he pays a total of $375.00 monthly per employee. Traditional employer insurance would have been double or triple the cost, he says.

Managing Care

When Umbehr started his practice a decade ago, Mike Scheidt and his wife, Jolene, (now deceased) were among his first patients. “I don’t know if I would have joined if my wife had not been so sick with cancer and he could streamline perfunctory things,” Scheidt says.
For example, Jolene had frequent urinary tract infections. “Before Dr. Umbehr, we would call her internist and he would tell us to come down to the clinic to do the lab work. My wife had one leg and a half amputated due to infection. I was an executive with Raytheon at the time and would have to take time off from work, hire a home health nurse to collect the urine specimen and drop it off, wait 3 days to get the lab results, and then go to Walgreens to pick up Bactrim, which always worked.”

When Umbehr became their primary care doctor, Jolene would call him up and mention a UTI, and he would start her on Bactrim, which he often dropped off at their house on his way home. Then, a lab technician or home health nurse the Scheidts hired would collect the urine specimen for analysis to confirm the diagnosis.
“She didn’t need to leave the house! I finally felt like she was being treated like a head of state. My wife told me many times that dealing with such serious matters wasn’t as scary with Dr. Umbehr shepherding her through difficult medical situations,” Scheidt says. “That alone was worth a pot of gold to her, and certainly to me as well.”

Leaving Traditional Insurance

Jeffrey S. Gold, MD, opened Gold Direct Care in 2015 in Marblehead, MA, after being employed as a family medicine doctor by North Shore Medical Center in Boston for 7 years. “It was a typical insurance-based practice where I was seeing 20 to 22 patients a day. I wanted to practice medicine and not insurance paperwork, billing, and coding.”

Gold was feeling burned out at age 36. “I was thinking of either quitting medicine completely or teaching at a local medical school. I saw no sustainability in seeing people in 10-minute increments daily for the rest of my career.”
Two years later, he left North Shore.
He read about Umbehr’s practice online and then visited him in Wichita to see it firsthand and decided to adopt a similar model. However, “there are differences between Wichita and Boston ― this area is heavy with big hospital systems that are insurance-based. Employers equate insurance with care, and trying to educate them about the value of this different primary care model is challenging.” [MORE}
https://www.medscape.com/viewarticle/925053#vp_1