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.