Pay as you go – Fort Worth Business Press

Physicians develop new payment models as changes occur

by Elizabeth Bassett

Source: Fort Worth Business Press 

The traditional model for health care used to be that patients would pay physicians directly for services given. With the advent of the health insurance industry, though, the traditional model is now for other entities-insurance companies or the government-to pay physicians for services on behalf of patients.

A small number of primary care doctors are turning away from the norm, though, in an effort to cut down on large patient loads and up the financial benefits of providing routine health care. Private physicians, concierge physicians, fee-for-service doctors: Whatever the name, some are adamant that they are a solution to the nation's primary care and preventative health care crisis.

It's a common complaint that primary care physicians-be they general practice, internists or family medicine specialists-don't get reimbursed adequately for the medical care they provide. The lack of adequate reimbursements, plus the daunting student debt young physicians take on, means fewer are choosing to go into primary care, instead going to higher-paid specialties.

With health care reform promising to open access and with the baby boomer generation getting older, the nation is in dire need of more primary care physicians. However, many primary care doctors are switching specialties or retiring because it's not financially lucrative to provide quality care-there's no extra reimbursement for good quality care, said Fort Worth physician Dr. James Bohnsack.

Bohnsack practiced in the traditional model for many years, handling close to 5,000 patients (several thousand is not unusual). About a year and a half ago, though, he said he got fed up with making so little money and not being able to offer the quality care he felt his patients needed.

At one point he had practiced with Dr. Chris Ewin, and he contacted Ewin to help him switch his solo practice into a fee-for-care business model, which Ewin himself has. Ewin's practice, 121MD, is a retainer model, and patients pay him a monthly fee (based on age) to have unlimited access to him. Ewin, who also has a consulting firm he uses to usher physicians through the business transition, worked with Bohnsack (now Ewin's partner) to make the switch.

"I was intimidated about taking 5,000 patients and making it 500 patients," Bohnsack said. " . . .The main thing for me was the quality, how much I could do with the patient."

Private physicians-there are estimated to be about 2,000 nationwide, represented by the American Academy of Private Physicians-argue that they give better health care to patients because they aren't limited by insurance companies and that a patient's money is better spent directly on a doctor rather than on a middleman.

Others would argue that limiting a primary care physician to only 500 or 600 patients isn't a way to deal with the glut of patients who need physicians.

Ewin, past president of the organization that is now the AAPP, said primary care physicians who switch to a private model can make as much or more than more highly-reimbursed specialist physicians, like neurosurgeons. He envisions a world where primary care physicians have a two-phase career: When they're fresh off their residencies, they join traditional practices with more experienced physicians, all working together to care for thousands of patients. The experienced physicians, after maybe a decade or so of practicing and earning the trust of patients, then transition out of the practice, taking a small number of patients with them and moving into a financially lucrative phase of their career.

It would be impossible for a new physician to build a successful private model practice without patients who trust him or her, Ewin said, but older physicians who are thinking of leaving medicine or suffering from burnout should be willing to make a change and at least still treat some patients.

"Doctors are afraid to change because they're making an income, they have kids in college," Ewin said.

Devon Herrick, a health economist and senior fellow with the National Center for Policy Analysis in Dallas, has written a brief on concierge physicians and said there's actually a wide variety of various medical practice designs that are focused on cutting out insurance companies or making health care easier for patients.

"I'm seeing a variety of different practice styles," he said. " . . . At the really high end, you're talking about services that you pay $10,000 and they don't even practice medicine, they just manage your health care. . . . We're also seeing some innovative ideas at the lower end of the spectrum."

In the brief, he pointed to a physician who targeted small employers, who were less likely to offer health insurance to employees. Employers would pay $40 a month for each employee, who would then receive primary care. Even though the employees pay out of pocket for diagnostic tests or specialist care, they get discounts negotiated by the physician.

While health care reform will make the need for primary care physicians more acute, Ewin said, there wouldn't need to be any policy shifts to encourage more private physicians. Instead, grassroots education and a mind shift among physicians is what's needed. He admits that a private physician does have to be a salesperson, working to convince patients to join his or her practice.

In terms of policy or law, though, what is needed is for the definitions of health care to be opened up more. For example, pre-paid physician services, like Ewin's, are are currently not included in the acceptable expenditures for health savings accounts.

Bohnsack said he is glad he transitioned out of his traditional practice, saying his new practice gives him more time to work on preventative care and managing a patient's health, instead of waiting on a patient to become ill to come in to see him (and for him to be paid). The various practice designs physicians are experimenting with are an indicator that quality care is something doctors still want to provide.

"When you're in the other mode of practice, you'd like to do it, it's the right thing to do, but you just don't have the time and there's no incentive," he said.


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