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The “I Get It” Moment In Direct-Pay Primary Care

After seven years, my wife has finally stopped asking me for “The Power of DocTalker” story of the day. Now when I start with the details of the latest case report justifying the model, she stops me with “I get it, I get it! Go write the case report up and post it on your website for others to ‘get it,’ too.”

Case reports center on the mission of our medical practice, with points regarding care that include quality, accessibility, convenience, affordability, empowerment, trust, and price transparency. Because our patients pay us directly for the service and don’t necessarily expect any insurance “reimbursement,” we are a very unique practice. We adhere to the points in our mission and also outperform all our local competition — i.e. medical offices that accept insurance payment for service in order to survive as a business.

To the patient, our services cost a lot less than services available via the insurance model. About 40 percent of our clientele have no insurance, and the other 60 percent have insurance yet chose to use our services because they believe it’s worth paying directly in order to assume control of their care. (As a quick aside — my favorite clients in this group are health insurance executives and CEOs of large companies, who have the best health insurance in the country.)

However, our practice offers a degree of access and control over their day-to-day health care decisions that they can’t otherwise find, and therefore paying $50 for a phone call consult or arranging a 15-minute office visit for 8:00PM (time-based billing means it will cost $75) is worth it. This group feels that they don’t have time to play games with doctors or their health.

Back to the case report: It’s Saturday, noontime. I’m at my computer catching up on a back log of notes. Our patient volume is low and I’ve only fielded my third caller of the day, and already I’ve found my “Power of DocTalker” case report.

The patient, Mr. G, is a 65-year-old man who is on vacation. He’s been using our practice since its inception in 2002. He transferred with me from my former medical practice, one of the first to make the early transition with many more following — 3,800 registered patients to date — as more “got-it.”

When he calls me, Mr G. is New York driving on the interstate. He reports that he’s had increasing left lower quadrant pain for the past 24 hours. “It feels like appendicitis,” he offers without my prompting. “It hurts when I push down.” The pain does not radiate and has stayed localized. “It’s just been getting progressively worse.” There’s no fever, no major change in appetite.

“Are you constipated?” I ask.

“Now that you mention it, a little.”

“When was your last colonoscopy?” I ask as I pull up his medical record on the computer screen from my home office.

“A year or two ago, and everything was okay.”

“I’m reviewing at the report right now,” I interrupt him. “It was done in 2008 and it showed diverticulosis.”

“That’s right.” he responds. “I remember that being mentioned.”

“Your story is a really good fit for diverticulitis — it’s consistent with the symptoms you are talking about now.”

“The pain isn’t that bad — I’m driving back to Virginia and I could meet you in the office on Monday.”

“No,” I answer. “That would not be a good decision. The treatment of choice is to start antibiotics — speedy treatment is important. If you don’t know a local pharmacy nearby, I could help you pinpoint one in a minute or two if you’d like?” He pulled off at the closest exit and found the nearest Rite Aid pharmacy.

Within twenty minutes I called and speak directly to the pharmacist. I start Mr.G on Cirpro and Metronidazole. Fortunately, he’s not allergic to either.

Although Mr. G knows he can call me 24/7 no matter what state he’s in, I called him 24 hours later to check in on him, and was glad to hear that he was improving. Mr. G then told me, “You really should write this story up so that people can better understand what you do. I don’t think many people really ‘get it.’”

Sadly, I agree, Americans are slow to “get it.” They remain trapped in a $1,000-a-month insurance model for a $20 co-pay that offers extensive delays and poor service for 80 percent of the problems. In reality, these problems typically should cost between $50 to $75 per issue and the total price for routine primary care issues for 75 percent of Americans being $300 per year. This means that affordable medical help is just a phone call away — even on the interstate.

Until next week, I remain yours in primary care,

Alan Dappen, M.D.

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