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The Future Of Primary Care: HSAs, Catastrophic Coverage, And Direct Payment For The Basics

gordonmooreI’ve been following the career trajectory of Dr. Gordon Moore since I first became aware of his low-overhead, high-tech model of medical practice. He’s come a long way since the AAFP first interviewed him in 2002. I had the chance to catch up with him at the recent Health 2.0 conference in San Francisco, and we discussed the future of primary care and a practice model that I believe in (I just joined DocTalker Family Medicine myself!) Here’s our peek into our healthcare crystal ball…

Dr. Val: Tell me about what got you interested in creating a new practice model for primary care?

Moore: I came into healthcare with a somewhat Pollyannaish vision of reducing suffering and improving health. Without any docs in my family, I had no understanding of what it meant to actually practice. About 5 years after residency, I realized that there was an increasing disparity between my vision of practicing medicine and its reality. At that time I joined a quality improvement initiative at the University of Rochester, and we looked at increasing efficiency in primary care, including creating the idealized design of clinical office practices.

These designs keyed off on the concepts of open access, health IT and the use of technology as a means to track chronic disease. I built on these ideals and created a no-staff, high technology-enabled practice that reduced the pace of care and its overhead.

Dr. Val: What was your practice like for patients?

Moore:  I worked all alone and had one room that I rented from an ophthalmology practice. The first day I had 6 patients and the phone rang in the middle of my doing a physical exam. I suddenly realized that I had one line and no answering machine, so I had to run out to Radio Shack in between patients to get one. I had all sorts of issues like that one in the first year – trying to figure out the details of my work flow. I had to give out my home and cell phone numbers to all my patients because I had no one else to answer phones.

I had no business model associated with the extra work I did on the phones – it came out of the lower overhead associated with being my own administrator. It was strange working alone at first – I had to wear all the hats, take out the trash, and do my own billing. There was a real documentation learning curve.

I realized that the machinations of office practice seem daunting because they’re obscure, but when we unmask them, it’s not that hard. We’ve learned how the endocrine system works, we can learn how to do billing. It’s a pain, I don’t like to do it, but it can be done… though the paperwork burden seems to be getting worse and worse.

Dr. Val: What do you think of practices who simply stop taking insurance so they can avoid all that paperwork?

Moore: It’s breathtaking. At first I was uncomfortable with the idea because I thought it would create a two-tiered healthcare system. However, when you think about it – we already have a two-tiered system now: those who can afford healthcare and those who can’t. Insurance-free practices cut out the “mother-may-I?” scenarios that keep doctors from doing what’s right for their patients.

In most places, insurance reimbursement is so low, and the administrative burden of accepting insurance is so high that it’s not feasible to practice medicine without some additional subsidy. And that subsidy comes in the form of a hospital center loss-leader for admissions, or a community health center supported by the federal government, or by charging patients cash for certain services or extra access.

Qliance and Hello Health (who are in the direct practice model) have achieved breathtaking simplicity. I love how they have been able to take their price point down to a place where average working folks can afford it. We need that level of simplicity in primary care in the US.

Dr. Val: What’s the major barrier to having more practices adopt this “breathtaking simplicity” model?

Moore: Fear of the unknown. A lot of docs I talk to yearn for simplicity but don’t have the confidence that they’ll be able to generate the patient volume to keep their practice afloat. They don’t know how to do it. I’ve joined Hello Health University to help physicians learn how to shed those burdensome legacy systems for their work flow.

The other barrier is that more employers need to recognize the incredible cost savings of buying a high deductible, direct primary care payment model, bundled in with a catastrophic plan. It’s cheaper, the care is phenomenal, and patients love it.

Dr. Val: What will the insurance companies do if high deductible plans and HSAs really start to take off?

Moore: The smart ones will get into the market early and vigorously and try to snap a bunch of it up. Others may try to dig their heels in and wait, but market forces will reward those who get in early. Insurance companies will have to figure out how to make do on what will be small margins on a contract basis, but will be a significant book of business if they get in early.

Dr. Val: Do you think healthcare reform will influence this potential new model of primary care in one way or the other?

Moore:  I’m not sure how things will pan out. But we seem to be pushing towards the idea that “everyone needs a ticket to ride.” Of course, full service health insurance is too expensive for everyone to buy, so a good solution may be to make sure everyone has a high deductible/catastrophic coverage plan, and uses a direct care model for their primary care.

That would create broader access to healthcare, happier physicians, and decompress the system. When practices can have direct relationships with patients (and stay in frequent contact by phone, email, house call, or office visit), the outcomes are vastly superior. It gives physicians the time they need to look research options, engage in care coordination, and help people make those lifestyle changes that affect their chronic diseases.

It’s better care that costs less.

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