Doctors make more time for fewer patients in direct-pay services

Dr. Lance Hamilton oversaw thousands of patients working as an internist with a hospital, clocking in 16-hour days but having only a few minutes for each patient because of paperwork and other demands. He felt more like a scribe than a doctor.

He made a drastic change in April, splitting from Northwest Health to start Northwest Arkansas Concierge Medicine in Bentonville and see about 200 patients. Those patients can get appointments quickly and at least half an hour focused on them and their concerns, plus 24-7 access to Hamilton by phone, text or email for $200 a month in cash, Hamilton said. Internal medicine physicians tackle all health issues affecting adults, referring patients to specialists if needed.

"The person knows you and trusts you, and they'll tell you anything. They'll talk about their bodily functions like it's nothing," Hamilton said. "I'm finally getting to do what I was trained to do. Finally. It only took 27 years."

Hamilton is one of a small but growing number of physicians in Northwest Arkansas and elsewhere who are slowing down their practices, whether with the concierge model or the similar but often less costly direct primary care model.

Moving to a business model that lets physicians see fewer patients for longer times leads to better and less expensive care for those patients and the ability to catch complicated health issues, the physicians and their patients say. The American Academy of Family Physicians supports that position, calling it a "meaningful alternative" to other care models.

The reduction in patients seen by concierge or direct primary care physicians nonetheless worries some experts, including at the family physicians organization, who point to a shortage of doctors and ever-mounting numbers of people who need health care.

Short on time

Around half of physicians spend between 13 and 20 minutes with a patient per appointment, according to a survey of about 19,000 doctors across multiple specialties this year in the Medscape Physician Compensation Report. Medscape owns the WebMD health care information website.

Appointment lengths have held steady or even increased over the past few decades, Medscape's report and a 2014 study in the American Journal of Managed Care found, but doctors and patients have reported feeling more rushed in their interactions with each other across the country. About four in five doctors feel overextended or at their full capacity, according to the 2014 survey from the Physicians Foundation, a nationwide advocacy group.

Extensive electronic records, regulations and documentation required by the federal government and insurance companies in order to reduce costs and prevent fraud, rising health care needs and hospitals looking to improve their bottom lines have all contributed to that feeling, doctors said.

The result can be an adversarial relationship with patients who try to go without visiting the doctor until they must, while doctors try to pull them in for visits, said Dr. Joel Fankhauser with Direct Care Clinic of Northwest Arkansas in Rogers.

"That's not a healthy way to have an interaction that's supposed to be based off of trust," said Fankhauser, who opened the clinic with Dr. Dan Weeden last year. Like Hamilton, Fankhauser sees around eight or 10 patients a day instead of 30 or more at a conventional clinic.

Michelle Sallerson, a 59-year-old Bella Vista resident, said time and business pressures hampered her health care when she and her husband moved to Northwest Arkansas four years ago from New York. Sallerson deals with a host of health issues, including Crohn's disease, autoimmune disorders and heart issues that several doctors either missed or ignored. For fatty liver, some physicians advised the slim-framed nondrinker to drink less and lose weight, for example.

"They're so busy typing they can't even look at you," Sallerson said.

She came to Hamilton about a month ago, and she said the difference has been immense after just a few visits, which can last two or more hours. She described finding him as a "miracle from heaven" and "beyond anything I could have ever hoped for."

"I finally feel like we're going to find what I actually have or don't have for the first time in years," Sallerson said. "I feel safe, and for the first time since we've moved here, I feel peaceful."

Benefits and costs

Hamilton and Dr. Torin Gray, another internal medicine physician who runs a similar clinic in Little Rock, said their care charge isn't covered by insurance but still saves patients money. Patients are more likely to heed advice to exercise more or stop smoking, for example, and future problems can be detected earlier because more time's spent looking for them.

"So much of what I try to do now is more prevention focus, it's more trying to head off problems before they become problems," Gray said.

Studies in the past several years in the American Journal of Managed Care and elsewhere have found improved patient outcomes for MDVIP, a 43-state network of physicians including Gray that offer direct-pay care. A 2012 study in the journal found those patients were one-eighth or less likely as other patients to be readmitted to hospitals for heart attacks or pneumonia, for example, saving hundreds or thousands of dollars per patient.

About 7 percent of physicians are using a direct-pay or concierge model, according to the Physicians Foundation's most recent survey of its members in 2014. Another 13 percent said they were planning to transition at least partly to the model.

More than 800 physicians are part of MDVIP, which charges patients a set fee typically around $1,650 a year. The network started with four physicians in 2000, CEO Bret Jorgensen said, and more doctors and patients join every year. Drs. James Baker and Stuart Benson, internal physicians in Bentonville, joined the network this summer.

"They say, 'Look, I'm mostly spending my time on a fast treadmill, I'm not doing the care that I want," Jorgensen said. "This is not a criticism of doctors, this is just the nature of health care today."

The growth of direct-pay care is part of a broader shift in health care from paying doctors based on how much they do to paying doctors for the results of their work, said Dr. John Meigs, a family physician in Alabama and president-elect of the American Academy of Family Physicians, which supports that transition.

"I get paid X amount, and my job is to take care of you and try to keep you and your family and community healthy" with a bonus for good outcomes instead of for more tests or procedures, Meigs said. "It just changes the dynamic."

Meigs suspects direct-pay won't grow beyond a niche market. Many can't afford its charges or at least don't think they can, given the relatively large upfront dollar amount, he said. The fees typically cover visits to a given direct-pay clinic, but insurance would take over for visits and services from labs and specialists.

Meigs also worried about the trend worsening a shortage of primary care doctors. The country could be short by more than 46,000 physicians compared to its needs by 2025, according to a report last year from the Association of American Medical Colleges.

If doctors halve the number of patients they see, "you have just doubled the shortage," Meigs said.

Mercy Northwest Arkansas and Northwest Health wouldn't comment, but Larry Shackelford, senior vice president for outreach services at Washington Regional Medical Center, also raised the affordability issue.

"Our internal medicine specialists, who have chosen to serve the community by working exclusively for the nonprofit Washington Regional system as employed physicians, are able to build successful relationships with their patients," he wrote in an email, which didn't answer questions about patient numbers or visit lengths. "Our physicians accept all patients regardless of their source of payment as part of Washington Regional's mission to improve the health of the community."

Hamilton and Gray pointed out their patients come from several walks of life, with a large proportion also on Medicare or Medicaid for more specialized care. They said many have complex health problems, but others just value their health. Insurance plans with high deductibles and co-pays can mean many people pay cash for their health care anyway, Meigs said.

Fankhauser said he and Weeden deliberately kept their charges low, ranging $40 a month for children and young adults to $160 for a family, no matter how large. Many clients remain uninsured despite federal requirements to have insurance. Both doctors are approaching 800 patients and are looking for a third to join the clinic, Fankhauser said.

Hamilton and Gray suggested people might be more willing to become doctors -- and stay in the field for decades to come -- if they're less stressed and more satisfied with the care they give, though the potential benefit could take years to show up because of the length of medical training. Only one-fourth of internal medicine doctors would choose that field if they could start over, according to the Medscape survey this year.

"Primary care almost seems overwhelming, I think, to younger medical students," Gray said. "If this (system) were to become more widespread, I think you would see better interest in primary care in particular."

One option among many

Physicians also are working on less drastic ways to improve patient appointments and experiences. A 2014 report from University of California, Los Angeles researchers found adding a "physician partner" to take care of the paperwork during patient visits made patients more likely to say the physician spent enough time with them, for example.

Dr. Scott Dickson, director of the University of Arkansas for Medical Sciences' family medicine residency program in Jonesboro, has almost wrapped up a five-year pilot project in which patients pay a set fee each month and a reduced fee per visit, a kind of hybrid of direct-pay and more traditional care that might lessen the pressure to see more and more patients.

It's too early to say if health outcomes are better, but patients say they're having more and better interactions with their physicians, Dickson said.

More doctors also are on the way, including in Arkansas. The Arkansas College of Osteopathic Medicine is set to open in August 2017 in Fort Smith with a class of 150. Mercy also recently started a residency program in conjunction with the medical school's Fayetteville campus and the Veterans Health Care System of the Ozarks to train internal medicine physicians. It has eight residents now and will have 24 at a time in three years.

Scott Smith, director of governmental affairs for the Arkansas Medical Society, a professional and advocacy group, said he saw direct-pay systems as just another option for physicians trying to give the best health care they can. His brother recently started a direct-pay clinic in Missouri.

"We haven't seen a whole lot of this starting up around the state," he said, adding, "What I'm hearing is the patients are happy."

Elizabeth Davis, a patient of Gray's in Little Rock, repeated that sentiment. She has an autoimmune disease called sarcoidosis, in which white blood cells will clump together and attack parts of the body. Before going to Gray, Davis said, she felt as if she were being treated for her symptoms instead of the root cause. Gray also found she had a wheat allergy that had caused sinus problems for years.

"He and I will visit and talk for an hour. I can tell you that I have never been able to do that in my entire life," said Davis, whose husband and grandmother also see Gray. "It's amazing what he's done for us."

NW News on 09/12/2016