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What’s my story, and why might it be of interest to LipidSpin readers?
I have practiced family medicine for nearly 30 years in my small North Carolina hometown of 5,000-plus. Years ago I developed an interest in cardiovascular disease (CVD) prevention, in part because of what I saw in my practice and also because of my father’s personal and family history I have strived to make it a major focus of my primary-care practice. Thanks to the support and education provided by the National Lipid Association (NLA), as well as the teaching of people such as Michael Davidson, Tom Dayspring, Alan Sniderman, Bill Cromwell, Robert Superko and my close friends and mentors, Tom Barringer and Kari Uusinarkaus, to name a few, I have had a rewarding and hopefully impactful career.
However, 3 years ago, at the age of 60, I began to experience the “burnout” that, unfortunately, has become far too common among those of us in health care. I was discouraged by how impersonal and hurried the practice of medicine had become, frustrated by an inefficient electronic health record, tired of dealing with the demands of insurance companies and unwilling to be bullied any longer. I made the decision to start a new and different practice. For my colleagues in the NLA and readers of this journal – particularly those in primary care who may be contemplating other career paths, or even early retirement – I hope this article provides some inspiration and reason for hope.
What was my solution?
I wanted to provide care my way, not someone else’s way. I wanted to have be independent again. I wanted patients to have access, to feel respected and to be genuinely happy with their care – and not simply to satisfy a survey. I wanted to recapture the personal satisfaction of practicing “relationship medicine” again. I wanted to be a better lipidologist. After much research and thought, I chose to open a “direct primary care” practice.
Direct primary care? Isn’t that “concierge medicine?”
No, not exactly. There are some similarities. Both arose from a desire to break away from the status quo and to provide care for a more manageable panel of patients. The typical concierge practice cares for somewhere between 400 and 600 patients, a direct primary care (DPC) practice sees between 500 and 1,000 patients. In each model, revenue is not solely dependent on “heads through the door”, enabling care via nontraditional means, such as secure email, text, phone or video. Visits lasting from 30 to 60 minutes are the rule, not the exception.
There are, however, some significant differences. Concierge practices typically charge an annual membership fee ranging from $1,500 to $3,500, contract with third-party insurers, charge co-pays and balance bill their patients. DPC typically charges a monthly retainer fee ranging from $40 to $100 and does not file or accept any insurance reimbursement. DPC practices are able to maintain a much smaller staff and operate at a lower overhead than a traditional practice. DPC is growing rapidly, with nearly 700 such practices currently operating in the United States.
What has been my experience?
I opened my practice in March 2015 in an old, renovated movie theater on Main Street. I hired two staff with whom I had worked for more than 25 years each in my former practice. I chose a very user-friendly (yes, there are some) electronic health record (EHR) system. We broke even in three months, were debt-free in one year, were closed to new patients by Year 2, and have attracted a young physician finishing his residency to join and open a second location. I care for patients with Medicaid. I offer free or reduced fees for those unable to pay. I am on call and available 24/7, but I rarely get a call after hours. I make house calls (and we charge nothing extra for them). Patients seem happy again. So am I. I feel I can practice like this for years to come.
Thomas White opened his practice in March 2015 in an old, renovated movie theater. He is now freer to provide more personalized care without onerous rules and restrictions.
So what about lipidology?
In my former practice, lack of time with patients was always a major frustration. Allowing only 7.5 minutes per patient and seeing 28.2 patients daily simply was not conducive to what I considered good care. Now I actually can review exercise and food diaries face-to-face in the office or by email. I know what my patients eat for breakfast and what they drink. Using technology more cleverly, I can depict and explain such concepts as CVD risk calculation, particle number, cardiac imaging and vulnerable plaque. I share videos. I can review the pros and cons of various nutritional strategies. I can show them their left bundle branch block (LBBB) and review their cardiovascular catheterization report.
On a practical level, I am freer to provide what the patient needs without onerous rules and restrictions. In my model, I include such basic labs as lipid profiles as part of the monthly fee, enabling me to draw what we need when we need it. To illustrate, a standard lipid profile costs me less than $2. I pass that savings on to the patient, achieving tremendous savings for everyone. For more advanced testing, the patient has the option of having the reference lab file their insurance or simply paying cash and avoid any insurance denials or hassles. Imagine an apolipoprotein B (apo B) or low-density lipoprotein (LDL) particle test for less than $40! I have negotiated a price for calcium scoring at a nearby radiology center for less than $100.
Am I completely “insurance free?” No. More than 90% of my patients still carry some form of insurance (more than 50% have Medicare) to cover more expensive and catastrophic care. I, too, have to engage in prior-authorization battles – think proprotein convertase subtilisin/ kexin type 9 PCSK9 inhibitors – on behalf of my patients. Having now reached a “steady state” for my DPC practice, I am in the position to finally accept “lipid consults" again... at an insurance-detached, affordable cash fee, of course.
What if someone is interested in exploring DPC?
Thankfully, there are many sources of support and education. The American Academy of Family Physicians (aafp.org/ dpc) offers a DPC practice “tool kit,” educational workshops and a “member interest group” for communication and networking. Other legislative and legal information can be found at dpcare.org and dpcfrontier.com. The DPC community is amazingly unselfish and collegial. Feel free to contact me. I would be honored to help.
Disclosure statement: Dr. White has received honoraria from Amarin and Janssen. He also owns stock in Ionis and Amarin.
Article By:
Hometown Direct Care
Cherryville, NC
Diplomate, American Board of Clinical Lipidology