Primary care physicians are perhaps the most overworked and important cogs in the medical system. But their profession is stressed. Can Eastside entrepreneurs and the nation’s new health care system help save it?
After a few minutes of searching on his phone, Dr. Scott Greenspahn quickly ditches his chair, gingerly sits on an end table next to me, and accelerates his speech while explaining his prize. In his hands is a chart comparing the annual cost of diabetes treatment and medication at a leading area medical facility with those of Coho Medical Group, the Bellevue clinic Greenspahn helped found in January.
First, there are visitation copays. A standard provider charges $20; at Coho, there are no copays. The rest of the chart also tips in Coho’s favor. Lipid panel tests: $127.63 vs. $3.60. A year’s supply of generic Lipitor: $1,860 vs. $59.01.
Greenspahn figures a diabetic taking low-end cholesterol meds will pay $613.81 in annual fees with the provider he price-checked, while the fees at Coho would fall below $110. “So right there, just by having diabetes, you save $500,” he says, his scratchy but excitable voice and ironic problem-as-a-perk pitch echoing an infomercial pitchman. Choose top-flight drugs like Lipitor, he says, and the price difference climbs above $2,300. He says that number slowly.
The steep discounts are a product of door-to-door negotiations by Greenspahn and cofounder Dr. Devon Zoller and a key element of their business plan — Coho doesn’t accept insurance payments. Greenspahn and Zoller have adopted a direct primary care model, in which patients pay a fixed monthly fee for 24-7 physical or virtual access to their physician. Extra tests and drugs are purchased a la carte.
Coho doesn’t bill like a traditional primary care provider, and it doesn’t look like one, either. Its waiting room has just four chairs, and there are two iPads for patients to play with. The receptionist sits behind a welcoming open-air desk. The exam rooms have bright orange accent walls and are large enough to hold small conference tables, just in case a patient would like to have a conversation sitting on something other than a paper-covered exam table.
Greenspahn and Zoller are among many who feel the primary care industry needs a shakeup. Family physicians across the nation are stressed, overworked, and increasingly in short supply, which results in patients often receiving middling health care for a top-flight price. So while Washington, D.C., tries to remedy the problem with programs supported by the Affordable Care Act, entrepreneurs like the Coho team are taking a bottom-up approach that could yield faster results.
It’s hard to get a doctor’s appointment these days. Patients in the Seattle area routinely must wait more than three weeks to see a family physician, according to one recent survey. Once they get in, the typical 10- to 15-minute appointment might not be enough time to address all their concerns. Large patient rosters, known as panels, restrict doctors’ abilities to spend significant amounts of time with patients. The average panel for a Washington physician is 1,700 patients, and the national average is 2,300. Surveys say the average family physician has 99 patient interactions per week.
Medical researchers agree there is a shortfall of primary care physician and general internists — and that the deficit will worsen in the coming decade. The American Association of Medical Colleges says the shortfall is roughly 30,000 today and will reach 65,800 by 2025. Washington isn’t exempt from the blight — researchers at the Robert Graham Center projected in 2010 that Washington would need roughly 1,700 more primary care doctors by 2030, an increase of 33 percent.
About one-third of U.S. physicians specialize in primary care — the Council on Graduate Medical Education (COGME) says that percentage should be 40 — and 12.7 percent are family physicians, those who are trained to work with every age and handle a range of maladies. The rest are specialists, and the numbers are similar in medical schools. Fewer than 9 percent of graduating medical students entered a family practice residency in 2014.
Understanding the working conditions and compensation of primary care physicians drives many medical students away from the field, even though 70 percent of med-school students show an initial interest in family medicine alone. According to a 2012 Physicians Foundation survey, 64 percent of active primary care physicians felt “somewhat negative” or “very negative” about their profession, and 53 percent said their professional morale fell in the same two categories. Common complaints included too much regulation and paperwork, the lack of a quality-oriented compensation system, and the loss of clinical autonomy.
“There’s burnout; it’s true. There’s a certain number of people who feel overloaded for one reason or another, feel encumbered, feel angry,” says Dr. Howard Miller, a family physician in Renton who has operated his own practice since 1977. “There are insurance issues, lots of forms, feeling they don’t get what they charge. There’s a certain resentment about that.”
The main driver of complaints is the fee-for-service payment system used by most insurance providers. Rather than being paid per panel member or in an outcome-based fashion, physicians receive payment for each individual service they offer. Every blood draw, cholesterol test, and X-ray leads to compensation from insurance companies. Thus, paperwork must be filed for each service, and finances are tied to these rather than outcomes or efficiency. The result is a corps of physicians widely accused of forcing unnecessary treatments on their patients. Furthermore, fee-for-service means doctors’ compensation is tied to volume, leaving many family physicians concerned about the quality of care they provide.
Compensation also is an issue. The Bureau of Labor Statistics says family practice doctors make, on average, $207,000 a year. A comfortable salary, sure, but specialists can make twice that. The average anesthesiologist’s $432,000 salary looks awfully tempting to a medical student with $300,000 of student-loan debt awaiting her after graduation.
“There’s some evidence that shows the amount of debt a student graduates with can influence the specialty they choose,” says Dr. Frederick Chen, associate director of the University of Washington Department of Family Medicine and Harborview Medical Center’s chief of family medicine. “I think the real answer, though, is making primary care better, more fun, and satisfying as a career.”
When President Barack Obama signed the Patient Protection and Affordable Care Act (ACA) into law in 2010, he said it upheld “the core principle that everybody should have some basic security when it comes to their health care.” The most tangent example of “basic security” is an emphasis on preventive care, much of which is done by family physicians. The government’s theory is that if people visit their primary care provider more often, they will catch maladies before a costly visit to a specialist or hospital is required. Thus, the ACA mandates a variety of free preventive services, such as colonoscopies and cholesterol screenings. If patients take the bait, they might be healthier, but that also stresses a short-staffed family practice workforce.
There’s ample reason for the federal government to try to shake up preventive care. According to the World Health Organization, the U.S. may well be the least cost-efficient health care system in the world. The U.S. spends 17.7 percent of its GDP on health care, and the average American’s health expenditures nearly reach $9,000 a year. Both are far higher than most developed nations. Among the 34-member nations of the Economic Organisation of Co-operation and Development, 9.3 percent of GDP on average is allocated to health, and the average per-person annual expenditure is less than $3,500. The United States’ spending isn’t producing results, either. America’s health spending has yielded the 36th-highest life expectancy in the world, trailing nearly every other Western nation.
COGME research shows that every primary care practitioner yields 1.4 fewer deaths per 10,000 people. To increase the number of primary care doctors, the ACA incentivizes programs that remove some headaches associated with family medicine. Accountable care organizations (ACOs) and patient-centered medical homes (PCMHs) put a family physician at the center of a patient’s health. The primary care provider coordinates care with a team of specialists while managing a smaller panel and being paid per patient, not only in service fees.
Group Health was one of the earliest pioneers of the PCMH model, and the medical community has taken notice of its success. During a pilot program from 2006-07, a study found that 10 percent of staff reported burnout after a year compared with 30 percent at control clinics. Patients seemed to enjoy the experience, as well. They reported higher ratings than control-clinic patients in six of seven experiential categories. And in the end, there was no substantial cost difference between the PCMH clinic and the controls.
“These new models of care where you’re responsible for a patient panel, where you’re working in teams so it’s not all on you to get everything done, and you’re paid appropriately will transform the industry,” UW’s Chen says. “It’s no longer how much can you do for a patient, but can you keep a person healthy, because you’re going to benefit from the cost savings.”
These alternative care models are showing promise, but they’re still tied to the medical insurance industry, an economic behemoth that likely can’t upend its practices fast enough to implement these new models on a widespread scale. To accelerate the process, a couple area practices are embracing a similar system that doesn’t rely on insurance companies at all.
Greenspahn and Zoller began their careers as hospitalists, facilitating the general care for those who are hospitalized. After a few years in that field, they felt most hospitalizations were “failures of primary care,” Zoller says. “People weren’t feeling well and couldn’t get in to see their docs, so they go to the emergency room. Or maybe they got discharged from the hospital, but couldn’t see their doctor for three weeks. So what ends up happening? They’re right back in.”
In response, the duo founded Coho with the intent to provide better front-line care while avoiding the drivers of burnout among other primary care physicians. The business model is simple, alarmingly so when compared with the rest of the medical industry. Coho charges a flat rate that ranges from $59 per month for patients ages 18-39 to $99 per month for those 65 and older. Included in that price is anytime virtual or in-person access to doctors.
Zoller and Greenspahn are limiting their panels to 600 — about a third of the state average — so they can devote more time to each patient, feel satisfied in the care they provide, and also preserve their own happiness and family lives. If both doctors max out their panels and monthly dues average $79, the mid-tier price, then Coho’s yearly revenue will top $1.1 million.
“The numbers work, and we don’t need to see a very high volume,” Zoller says. “That said, we’re not going to be buying Lamborghinis. But I don’t want to buy a Lamborghini. I want to take care of 500 patients well instead of 2,500 patients poorly.”
Coho Medical isn’t the first direct primary care clinic on the Eastside. Dr. Erika Bliss and her cousin Garrison, both practicing family physicians, founded Qliance Health in 2006 in Seattle, and they now operate six offices, two of which are in Bellevue.
“Just in the past couple of years, there’s been a big shift in the way family medicine is thinking about (its) role in the health care system,” Bliss says. “Until recently, nobody really could see anything beyond tweaking with the fee-for-services system. The fact that we’ve been around for eight years and have had some significant success both in growth and in demonstrating savings and exceptional outcomes, people are coming around to the realization that this is actually possible.”
Coho and Qliance both recommend their patients maintain insurance to cover visits to specialists and hospitalizations (Qliance, unlike Coho, does accept insurance payments), but they say even patients with comprehensive and expensive plans can benefit from direct primary care.
“This is a model that could work for any population at any stage of their life, no matter what their health care situation is,” Bliss says. “Let’s say, God forbid, they lose their kidney function and go into dialysis. They’re not just kidneys; they’re still a person with other health care needs and issues.”
Bliss and the Coho team say their model allows a familiar face to coordinate all medical care, thus justifying the monthly fee. But UW’s Chen doesn’t think direct primary care will become widespread. The model does allow longer visits and greater availability, he says, but the Affordable Care Act will hinder direct primary care’s growth. “Their model worked for uninsured folks; now a lot of people have insurance that covers their primary care,” he says. So even if Coho and Qliance offer better access and possibly better care, they still have to convince patients to fork out an extra $80 per month, and that fee becomes less enticing for patients with more comprehensive insurance that would cover many of the costs outlined in Greenspahn’s diabetes scenario.
Coho has yet to take off — it has about 20 patients — but Qliance has seen success, and similar practices are popping up across the country. One positive sign is that recruiting doctors hasn’t been a challenge. Bliss and Zoller both say they have a backlog of physicians clamoring for a job. If nothing else, the principles of direct primary care could again make family medicine a desirable career for doctors.
Devin Schock looks tired. “My dad said I should have known better,” he says, referencing his father Peter, a doctor at Bellevue Family Practice. “It’s a lot of work, and it historically hasn’t been as good of pay relative to other specialists who work less and get paid more. On the other side of that, I think he’s joking. His practice has always been very rewarding. He knows all his patients by their first name.”
Schock is in the middle of a three-year residency at Valley Medical Center in Renton. His biggest complaint is that he rarely “cures” anyone. “There are days I wish that 90 percent of my patients walk out feeling better than when they walked in,” he says. “Most days, it’s 10 percent or less.” This is where specialization can be attractive — cancer is beaten, broken bones healed, diseases cured. That’s rarely the case with a family physician, when the work is often spending 15 minutes trying to persuade the patient to take the best course of action. Most drugs and all lifestyle changes have to be administered by the patients themselves, outside the walls of the doctor’s office.
But the rewards of family practice are unmatched, according to Miller, the family physician in Renton. A baseball-enthused New Yorker, Miller has covered his office walls with signed Brooklyn Dodgers and New York Yankees photos. He adopted the Mariners when he moved to Renton, though, and one of his most prized mementoes is a pair of tickets from Felix Hernandez’s perfect game in 2012.
“I give about 25 percent of my tickets to patients. One day, I gave a patient and his father game tickets, and that’s the day Felix pitched a perfect game,” Miller says. The patients then returned the tickets for Miller’s memorabilia collection. “It’s a give and take, and that’s what it’s all about. This kind of relationship you get with your patients, you don’t get that in specialty medicine.”
Schock is starting to see that side of the business. He recently had a visit with a diabetic patient who for two years had refused to take insulin, until Schock finally persuaded her to use the drug.
“(The patient’s) daughter-in-law went to my supervisor and said they were very thankful for all the time that I had taken with her. She really trusted me and made a big difference in her finally deciding to take the medication,” Schock says. “That’s why we do what we do. I’m like a coach or a teammate to my patients, trying to get them to buy into their role. When they finally get it and you see it click, it’s really rewarding.”