1. Alternative Models for
(Primary) Care Delivery
Direct Primary Care: It’s About Time
EXPLORE: Oklahoma Healthcare Summit
August 15, 2014
Brian Birdwell, MD
Lawton, Oklahoma

2. Not today’s situation.
08/15/2014Brian Birdwell, MD - © 2014 - Alternative Models for (Primary) Care Delivery 2
Photo: pamelynferdin.com

3. Not today’s situation.
08/15/2014Brian Birdwell, MD - © 2014 - Alternative Models for (Primary) Care Delivery 3
Photo by: W. Eugene Smith—Time & Life Pictures. Dr. Ernest Ceriani makes a house call
on foot, Kremmling, Colorado, 1948.

4. Today’s situation.
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Fifty years in the making: Unsustainable
growth for the country as a whole
Unchecked cell growth
threatens the host

5. Today’s situation.
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Cost of health insurance vs. what companies
and workers have to spend
Unstainable growth for
households, too

6. Today’s situation.
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Spending disassociated with
outcomes
Spending disassociated with
quality care

7. Today’s situation.
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Photo: The National Journal

8. What happened?
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Primary care drives 80% of
spending, with 7% of resources
Wage growth gap keeps pressure
on primary care providers

9. What does this mean?
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Tyranny of the
15-minute
patient visit
Spending pushed toward
high tech, exotic therapies
RISK
Payor
contracts
reduce primary
care
compensation
… and pile on
administrative
overhead
Save Medicare by
deeper cuts in
physician
reimbursement
$50 per encounter
for coding, billing
and collections
Now it takes 20
to 30 visits per
day just to make
ends meet

10. Healthcare, Inc.
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http://www.cartographersguild.com/town-city-mapping/25898-tarlus-wip.html

11. It’s about TIME.
Consider Helen, a 77-year old patient who
needs:
 Timely (same day/next day) access to care
 Thoughtful listening and expert interpretation of
multiplicity of symptoms and complaints
 Coordination of medications
 Extensive preventative care
 Prudent referral / ongoing coordination of
specialist care
 Family consultation
 Hospital to home / other living venues
 Coordination with home health / hospice
 Taking the keys
 Advanced directives / end of life
 House calls?
Medical history:
Coronary artery disease –
multiple cardiac stents;
inoperable, stable angina
Epilepsy
Fibromyalgia
Osteoporosis
Arthritis
Sleep apnea
COPD
Hypothyroidism
Depression
More than 20 active
medications
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12. It’s about care…
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…care that requires TIME.
“The lack of meaningful interaction and sufficient
time for primary care is eroding the doctor-patient
relationship. Patients suffer when doctors must
see so many of them … These problems are by-
products of an overloaded third-party payment
system [that does not reimburse appropriately]”
-- Daniel McCorry, “Direct Primary Care: An Innovative Alternative to Conventional
Health Insurance,” The Heritage Foundation, August 6, 2014

13. Helen’s care requires TIME.
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What happens without sufficient doctor-patient
TIME:
What can happen with TIME:

14. Helen’s care requires TIME.
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What happens without sufficient doctor-patient
TIME:
Ethical/moral dilemma:
 A doctor knows her problems are not adequately
addressed in a 10- to 15-minute evaluation, and thus
 Over-referral; over-utilization; and cost explosion
 Patients experience not being heard (the 10 minute
rush) and then
 Fragmentation of their care

15. Helen’s care requires TIME.
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What can happen with TIME:
 Symptoms, understood in context, require fewer tests,
fewer referrals
 Appropriate level of care, fully comprehended and
coordinated at the appropriate level: primary care
 Professional and vocational satisfaction
 Patients know they’ve been heard; less anxiety about
their care

16. Healthcare, Inc. ≠ care
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Busy Doctors, Wasteful Spending
“There is no more wasteful entity in medicine than
a rushed doctor ... referral to specialists is one of
the most costly of all, and leads to fragmentation
of care with little or no evidence that quality or
health is enhanced.”
-- Sandeep Jauhar, “Busy Doctors, Wasteful Spending,” NYT July 21, 2014

17. A path forward.
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Photo by: W. Eugene Smith—Time & Life Pictures. Dr. Ernest Ceriani makes a house call
on foot, Kremmling, Colorado, 1948.
The way forward may be a return back in TIME.
Remember this guy?

18. A new model for primary care.
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Patient-centric medical practice drives the
business, not the other way around
Culture of care,
30- to 60-minute visits
Focus on outcomes
(How do you feel?)
Doctor-patient alignment
(No intermediary)

19. How it works.
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Membership dues, a flat monthly fee
Membership means no more coding
Thus, every contact option is now open:
Phone, Email, Text
Telemedicine …
Even house calls!

20. Direct primary care:
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Observation Traditional Direct primary care
Patients per day 30 9
Doctor-patient face time (min) 8 35
Out-of-pocket patient costs $2,500 $2,200
Typical # visits per year 2.5 3.7
Total doctor-patient minutes (avg) 20 130
Early evidence: North Carolina State Univ. Study
* MBA project comparing North Carolina direct pay medical practices to data
collected from traditional practices

21. Direct primary care:
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Referral Type Qliance* Benchmark Difference Savings
ER Visits 73 158 -53% $84
Hospital days 155 184 -16% $102
Specialist visits 850 2,000 -58% $345
Advanced radiology 273 800 -66% $1,054
Surgeries 28 124 -77% $960
Primary care visits 4,411 1,847 139% ($528)
Savings (patient/year) $2,017
Early evidence: Qliance, Seattle, Washington
* Data provided by Qliance direct pay clinic in Seattle, Washington based on
1,000 direct pay patients

22. Direct primary care:
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Television commercial for MIO Liquid Water Enhancer

23. Thank you!
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It’s about care, not coverage.®
Brian Birdwell, MD
Birdwell Ferris Clinic
1930 NW Ferris Avenue
Lawton, OK 73507
www.ferrishealth.com

24. Bibliography
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Direct Primary Care: An Innovative Alternative to Conventional Health Insurance
Heritage Foundation
http://www.heritage.org/research/reports/2014/08/direct-primary-care-an-innovative-
alternative-to-conventional-health-insurance
Busy Doctors, Wasteful Spending
www.nytimes.com/2014/07/21/opinion/busy-doctors-wasteful-spending.html
Why the Direct Pay Model would work well for the poor
http://directprimarycare.wordpress.com/2014/03/24/why-the-direct-pay-model-would-
work-well-for-the-poor-population/
Direct Primary Care Practices Bypass Insurance
California Healthcare Foundation
http://www.chcf.org/publications/2013/04/retainer-direct-primary-care
The Cost Conundrum: What a Texas town can teach us about health care
http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum