Thanks for your post. We are lacking right now in the direct practice space a national directory of providers. The closest thing is what SIMPD is doing, as well as the work by HelloHealth who is creating a University for physicians who want to learn to practice in the way I describe.

In terms of the quality of the physician, that is still open for discussion. I realize that you feel that practicing in a large practice implies that your physician has been “screened”, but I can tell you from the inside that physicians themselves have no idea how good they are because there is very little information that even they have to actually know. The variations in care are astounding, and disappointing, and we need to continue to push for doctor rating systems that are based on objective evidence of quality – instead of the Zagat-style popularity contest. We need real clinical outcomes measures to help people know that their knee surgeon has performed 4,123 arthroscopies, is currently 75 days without an adverse outcome, has a 2.5% infection rates, and and overall patient satisfaction score of 4.23 (out of 5) with access to former patients comments and contact information.

It is only in that environment that you are going to be able to truly judge the quality of the physicians. We are not there. but heading there.

2. How does one know that he/she is a good doctor? I would rather have a doctor who knows me better, has time to listen, etc., but even if I somehow find one who follows the direct practice model, I’ll be missing the reassurance that a large practice gives (namely, that the doctors in a large practice have been closely evaluated and chosen because they are good doctors). There’s no screening process for a doctor who decides to go it alone.

I opened one of the first concierge practices in this country 8 years ago. I’ve just written the first book to be published on the subject, “Concierge Medicine, A New System to Get the Best Healthcare” (Greenwood/Praeger, May 2008). I used the politically incorrect term in my title, because most people don’t know what a “direct practice” is.

Though there are controversies, concierge medicine is now available for the middle class and is quite affordable in many areas of the country. Most of the arguments against concierge medicine fall apart under scrutiny. I have an entire chapter in my book devoted to this issue.

Concierge medicine is driven by patient dissatisfaction over our present fast-food medical model of HMOs, PPOs and a failing Medicare system. Patients love the time they have with their concierge doctors. Doctors love having the time to do what they were trained to do. Unless primary care medicine becomes more attractive to young doctors, by implementing models such as concierge medicine, no one will opt for a career in internal medicine, family practice or pediatrics and the shortage of primary care doctors will only worsen.

Steven D. Knope, M.D.

Unfortunately, I don’t drink coffee – perhaps a large sports beverage of your choice?

You raise some valid points which I will clarify.

“Going off the Grid” implies dropping out of the insurance paradigm only for those small expenses that consumers should not be using insurance for anyway. Please see my recent article on “True Insurance” which provides the most succinct description of what the term insurance should mean within health care. People in direct practice models still need to have insurance – a financial risk instrument that protects them against catastrophe (lets say anything above $50,000 in a single year). They could also benefit from having some type of financing mechanism for everything between (lets say $10,000 to $49,999) that “insulates” them from the full cost either through price discounts (the network) or through some type of risk/cost sharing program coupled with some sort of financial planning/long term repayment program. In this model, you have three layers of coverage:

1. Cash
2. Co-Share (variety of cost sharing means)
3. Catastrophic (True Insurance)

Interesting concept. I bet somebody is working on it. ; 0

You are also right about Millennial Care. I am not making the argument that it is about social networking. I am making the argument that it is about a new social contract between the provider and the patient as partners. The velocity aspect comes in with using technology to enable the new relationship – extend it, deepen it, and make it more personal (not less!) by the smart application of technology. This is seen in terms of access to the physician (email, text, etc) on terms that are efficient to both parties while simultaneously removing the dead carcass administrative burden of the current paradigm.

The policy implications of the direct practice model are concerning. If all physicians jump ship to this model, we will be in a worse crisis in terms of primary care. However, Wal-Mart has already got that figured out. Those NP degrees just went from gold to platinum, baby. The only way I see to do this is to extend the concept of primary care to providers who are trained, can follow algorithms, and can be distributed to the new delivery system – big box stores on every street corner in America.

In terms of your bet, I could be way off. But I am comfortable with my knack to predict next waves. See you at takeoff.