1. Direct Primary Care to Achieve Medical Student Competencies and Family Medicine Recruitment Sharon McCoy George, M.D. James Breen, M.D. STFM Medical Student Education Conference Phoenix, AZ January 29 th, 2016

2. Introductions & Disclosures Sharon McCoy George, MD, MPS– nothing to disclose Family Physician, Saint Louis, MO Founder, Renaissance Family Medicine, solo membership practice, Irvine CA Former Associate Clinical Professor and Director of Primary Care for Medical Student Education, Washington University School of Medicine Associate Professor of Family Medicine, University of California, Irvine School of Medicine (Volunteer) Founder, MD Mentors James Breen, MD– nothing to disclose Associate Professor, Department of Family Medicine UNC at Chapel Hill School of Medicine Cone Health Family Medicine Residency Program Greensboro, North Carolina

3. Objectives 1. Participants will be able to explain how direct primary care supports student education around ACGME core competencies in Systems-Based Practice (SBP). 2. Participants will be able to describe ways that direct primary care practices add value to patient relationships in ways that are not supported by conventional third-party practices. 3. Participants will be able to explain the basic business decisions that influence the desirability of starting a DPC practice.

4. I. Definition and Overview of Direct Primary Care A. AAFP Policy B. Historical Perspective C. DPC and ‘Value’, ‘Quality’ II. DPC and the Physician Workforce A. Successful DPC Practices B. Opportunities for DPC Employment C. Family Medicine for America’s Health D. Workforce Implications III. Counseling learners about DPC practice A. Considerations before deciding on a DPC practice B. Process of practice planning C. Networking/resources to develop a DPC practice

5. I. Definition and Overview of Direct Primary Care A. AAFP Policy B. Historical Perspective C. DPC and ‘Value’, ‘Quality’ II. DPC and the Physician Workforce A. Successful DPC Practices B. Opportunities for DPC Employment C. Family Medicine for America’s Health D. Workforce Implications III. Counseling learners about DPC practice A. Considerations before deciding on a DPC practice B. Process of practice planning C. Networking/resources to develop a DPC practice

6. AAFP DPC Policy (http://www.aafp.org/about/policies/all/direct-primary.html)http://www.aafp.org/about/policies/all/direct-primary.html Issued 2013

7. AAFP DPC Policy (full text 1 of 3) The direct primary care (DPC) model is a variation of the retainer practice framework for primary care physicians. DPC practices charge patients a flat monthly or annual fee, under terms of a contract, in exchange for access to a broad range of primary care and medical administrative services. The retainer practice framework includes any practice model structured around direct contracting with patients/consumers for monthly or annual fees which serve to replace the traditional system of third party insurance coverage for primary care services. Typically, these “retainer fees” guarantee patients enhanced services such as 24/7 access to their personal physician, extended visits, electronic communications, in some cases home-based medical visits, and highly personalized, coordinated, and comprehensive care administration. The AAFP supports the physician and patient choice to, respectively, provide and receive healthcare in any ethical healthcare delivery system model, including the DPC practice-setting.

8. AAFP DPC Policy (full text 2 of 3) The DPC contract between a patient and his/her physician provides for regular, recurring monthly revenue to practices which typically replaces traditional fee-for-service billing to third party insurance plan providers. For family physicians, this revenue model can stabilize practice finances, allowing the physician and office staff to focus on the needs of the patient and improving their health outcomes rather than coding and billing. Patients, in turn, benefit from having a DPC practice because the contract fee covers the cost of all primary care services furnished in the DPC practice. This effectively removes any additional financial barriers the patient may encounter in accessing routine care primary care, including preventative, wellness, and chronic care services. Most patients, depending on affordability, choose to still carry some form of insurance, such as a high deductible health plan, for coverage of healthcare services that cannot be provided in the primary care practice setting, such as specialty care and hospitalizations.

9. AAFP DPC Policy (full text 3 of 3) Ideally, the DPC model is structured to emphasize and prioritize the intrinsic power of the relationship between a patient and his/her family physician to improve health outcomes and lower overall health care costs. The DPC contract fee structure can enable physicians to spend more time with their patients, both in face-to-face visits, and through telephonic or electronic communications mediums should they choose, since they are not bound by insurance reimbursement restrictions. For these reasons, the DPC model is consistent with the AAFP’s advocacy of the PCMH and a blended payment method of paying family medicine practices. (2013 COD)

10. AAFP DPC Policy (summary 1 of 3) variation of the retainer practice direct contracting with patients/consumers for monthly or annual fees which serve to replace the traditional system of third party insurance coverage for primary care services highly personalized, coordinated, and comprehensive care administration regular, recurring monthly revenue to practice this revenue model can stabilize practice finances, allowing the physician and office staff to focus on the needs of the patient and improving their health outcomes rather than coding and billing

11. AAFP DPC Policy (summary 2 of 3) regular, recurring monthly revenue to practice this revenue model can stabilize practice finances, allowing the physician and office staff to focus on the needs of the patient and improving their health outcomes rather than coding and billing…. Patients, in turn, benefit… (removing) additional financial barriers the patient may encounter in accessing routine care primary care Most patients…choose to still carry some form of insurance, such as a high deductible health plan

12. AAFP DPC Policy (summary 3 of 3) Ideally, the DPC model is structured to emphasize and prioritize the intrinsic power of the relationship between a patient and his/her family physician to improve health outcomes and lower overall health care costs. The DPC contract fee structure can enable physicians to spend more time with their patients, both in face-to-face visits, and through telephonic or electronic communications mediums should they choose, since they are not bound by insurance reimbursement restrictions.

14. “Medicine is no longer a profession; it's a trade. Whether we acknowledge it or not, we work for the medical-industrial complex. We're employed by them, directly or indirectly, and we become almost like a purchasing agent for them. We have an interest in the success of the company. You don't make money by holding somebody's hand. You make money by doing tests and putting them in the hospital.” --Dr. Lynn Carmichael (Fam Med 1992; 24:53-7)

15. My patients were what I was taking care of, not their particular illnesses. This was a revelation to me. I had, like most people in medicine, been raised with the idea that diseases existed and that our job was to treat diseases. I found out that diseases don't exist. What exist are people who have different kinds of health problems. We don't treat diseases; we take care of people. We label them with a disease name as a way of simplifying it. (Voices of Family Medicine: Lynn Carmichael.Fam Med 1992; 24:53-7) -- Dr. Lynn Carmichael

16. I. Definition and Overview of Direct Primary Care A. AAFP Policy B. Historical Perspective C. DPC and ‘Value’, ‘Quality’ II. DPC and the Physician Workforce A. Successful DPC Practices B. Opportunities for DPC Employment C. Family Medicine for America’s Health D. Workforce Implications III. Counseling learners about DPC practice A. Considerations before deciding on a DPC practice B. Process of practice planning C. Networking/resources to develop a DPC practice

17. I. Definition and Overview of Direct Primary Care A. AAFP Policy B. Historical Perspective C. DPC and ‘Value’, ‘Quality’ II. DPC and the Physician Workforce A. Successful DPC Practices B. Opportunities for DPC Employment C. Family Medicine for America’s Health D. Workforce Implications III. Counseling learners about DPC practice A. Considerations before deciding on a DPC practice B. Process of practice planning C. Networking/resources to develop a DPC practice

18. Networking to Develop a DPC Practice AAFP Member Interest Group on DPC Other physician communities Ideal Medical Practice—IMP www.IMPcenter.org DPC Docs Facebook Group (message Sharon McCoy George to join) DPC United Direct Primary Care Coalition Annual DPC Summit (July 8-10, 2016 in Kansas City)

19. Contact: Sharon McCoy George, MD MPS www.sharongeorgemd.com SharonGeorge@cox.net James Breen, MD www.AcademicDPC.wordpress.com James.O.Breen@gmail.com