Over time, I’ve become increasingly frustrated by the current medical situation. I joined a really wonderful family medicine office immediately out of residency, and actually spending time with my patients was fascinating, fun, and fulfilling: I knew I was making a difference in their lives. But I also began to question the way in which money drives medical care. In a typical medical office, only 25-35% of what you pay to see the physician actually goes to the physician. The rest goes to pay overhead.
Why such a large overhead? Well, dealing with insurance is painful and time-consuming, so physicians hire billers to cope with it, and sometimes a referral person to argue with insurance companies and make sure every specialist appointment or imaging study is covered before it is done. In order to cover their pay, the physician must see more patients. To improve efficiency, a receptionist checks the patient in, and a medical assistant takes vitals and moves the patient to a room. As the physician runs from room to room, a triage nurse decides if someone’s problem is significant enough to squeeze in the same day. A practice manager organizes everyone. All this staff means that patients (or patients’ insurance companies) are not just paying for their doctor’s time, but also for numerous people who have been hired to deal with the insurance company and increase the doctor’s efficiency. Studies have shown that in a typical practice, 40% of the cost of medical care goes directly to dealing with the insurance company. The higher cost of medical care also leads to higher insurance costs.
But what if you start eliminating this complexity? First, providing care tailored specifically to people who are paying out of pocket eliminates insurance companies. No biller. No referral specialist. The physician slows down and sees fewer patients. She rooms those patients herself, checks blood pressures, and draws blood. No receptionist, no medical assistant. By slowing down, the physician is able to see everyone the same day they call. No need for a triage nurse to decide if someone’s story is good enough to warrant an immediate appointment. No staff means no practice manager to manage them all. Pretty soon, you are down to the key relationship in medical care: a patient and a physician.
My husband, Tim, and I have joked for years that if someone would just pay our bills, I’d work for free. We’d heard of physicians providing care for a set fee no matter how much or how little someone comes in. Some such practices are prohibitively expensive…$2000 a year for the “Gold Membership,” $3000 a year for the “Platinum Membership” — but we figured that by keeping overhead low, we could manage on $30 a month per person. We’d seen such a system compared to a gym membership or a club membership, but we didn’t like that concept because we don’t do gym memberships or club memberships. We’d also heard these sorts of practices described as “self-supporting,” which we thought was silly since it was obviously the patients providing the support. We didn’t like the focus on the physician. A physician is merely an adviser, prescriber, and piecer-togetherer…truly, the medical care belongs to the patients.
Inspired by the concepts of an Ideal Micropractice and Direct Primary Care, we envisioned a community of people coming together to support a primary care provider who would, in turn, provide medical care for those people. Because the provider’s income was assured, there would be no need to charge extra for appointments or refuse to talk with patients via phone or email, which doesn’t pay. This would allow the members direct access to their provider. The provider could also easily offer alternatives to the traditional appointment when appropriate, such as group classes and workshops, at no charge to the members. One evening, we were tossing our alternative idea around with friends and one of them commented, “It sounds like Community Supported Agriculture.” And so the concept of the community supported medical home was born.