Primary care is in trouble, and many patients can see it. Despite paying more and more money for their health insurance, they find that their waits for the primary care provider are getting longer, and their visits are shorter. When they talk to their primary, they may notice they are harried or frazzled. Patients may even feel that although they know their doctor is smart, normally-attentive, and knows them, the quality of the care is slipping because the docs seem overwhelmed. Things might get missed. They may find that they can't even get in with their own actual doctor, because the practice is so busy. When they call the office, they rarely get a live person, and may wait days for a call back to address their concern.
Why, in a country that supposedly has the best health care system in the world, is this happening? And why is it getting worse?
In part, it's because our health care system is oriented towards reacting to diseases and problems, rather than pro-actively preventing them. We are not in a wellness-oriented system. As a result, the payment for care in this country is oriented towards paying for procedures to fix medical crises, rather than the time that could be spent to prevent them. Fifty years ago, when most family doctors did a mixture of live visits with their patients in addition to procedures, that didn't matter—thanks to doing both forms of care, they could make a living. Now, however, our physicians have become split, with specialists doing the procedures, and primary care doctors--that is, pediatricians who see children, internists who see adults, and family doctors, who see both—are doing the management: Talking to you, listening to you, designing care plans and writing prescriptions or ordering tests. As our medical system becomes increasingly complicated, the primary doctor becomes much more important in seeing the forest for the trees. An elbow orthopedic surgeon may know your elbow very well, but may not be up to speed on the rest of you.
So, at a time when primaries are needed more, and need MORE time with patients to do thoughtful work, they have found their reimbursements for all the time listening to, analyzing, and educating their patients--not to mention making phone calls to coordinate with specialists, social workers, family members, or anyone else involved in the care--those reimbursements are low or even non-existent.
Have you ever called your doctor's office for a prescription for something you've had before--say, an antibiotic for a sinus infection--and been told, "You have to come in." But then they don't have any free slots until 1-2 days later, and it's in the middle of your work day? So you have to cancel your work stuff to drive across town to wait 40 minutes in the waiting room to have 10 minutes with your frazzled primary, to get a scrip that you know she or he knows always works for you. WHY does this happen? Because the primary only gets paid for the in-person visit by your insurance, because an in-person visit is, according to our silly insurance system, a "procedure." But because this sort of "procedure"--which is mainly spent talking and maybe getting examined and having some tests ordered and prescriptions filled--is poorly paid, your primary may have to see 25-30 people a day just to keep the office afloat. Many primaries--myself included--found that despite working harder, they were only able at the end of the month to pay their staff, but not themselves.
E365, the model of primary care we're doing at the Sunrise Greenfield model,” because it was first created by a medical practice by that name located in Portland , Oregon Greenfield Argyros Health Center
How is E365 different? The visits are longer--an hour at the first visit, and half-hours for followups. The doctors see fewer live in-person visits per day, so they are less frazzled. They use computerized communications with their patients, a system called "RelayHealth" which allows patients to get their lab and X-ray results right into their own personal, and confidential, email account. Patients can send email messages to their doctor and the doctor's team whenever they wish, with a response within 24 hours. As opposed to a standard primary care office, where a patient may be told "you have to come in," in E365, the doctor and patient handle things by phone or email as they wish. In-person visits happen if doctor and patient agree this is the best or the necessary option. And the doctors have about 1/3rd as many patients to follow, resulting in more attentive care.
How does E365 make this possible? One factor is an annual membership payment that patients make to support the enhanced computer systems and staffing that make a preventive-care oriented model possible. (Maybe someday our insurance system will start paying practices to serve as this sort of “medical home," as it is called, but right now, insurance plans don't pay for any of this. EMA intends to conduct research demonstrating the improved outcomes with our system, to argue for more insurance support for such models.)
Many patients balk at the idea of paying a yearly amount to support care. "I"m already paying for the insurance," they comment. Agreed--but look where that, by itself, is getting us!
Think back to 1975. If, back then, you told someone you had invented something called "cable TV," for which they would pay an annual fee, they would say, "Pay for TV? You're crazy!" Of course, once people saw they could get more (and better) shows, with fewer commercials, paying an annual or monthly fee for cable seemed a great value.
Think back to 1980. If, back then, you told someone you had invented something called "Costco," for which they would pay an annual fee, they would say, "Pay, to shop at my grocery store? You're crazy!" Of course, once people saw they could get less-expensive goods all under one roof, the annual Costco membership seemed like a great value.
Likewise, E365, as a model that involves an annual payment, may seem "crazy" at first glance--just as cable TV and Costco did. But today, those things seem like a good value for a lot of people. Given our patient satisfaction scores at the existing La Quinta office, we believe E365 is giving people exactly what they wanted out of primary care: a strong relationship with a primary who really knows them, and whom they can reach when they need them. What may at first seem crazy, after trying it out seems "crazily good."
Is E365 concierge medicine? No. Although E365 has many of the conveniences of a concierge model, such as much better direct access to your doctor, E365 is not a concierge model. A concierge doctor typically has only 200-300 patients, and the annual fee usually starts around $1800 up to $5000 per year or more. In return, patients usually communicate just with the doctor via a direct cell phone. The fee for E365 is less than a third of the lowest concierge fee (and dependent children under age 18 are free). Also, given that the doctor may be in the middle of something when you are calling, E365 links your communication with a team, including the doctor's medical assistant or nurse and the front desk staff. Tasks are handled according to which staffer can get you what you need the fastest. E365 is an attempt to give patients many of the things they would like about a concierge experience, minus some of the pitfalls, at a more affordable price.
The cost for E365 membership is less than half what you might pay for bundled cable TV and internet services with TimeWarner. In fact, it’s half what you'd pay in a year for a daily Starbucks latte. If you belonged to a standard practice, and--even once--visited the ER because you couldn't easily get in with your primary for something, you will have paid more out of pocket for that single ER visit than you would have paid for your annual membership with E365.
We designed the E365 model to give people the things they wanted out of their primary care in the first place. But, we also recognize that, just as not everyone shops at Costco or has cable TV, this model won't be for everyone. Eisenhower Medical Associates also has standard, appointment-based practices across the Valley, including at our sister practice at Rimrock Shopping Center
One additional aspect to E365 and Eisenhower Medical Associates is that all of our doctors will be involved in Eisenhower's new educational programs, including training of medical students and resident doctors. We believe that by being medical educators in addition to care providers, we can guarantee our doctors are up-to-date on the latest and best knowledge for taking care of patients. We also hope to produce the next generation of doctors for the Coachella Valley
