Potential differences in philosophy in employer based d.p.c. model

(cjs56) #1

I was wondering if anyone in the employed D.P.C. model (either at an office at the employer work site OR at an office off-site from the employer location) has ever experienced a situation whereby the patient(s) request a medication or service that is not agreeable to the D.P.C. physician? That is, suppose an employee (patient) requested new or continued opioids (or even antibiotics for a viral illness) and the D.P.C. physician felt strongly that the patient (employee) did not need the medication or the medication could be detrimental to the patient (sound medical judgment). However, let’s say the patient complains to his/her employer who then complains the the D.P.C. physician’s employer? Or, even if the D.P.C. physician had his/her own private D.P.C. practice, how could the D.P.C. physician resolve the issue with the patient’s employer without losing a 50 patient panel (all the employees)? Or, would the D.P.C. physician only lose those employees that were in disagreement? This could be a potential source of disagreement between the physician and his/her employer as well as a conflict of interest between the physician and the patients’ employer. I would assume there would be much more leeway for the private D.P.C. physician who could spell this out in a written contract with an employer group. But, I could see that as an employed D.P.C. physician, there could be a difference of philosophy. Has anyone experienced this and what suggestions would you have for resolution without losing D.P.C. patients? I know this happens at urgent care clinics as well as Federally Qualified Health Centers and most times it is left up to the individual physician’s judgment.

(Robin Dickinson) #2

@drcflanagan Is this a situation you’ve run across? I personally cannot imagine an employee complaining to an employer about not getting opioids :slight_smile: but maybe the antibiotics.

From my perspective not dealing with employers at all, patients trust me so even in those annoying situations where I eventually end up starting abx and they get better right away, they believe me when I explain that it was viral and then became bacterial and that earlier antibiotics would have caused a resistant infection. They know I’m seeing them repeatedly without charging more so I’m not just trying to line my pockets, they know I’m the one risking having to deal with them on the weekend instead of just prescribing, that I really just want what’s best for them.

(cjs56) #3

Have not run across it. But, was trying to see if it could apply to a D.P.C. employer based model. I assume it could but was trying to get the point of view of physicians already in the D.P.C. employer model.

(Robin Dickinson) #4

@cjs56 Lots of practices work with employer groups. For some it’s small scale where most of their practice is individuals and family. For others, it makes up the bulk of their practice.

(Bruce Jung) #5

@cjs56 and @Robin_Dickinson, I certainly see this as a valid DPC concern about any third party payer, whether it be the employer, a friend, an insurance company or Medicaid/Medicare. I have no definitive answers, but maybe a few helpful safeguards. (BTW, I have 58 employees from 8 different employers, with the largest two employers having 21 and 18 employees. I have 374 privately contracted patients that make up the rest of my panel.)

  1. Contract with large employers (my definition of large is >50) with some trepidation. As you mentioned, losing one large employer can have dramatic repercussions, as I suspect most employees would not sign up for our plan on their own, if the company dropped their contract with us. (Not that our plan is expensive. It’s not, but that our community is indigent).
  2. Advise the HR person or owner up front that you are the patient’s physician, not the company’s doctor. You appreciate their willingness to offer a payroll deduction or pay outright for their employee’s membership fee, but when push comes to shove, you will advocate for what you understand to be the best care you can offer to the patient, payer not withstanding.
  3. As Robin indicated, develop relationships of trust and integrity, first with the patients/employees and then also with the employer.
  4. Recognize that member-by-member growth is slower, but also more stable. People are more inclined to appreciate the value of your DPC service when they are contributing to the cost. When someone else pays for the care you offer them, they are less likely to appreciate it and more inclined to feel “entitled” to their own whims or perceptions of good care.
  5. It is probably worth involving an attorney in developing a contract with a large group. For instance, I have courted a local soft drink company with well over 300 employees and would need to hire another provider if they signed up. For that reason, I would want to have a guaranteed contract length and/or large early termination penalty to help compensate for all the trouble in having to release a provider I could no longer afford. Plus, with a longer contract period, it is more likely that the new provider will have established a significant enough patient base to continue to work even if the large employer contract ended.
    Not sure if any of this helps, but some thoughts that came to mind at first blush.

(Robin Dickinson) #6

That’s brilliant and not something I’d thought of. For sure large employers are more risky to take on but those are ways of mitigating the risk.

I really appreciate your perspective as someone who does employer groups!

(cjs56) #7

That’s pretty good Bruce. Excellent advise. It seems private D.P.C. is better when contracting with smaller employer groups. More personal.

Thus far, my intense but short research (2-3 weeks) regarding D.P.C. physicians being employed by “corporate D.P.C. groups” that contract with employers and use either “on-site clinics” located at the work site …or… medical offices close by the work site… has been pretty bad.

The webinars allow much learning.

  1. But, there is always a void in the answers given regarding what to do if the patient requests opioids that are not indicated. It seems that the physician is still in the same bind as a traditional practice. There is no guarantee that the company employer or the physician employer would be empathetic with the physician employee.
  2. Further, these employed D.P.C. models can also have an occupational medicine component which is a disaster for a physician not interested in this type of medicine. Patients linger on and are slow to get better from minor back injuries. Also, the legal documentation has to be very specific.
  3. The employed D.P.C. model can’t really give an idea on how many pediatric patients would be seen.
  4. The phone and email contacts of the employed D.P.C. models are frequently non-physicians who really do not understand how a medical practice functions.
  5. As in a traditional practice, the employed D.P.C. physician’s incentive or bonus is dependent on patient outcomes. This is fair enough. But, what happens if the patients are all smokers and beer drinkers in a Michigan or Pennsylvania factory? And, the outcomes are not that great, and in addition, are not due to the fault of the D.P.C. physician?
  6. Then, the employed D.P.C. physician does not get a bonus. Just like an employed traditional model.
  7. The hybrid (practices that incorporate both D.P.C. and traditional model practices) are a whole different animal. There is no guarantee when or if a new “D.P.C. physician” would see any direct primary care patients in these practices. The model is so unpredictable. There is never any time line when the traditional insurance patients would transition into a D.P.C. model. Frequently, nurse practitioners are used to see all the traditional insurance patients until the D.P.C. practice employer decides if and when to transition.

This is what I have learned thus far.

(cjs56) #8

Hi Clint. In the April 2017 Hint Summit (I think in S.F.), you mentioned that Nextera can do some of the “blocking and tackling” for the private D.P.C. physicians with reference to assisting in obtaining large employer groups as “clients” (or a larger number of patients through patient panels).I know that talk was only fifteen minutes. But, I was wondering if you could clarify what you mean by blocking and tackling? I assume and am pretty sure you mean: marketing, legal contracting, H.I.P.A.A. issues, outcome studies, etc., etc. But, can you elaborate a bit more on some of the other value-added services that would benefit D.P.C. physicians.
Thank you for your time and clarity.

(Robin Dickinson) #9

@drcflanagan see above from a physician (from Calif)

(Dr Clint Flanagan) #10

May I ask who is posting this?

(cjs56) #11

Hi Clint. I am Stephen Croughan, M.D., Family Medicine in CA. I saw your lecture at the April 2017 Hint conference in S.F.

I had a quick question regarding D.P.C. and employers (see previous email).

Also, what would be the major functions of a broker? I have an idea that brokers function in gathering outcomes data from D.P.C. practices and presenting that data in an understandable way to the employers. This is probably done through technological instruments which make the data and information more easily comprehended. But, I was wondering in what ways the brokers can provide a better understanding of the data as opposed to the D.P.C. physicians? In other words, what would the D.P.C. physicians lack that the brokers have? Would it be more time and better technological knowledge to know what to do with the data?