I was in Harrisburg on Friday morning, presenting the concept of Direct Primary Care to a room full of employers, employer benefits specialists, and other doctors. It was the inaugural conference of the Free Market Medical Association, Pennsylvania Chapter. For many in the audience, it was the first time that they had heard of such a thing as Direct Primary Care. I always love the reactions I get: excitement, relief, and hope for lowering cost on something so foundational as primary care. Employers and patients love that there is a solution to the health care squeeze. An attendee quoted the following during my presentation: “@CovenantMD is giving an enlightening talk on Direct Primary Care medicine at FMMA PA chapter meeting. This folks is the future! Sign me up.”
Dr. Rohal speaking at the FMMA in Harrisburg last Friday.
After my talk, I was approached by a representative of the Commonwealth Foundation, a conservative think tank in Pennsylvania. “We would like you to share some patient stories with us, stories that we can take to lawmakers in Harrisburg in order to advocate for DPC-friendly legislation and raise awareness of free market medicine.”*
And so I’ve written this blog post in answer to that request, and also to tell of our experience in the first ten months of the life of CovenantMD. For the sake of context, especially for those that might read this post that are not familiar with us: CovenantMD is a Direct Primary Care practice. Patients pay us a monthly fee, and enjoy same and next day visits, extended time with the doctor, 24/7 call coverage, discounts on medications, labwork, and radiology, and housecalls. A family pays less than the price of cable for all of these amenities. We keep the practice small, capping at 600 patients per doctor, whereas the average family doctor cares for 2500. This ensures that we can always deliver high quality care for great value.
Why are we doing this? Because primary care is broken. We believe that the first step in restoring primary care, and ultimately the doctor/patient relationship, is to remove third parties from paying for it. That’s why we don’t bill health insurance. Instead, our patients reserve their insurance for the less common, more expensive occurrences. Like how car insurance works.
And how are we doing? We're one of the fastest growing Direct Primary Care practices in the country. I think this indicates that people in south central Pennsylvania are ready to think outside of the box when it comes to healthcare and saving money.
So onto the stories. I’ll group them under two headings, each representing a major appeal of Direct Primary Care: 1) the value proposition, and 2) the quality proposition. (I do not use patient names. Each of the patients described in these vignettes have graciously given their consent for me to use their stories.)
DPC BRINGS VALUE
A type 2 diabetic working a low wage job joined CovenantMD. She was paying $400 quarterly to the local hospital for routine bloodwork. She now pays $30 quarterly to CovenantMD for the same bloodwork. And we have the time to coach her through dietary choices, which are far more powerful for controlling diabetes than any pill we can prescribe.
A couple was paying $790/month for their medications. They joined CovenantMD and now get the same medications, dispensed right from our in-house pharmacy, for $92/month. This couple MADE money by joining CovenantMD.
A family of four joined us when we opened in January. They transitioned from Highmark, whose skyrocketing premiums became unaffordable, to Samaritan Ministries (a sharing plan), which decreased their cost of catastrophic coverage by 75%. As Samaritan does not cover routine or preventive care, they went with CovenantMD for primary care services. It turns out they had a rough few months out of the gate— 5 visits to the doctor, two of which were home visits. All of these visits were no additional charge.
Just last week, a patient joined us, attracted by the time she could spend with one doctor, and by the discounts we are able to facilitate on radiology. Two months ago, she paid $965 to a local hospital for an ultrasound. She was not aware of this price, and her responsibility for paying ALL of it, until she received the Explanation of Benefits from her insurance company six weeks later. This bill has caused her to forego other tests that physicians have recommended, for fear of cost. She is now in need of another ultrasound. We were able to arrange one for $120, payable before the test, with no surprises. We were then able to get some of the lab testing she had avoided for fear of the cost — our price was $3. Decreasing cost reduces barriers to care. It also facilitates better patient outcomes.
DPC BRINGS QUALITY
Dr. Rohal and Hannah Barry, R.N.
What happens when your primary care physician (and his nurse), has the time to sit down with you and parse through your dietary choices, and then make recommendations that may in themselves be just as therapeutic, if not more, than medications? A type 2 diabetic joined CovenantMD a couple of months ago. He was taking 70 units of long-acting insulin at night. Insulin is, obviously, a very effective medication for controlling blood sugar. But it can also perpetuate the cycle of insulin resistance that is the core problem in type 2 diabetes, and cause weight gain. So we counseled him to adopt a low carbohydrate diet, to essentially decrease his body’s need for insulin, naturally. He is now OFF of insulin.
One of our patients sustained a laceration one Tuesday evening. She immediately called my cell phone, and I arranged a visit in the office for 30 minutes later. She had no wait for the visit, the stitches were placed by the physician who knows her, and she left with a scheduled visit for stitch removal at no additional charge. Time in office: 45 minutes. Cost: $50 (our after hours fee). The comparable cost in an Emergency Room: $1200, with a long wait to boot.
We run a weight loss program at CovenantMD. No additional cost to our patients, and based on a whole foods diet. We have 45 patients enrolled. Our nurse, Hannah, follows up weekly with these patients to provide encouragement and troubleshooting. Again, here’s that factor of TIME. Average weight lost is 14 pounds for those that have been with the program at least three months.
An 11-year-old boy, who followed me to CovenantMD from my prior practice, needed stitches on a Tuesday afternoon, which I placed in my office. I performed a housecall one week later to take them out. His 4 siblings had a field day rifling through my doctor bag, then watching with rapt attention as I took out their brother’s stitches. When I was finished, he took down a wrapped gift from his mantle. I opened it, and found the name plate, spelling “Dr Rohal”, pictured at the top of this post. He traced the letters himself, and spent a week carving them out using a scoring saw. “I have favor with you as my doctor,” he said. I can’t think of a greater gift, nor a greater compliment. I display that nameplate proudly.
I drove 30 minutes to my Amish patient’s home one weekday morning, and sat with him and his wife at their dining room table, divulging the results of his screening chest CT scan the day before: a large tumor in his right lung. In that quiet kitchen, there were some long silences, and some tough questions. I did the best I could in answering them. I cringe to think of what my patient’s experience of receiving this news might have been in a standard family practice, with a crowded waiting room, a physician running behind, a 10 minute appointment. Direct Primary Care brings freedom for the both the patient, the patient’s family, and the physician.
There’s some snapshots of ten months of Direct Primary Care at CovenantMD.
Patrick Rohal, MD, FAAFP is a family doctor and the founder of CovenantMD. He lives in Landisville with his wife Lynn and three little soccer and piano players.
*Though Pennsylvania is friendly to direct primary care, some states see it as a form of insurance, given the monthly fee. 16 states have legislation explicitly recognizing direct primary care as NOT insurance, and efforts are underway to advocate for such legislation in Pennsylvania.