OUR PRACTICE, Megunticook Family Medicine, is an outpatient direct primary care (DPC) practice in mostly rural Midcoast Maine. DPC practices bill patients or employers directly for care via membership dues rather than fee for service from third-party payers (Huff, 2015). While the DPC model is a descendent of concierge practices, with 1 physician and 1.5 full-time employees and just under 600 patients, we are also very much a product of the Ideal Medical Practice project (Moore & Wasson, 2007). Our patients range from retirees and coastal summer residents to lobstermen, other blue-collar workers, and some economically struggling patients who receive free memberships. About 25% are uninsured, 50% have high deductible plans or the equivalent, and the remainder have Medicaid, Medicare, or the few remaining “good” lower deductible insurance policies.
The local hospital, like many, is now owned by a large hospital network. Only a few independent practices survive so, like many rural areas, the hospital network has a local monopoly on most medical services.
Maine is mostly rural, with only a few, small urban areas, and significant portions of the economy, especially here near the coast, are heavily dependent on tourism from other states. Due to state business shutdowns and quarantine requirements, the local economy has been greatly affected. This has driven much of the political debate in our media. While Maine politics may be polarized, political views have not yet been an issue in the office. A significant minority enter the office without a mask but have been apologetic when reminded that data suggest masks reduce the risk to our staff and fellow patients. Contrary to what we recently encountered during an antivaccine referendum, those voicing skepticism about the pandemic itself, or the effectiveness of precautions, seem to be less certain of their convictions. Whether our brief interventions with them change high-risk behaviors for coronavirus disease-2019 (COVID-19) transmission in the community is open to speculation.
We maintain a small but active presence on some social media as a means of advertising the practice and educating about our direct care model. At the start of the pandemic, we noticed a surge in interest, especially our first postings related to initial Centers for Disease Control and Prevention (CDC) isolation, return to work, and other COVID-19 recommendations.
PRACTICE SUSTAINABILITY AND COSTS OF CARE
As a DPC practice, our finances have been remarkably stable thus far. While independent practices both locally and nationally have suffered severe cash flow problems due to reduced fee-for-service revenue, DPC practices, which instead depend upon monthly dues paid directly out of pocket from patients or via an employer (Busch et al., 2020), have been quite stable. With travel safety concerns and a current 14-day quarantine for anyone returning from other states, some of our “snowbird” patients have delayed their spring return to Maine, so we had much less than our typical 4% seasonal increase in panel size. Otherwise, membership numbers have been quite stable.
Several factors likely explain our membership stability. Our patients who pay individually for membership frequently have complex medical problems or have high out-of-pocket costs or both. Our complex and elderly patients are especially fearful of virus exposure and many now value our small office for visits and blood draws compared with the larger, busier clinic and laboratory run by the local hospital. Both groups value our better access, as they fear the emergency department due to perceived infection risks and known high prices. Our high out-of-pocket cost patients also value the savings we offer or find for laboratory tests, generic medications, imaging, and even surgical procedures. These savings significantly reduce their costs for primary care membership and, for our uninsured patients charged the full chargemaster pricing by the local hospital network, can frequently exceed their annual membership fees (Megunticook Family Medicine, n.d.).
Our employer-sponsored memberships have only been slightly affected by pandemic economics. One employer, whose business shut down, laid off several employees and discontinued payments for their memberships. These patients were kept in the practice.
Our business model also simplified our responses to the changing needs of practice in a pandemic environment. Without payer requirements to consider, we already used telephone and Internet messaging in lieu of office visits more than traditional practices and easily expanded these. Video visits and secure texting via Signal, a free encrypted application produced by a nonprofit (Signal Messenger, LLC, 2020), were added in an afternoon once the federal government's requirement for Business Associate Agreements from vendors was relaxed.
PATIENT EXPERIENCE OF CARE
The initial weeks of the pandemic were strangely quiet and slow. Between March and April of this year, we saw less than half the typical number of patients per day (Figure). Initially, we also had a slight increase in house calls, which suddenly became complex with the careful choreography of donning and removing personal protective equipment (PPE) alone in driveways and seeing patients on porches or outside their house when possible. Fortunately, we have settled back to the usual pace of a few house calls per month. With social distancing rules in place, we saw more patients utilizing the option for telephone, video, or secure messaging. Our practice already utilized messaging on our online patient portal to handle nonvisit needs, and we have seen that service utilized more in recent months to avoid in-person visits.
Most of our newly freed time was spent increasing our PPE stores, researching Medicare emergency billing in preparation for a return to inpatient work in the event of a hospital physician shortage, and completing enough precepted cases to begin point-of-care ultrasound, especially for lung imaging that might be needed as COVID-19 cases increased. Fortunately, Maine has not yet experienced full hospitals nor physician shortages and Maine's CDC delivered supplies of PPE to our office early in the pandemic response. Our new ultrasound capabilities have not been needed for COVID-19 cases but have saved some patients an expensive trip, and exposure risk, to the hospital to rule out deep vein thrombosis.
Nasopharyngeal swab testing, point-of-care coagulation tests, and nebulizer treatments are now usually done in a partitioned portion of our office porch or, occasionally, with the patient still seated in their car in our parking lot.
After 2 months of adapting to the pandemic and social distancing, we note requests for office visits increasing. Many requests are for annual health maintenance reviews that can be appropriately managed by phone. When prompted, most patients are amenable to minimizing their risks by handling appointments by phone, message, or video visits but there is a wide range from those eager to schedule annual “physicals” to those still reluctant to come in for overdue laboratory tests. The care patients want has changed as a reflection of the outside circumstances of the pandemic.
Outside our office, we noticed a big shift in availability of our consulting specialists at the time office visit volume markedly dropped. Consulting specialists that had long waits for the next appointment suddenly were readily available, and patients could get consultations by phone instead of traveling long distances to their offices near one of Maine's tertiary care centers. This may be short lived, as we have already noticed a decrease in availability and return to the normal wait times. Worse, despite the surge in interest in telemedicine nationally and Maine relaxing in-state licensing requirements for telemedicine providers, we have yet to find appropriate vendors to expand our patients' options for telemedicine consultations to reduce their frequently long waits, long drives, and high out-of-pocket costs.
One subset of our patients very affected by the changes have been those we are treating for substance use disorders. We had hosted regular group counseling by an independent addiction counselor within our office suite, which was not suitable for social distancing precautions. Our medication-assisted treatment patients report the change to individual phone or video counseling lacks the mutual support and camaraderie with their fellow patients. Plans for an outdoor counseling session with proper social distancing are being made to provide this camaraderie that has been lacking in recent months.
With another subset of patients, those admitted to the local hospital, our frequent use of social rounds is no longer worth the infection risk, but the local hospitalists have been good at communicating by text, and, when needed, we have simply contacted these patients by phone.
While many aspects of the pandemic response are beyond our control, adapting our practice to better meet the needs of our patients during this time has been very challenging yet very rewarding professionally.
Some new opportunities and challenges lie ahead. In the near term, during this window of reduced state licensing requirements, we will continue to search for new telemedicine options for consulting specialties. We hope to find a setting for group addiction counseling compatible with both patient privacy and pandemic precautions. We are cautiously adding new patients from our wait-list as capacity allows. Besides serving more patients, this provides some additional financial stability in case prolonged economic hardship begins to take a toll on dues revenue.
Longer term, while we have been able to continue improving our patients' experience of care and their costs despite a pandemic on top of an already frequently dysfunctional medical care economy, both our pandemic responses and our DPC model itself need outcomes data.
Busch F., Grzeskowiak D., Huth E. (2020). Direct primary care
: Evaluating a new model of delivery and financing. Retrieved from https://www.soa.org/resources/research-reports/2020/direct-primary-care-eval-model/
Huff C. (2015). Direct primary care
: Concierge care for the masses. Health Affairs, 34(12), 2016–2019. doi:10.1377/hlthaff.2015.1281
Moore L. G., Wasson J. H. (2007). The ideal medical practice model: Improving efficiency, quality and the doctor-patient relationship. Family Practice Management, 14(8), 20–24.
Signal Messenger, LLC. (2020). Signal—Private Messenger (Version 3.11) [mobile application software]. Mountain View, CA; Author.