WASHINGTON — Primary care physicians can curb healthcare costs and improve patient outcomes via telemedicine and new payment models and purchasing options, witnesses told the Senate Health, Education, Labor and Pensions Committee on Tuesday.
In a direct primary care model — what Joshua Umbehr, MD, of Atlas MD in Wichita, Kansas, characterized as a more affordable cousin of “concierge care” — patients pay a monthly fee based on age.
Most adults in his practice pay $50 per month, and coverage for children starts at about $10 per month, Umbehr told the committee.
That membership provides patients with unlimited home, work, and office visits and telemedicine services, all without copays, he said. In addition, most basic procedures that a primary care physician performs — such as stitching, lung or bone testing, and biopsies — are all free in his practice, he added. Other physicians may charge a nominal fee — perhaps $5 — to cover these services.
“We can get typecast as anti-insurance or anti-government,” Umbehr said, but he said he supports the idea of insurance, when it’s used appropriately.
“Insurance is perfect for expensive things, hospitalizations, major car wrecks, your house catches on fire, but … you don’t submit an insurance claim to wash your car, to paint a new room in your house, [or get] an oil change. … Insurance is a great tool, but not for affordable things,” he told reporters after the hearing.
Asked by Sen. Doug Jones (D-Ala.) whether physicians practicing in direct primary care ever drop patients when they become seriously ill, Umbehr said that would be “inconsistent [with] the physician oath.”
Another way his practice saves money is through thoughtfully purchasing supplies and medications. Umbehr said he can purchase medications for up to 95% less by buying them wholesale.
“We’ve been able to get breast cancer chemotherapy for $6 a month, when the patient was quoted $600 a month with her health insurance, not because we’re special, but because that’s the wholesale price,” he said.
Umbehr noted that such purchases are possible for physicians in 44 states, where it’s allowed by law.
Sen. Lamar Alexander (R-Tenn.) asked, “well, if any doctor can do that in 44 states, why not do more than that?”
“Most don’t know they can,” Umbehr replied. “Most physicians still are surprised to find out what the true wholesale price of medicines are.”
Katherine Bennett, MD, of the University of Washington in Seattle, highlighted the role of telemedicine in increasing access to primary care services.
Bennett cited Project Extension for Community Health Outcomes (ECHO), which began in 2003 in New Mexico as a program for hepatitis C patients and succeeded in reducing wait times for those patients from 8 months to 2 weeks.
The program employed a “hub and spoke” teaching and consulting design, with the hub being specialists at an academic medical center and primary care clinicians in community clinics as the spokes. Researchers found that care provided to hepatitis C patients by ECHO- trained primary care clinicians was “just as good, with the same cure rates” as care from specialists, Bennett noted in a written testimony.
There are currently more than 400 ECHO programs across the country, including 10 active programs at her institution. One is focused on geriatrics, of which Bennett is the founding medical director, with an aim to enhance the quality of care primary care clinicians provide to older Americans.
A unique feature of this program, according to Bennett, is that it focuses on family medicine residents. While residencies in the region require 100 hours of training in geriatrics, most of these residencies aren’t staffed with geriatricians who can support the requirement. As a result, geriatric care suffers, she said.
Bennett noted that because primary care clinicians receive minimal geriatrics training, many of the older adults she sees are on long lists of medication, have untreated osteoporosis, and have dementia that’s gone undiagnosed for years.
While there aren’t extensive patient outcomes data on the 10 Project ECHO models that target geriatric care throughout the country, Bennett noted that some have helped to reduce hospital admissions and use of physical restraints in nursing homes. Some pain management ECHO programs have also cut use of opioids for chronic pain, curbed inappropriate referrals to surgeons, and increased referrals to physical therapy.
Bennett urged for greater investments to research these care models.
“We need continued funding to obtain this critical information,” she said.
Asked about other obstacles to expanding these payment and delivery models, Umbehr urged Congress to help broaden the Internal Revenue Services’ definition of a health savings account expense.
As for telemedicine, Sapna Kripalani, MD, of Vanderbilt University Medical Center in Nashville, spoke of eliminating the “originating site” rules of reimbursement that, in her state, require care to be provided in a clinic instead of patients’ homes.
For many patients, childcare and transportation are as much a barrier as physical distance. Offering “clinic to clinic coverage” won’t help with either of these challenges, she said.
As for the primary care workforce, Kripalani told MedPage Today after the hearing that help with educational loans, expanding medical training to include more outpatient care, and simply increasing reimbursement for primary care services can alleviate the primary care physician shortage.
Residents “recognize this half-the-pay, twice-the-work type of burden that makes them feel like … going into another field where they don’t have to deal with some of those burdens,” she said.