How good could the future be?

Instead of a traditional primary care provider, you have Nancy. Nancy is a physician’s assistant, but with an educational background that included much, much more exercise physiology, nutrition, and mental health training than PA’s and Nurse Practioner’s were getting at the beginning of the 21^st century. Nancy belongs to a group that calls themselves a ‘Direct Primary Wellness’ practice.

But Nancy doesn’t call herself a PA when you meet her, and she’s not wearing the traditional white Dr/PA gown. And she doesn’t call you a ‘patient’, either. During your introductory visit, Nancy explains that the reason she’s wearing a sports polo is that she will be filling the role of your coach, and that you, in turn, be treated like a high performing athlete. She explains that she works for you – you are her customer – and that her role in your care will start with getting to know you as a person. To do so she will ask you some fairly deep, probing questions about your personal beliefs; your present state of health or details about any chronic conditions; and your personal and family medical history. With that, she and the rest of her coaching staff will collaborate with you on a personalized health and wellness plan with the goal of optimizing your quality of life – for the rest of your life. One topic to discuss will be the possible use of predictive genetic screening and the frequency and contents of periodic physicals based on your unique circumstances and, most important … your own desires.

Nancy explains that the first and most important part of your new relationship is to establish trust; that with trust, you can work together and incredible things are possible. Absent trust, her contribution, based on her unique experiences and education, won’t be helpful to you. So she asks you to prepare to check in on trust before continuing forward, and to be brutally honest. If the two of you can’t connect, she explains, she won’t take it personally. Instead she’ll introduce you to other colleagues who differ in education, experience, age, sex, religion, life experiences or beliefs with the goal of finding a better fit for you. Once you’ve teamed up with your trusted coach, Nancy goes on to explain, there will be both a backup primary coach whom you’ll also choose, as well as your chosen primary physician and a backup for them.

Additionally, Nancy explains that you have an entire stable of specialty coaching studs who can be brought in to advise as you need them. Each is an expert in their own area, including nutrition, exercise physiology, sleep management, behavioral health/psychology/psychiatry, physical and occupational therapy, chiropractic care, internal medicine, OBGYN, cardiology, ENT, geriatrics, surgery, and genetic counseling.   All are accessible via secure video, text, or email when a human touch isn’t necessary for the question at hand. Depending on your needs, some of the specialists may provide telemedicine consults, provide second opinions, or simply prep you with good questions for you to share with your chosen local specialist. There are also experts in healthcare insurance and reimbursement, and medical/legal topics such as healthcare powers of attorney, advance directives, and trusts. The key is that all of your coaches are completely aligned with your best interests. None benefit from over utilization or under utilization of services or procedures. None have a financial stake in your options. All are dedicated to helping you make well informed choices unique to your personal circumstances and beliefs.

Finally, Nancy explains that when you need it, you’ll have access to expert medical ‘shoppers’. What are ‘shoppers’, you ask? Nancy explains that they are a team whose soul function is to help you understand what options you have available to you when you eventually need a diagnostic test, a surgical procedure, a piece of durable medical equipment, or some other specialized medical service or product that Nancy’s practice doesn’t provide. The Shoppers, who all have their own areas of expertise, will provide you with whatever Centers of Excellence, quality, outcomes and cost information is publically available so you can make your decision on what to do and where to go based on the best information available. If you receive an Explanation of Benefits or bill from another provider that you don’t understand, your Shopper will help explain it to you and, if needed, Proxy on your behalf in discussing questionable charges or negotiating a discount or payment plan with that provider’s billing staff.

You’re intrigued, you tell Nancy, but you have a few questions.

First of all, you ask, walk me through an example of how this whole thing works. What happens if I hurt my back while I’m doing yard work, and have to have back surgery?

Great example, Nancy replies. I couldn’t have picked a better one if I were writing a script for this conversation! For starters, we use a fairly intensive on-boarding process to get acquainted with our new athletes. That includes understanding both your exercise preferences as well as your typical activities of daily living. From this, if we now understand that you do quite a bit of yard work including occasional heavy lifting, our first goal would be to make sure you received some specific coaching on how to lift heavy objects – as well as when to choose not to lift them. Remember; we want to do everything we can to collaborate with you and keep you out of the healthcare delivery system. Life happens, though, and if you still strained your back, you and your coach would work with our orthopedic specialist to come up with viable alternatives to treat your injury. Options might include some combination of physical therapy, pain management (prescription or OTC meds, or other), yoga, exercise, massage therapy, surgery, chiropractic care, or acupuncture. Some of which we may be able to provide, most we would not. In the course of the discussion, the coaches share what data is available in regards to comparative effectiveness of different treatments (including Numbers Needed to Treat and Numbers Needed to Harm – NNT and NNH – when available), and mention that back surgery, while viable, is one of the most over-utilized procedures with some of the weakest effectiveness data and the least favorable NNT/NNH available.

If we know of social networks specific to your condition, we’d bring that to your attention so you have the option of communicating with (and possibly learning from) others who have gone or are going through similar experiences.

Our shared goal throughout this process would be to make you aware of your options, their pros and cons, and our best advice on what might be most effective for you given your unique circumstances, beliefs, and, if applicable, past medical and family medical histories. In contrast, we are not motivated to provide you with more services that we can bill for (since we generally don’t bill for individual services), or evangelize for any specific specialty or profession.

With options identified, you would decide how to proceed. If you chose an option where our shopper might help, they would get involved at that stage. If needed, we’d help you share some or all of your Personal Wellness Record with other providers you’ve chosen, and we’d collaborate with them until your care was complete and you were returned to full health.   If yours was a chronic condition requiring care from several providers over time, we’d act on your behalf as your PCP and coordinate care, treatments and medications across physicians. In our role in helping you with your chronic condition, we’d encourage progress toward returning you to full health as opposed to simply treating your symptoms.   Likewise, if you needed diagnostic tests (such as labs or images), or a surgical or hospital visit, our shoppers would help you select the diagnostic testing agency, hospital or surgical center, and your coach or PCP would be available by phone to advocate on your behalf and coordinate with your providers throughout any required inpatient stay. If there were questions or difficulties with your insurance or billing, our specialty coaches would help with that as well.

Another question. Does your practice use an Electronic Health Record?

Nancy actually rocks back in her chair and laughs at this one. No, we don’t, she says. We don’t have an Electronic Health Record like other physician’s offices or hospitals. We don’t believe in them.   You’re surprised – in the little bit of time you’d spent trying to understand how healthcare could improve, EHR’s had always been mentioned. But before you can ask a follow-up question, Nancy goes on to explain that instead of an EHR, the practice uses a Personal Wellness Record or Personal Health Record. The difference is that Nancy and her fellow coaches are engaging with their athletes on a life-long basis. The only way to support continuity of care over that timeframe is to assume that their athletes will, over the course of their lifetimes, see other coaches of various types, and other physicians, and will visit several or more hospitals. And, of course, many of them will eventually discontinue their relationship with Nancy’s practice and move on. So to stay true to their commitment of focusing on what’s best for their athletes, as opposed to what’s best for the practice (using electronic records as a patient retention tool), they want to ensure that all records truly belong to the athlete. Nancy describes a portion of their on-boarding process where each new athlete is asked whether they currently have a Personal Health Record. If they do not, the coach establishes a new personal wellness record for them, gives the new athlete their credentials, gives them a short tour, and explains their privacy and security policies. In the course of the tour the coach explains how this record will belong to the athlete for life – even if or when they eventually leave the practice. In addition to wellness plans and goals, personal fitness device data, and home monitoring device data, all traditional medical information is stored and – at the athlete’s request – accessible to other physicians or providers via national (‘Meaningful Use’) interoperability standards or via temporary access credentials. Each individual athlete can share what they want with whomever they want, and can withdraw access from any coach, physician, or other provider at any time. Including Nancy or her colleagues. A log of all access to their records is always available to them.

If the new athlete does already have a PHR, they review it’s current contents together and compare it’s capabilities with the practice’s chosen PWR. At that stage, the new athlete has a choice: if they want to keep their current PHR, then the practice’s coaches will either request credentialing to access it directly, or enter new information into the practice’s PWR and transmit it on to the existing PHR via national interoperability standards.

Your visit is about to wrap up, but before you go, you can’t help but tell Nancy that she really seems to enjoy what she’s doing. Does she like her job, you ask?

Nancy leans forward and puts her hands on the table. I absolutely love it! Before coming to work here, I worked in four different primary care outpatient clinics, first as a pediatric nurse, then as a PA specializing in internal medicine. Two of them were owned by hospitals, but they were all about the same. I was miserable. My fellow nurses were miserable. But compared to the doctors, we had it easy! They were so frustrated that some of them actually retired early or left practice for another profession.

Reimbursements were continuously declining, so we were under constant pressure to see more patients and do more diagnostic tests from our in-office lab and imaging departments. It wasn’t unusual to see 35 or more patients in a day. Crank’em through. You had about two minutes to ask a question or three, then it was prescribe, refer, or order tests. I rarely took lunch. But worst of all, I never got to know my patients, and rarely saw the same patient twice. I never got to listen to them. I never knew if they got better. I’ll never forget the day after Christmas when I was in the office, and one of the doctors and I made eye contact and both said at the same time, ‘this is NOT what came into medicine for!’

That’s why I came here. My role is completely designed to focus on each of my athletes as unique individuals. Each has their own story, and their own path to follow through life. It’s my job to listen to them and know them! It’s my job to keep them healthy and completely out of the hospital and even the doctor’s office as much as possible! Then, when they’re sick or injured, it’s my job to cure them; not to do tests on them. Not to medicate them. I may need to do some of that, but I’m motivated by getting them back on the path to total health. I’m not motivated by doing as many services or tests as possible so my clinic can keep it’s doors open. I’m supported. I’ve got a whole slew of doctors and other colleagues I can draw from – all of whom team up to give our athletes choices. We work as a team, and we’re proud of what we do. We’re paid fairly, and we have a decent work/life balance, largely because we’re dealing with fewer medical crisis’ and have virtually no dealings with insurance companies about what we can or can’t do.

My athletes are like my family. Do you know I’m getting Christmas cards from a lot of them? That’s never happened to me before! This is why I came into the medical profession. And all of my doctor colleagues here feel the same. And … this is admittedly perverse … most of us take some satisfaction in who we’re pissing off with this model. Our drug reps hate coming here, because we write a fraction of the prescriptions others write and we recommend generics when we can. Our professional associations have disowned us because we advocate outside of our specialties.   Our cardiologist and orthopedist are either openly scorned by their colleagues, or secretly admired, because they often advocate for something other than a surgical procedure. But screw’em! Life gets simple and very, very rewarding when your only motive is what’s best for your athlete.

This all sounds great, you’re thinking. But now it’s time to ask the big question. How much does all of this cost?

Nancy smiles again. What do you consider expensive, she asks? About what you pay for your cable TV? Nancy goes on to explain that their fees are simple; there is a monthly subscription fee based on a single individual; individual plus spouse; or individual, spouse and children.   There is a discount if you join us young, and you get to hold that discount throughout your lifetime relationship with us. But, forgive the pun, the dollars do make sense. Compared to what our athletes would pay out of pocket for similar services, along with what we save them by helping them make value-based decisions and avoiding unnecessary over-utilization, we’re financially competitive.   It’s unfortunate that standardized quality measures that would allow us to compare to mainstream primary care are lacking, but I will say we take great pride and satisfaction in the care we deliver. And we can provide all the testimonials you’d care to read from our existing family of athletes.

It’s not for everyone, Nancy admits. But for those who share our beliefs and values, it’s the best deal going.