Hello, everyone. My name is Dr. Eskew. I'm a family physician and I've practiced in the direct primary care setting for about a decade now since finishing residency. And we're going to talk today about looking at different conflicts of interest that can come up even when you're using a model like direct primary care that's designed to minimize those conflicts of interest. And then we'll do this not only abstractly, but we'll walk through several different clinical models. This is the kind of thing that physicians have come to Washington, D.C. to discuss for years and have had various frustrations with. So we'll go through several examples here. So how do medical ethics and practice models interact and create conflicts? And how can we ask policymakers to address those? If you hit one side of the spectrum, do you make things worse on the other side? So we'll see how some of that can play out. There are different clinical examples of how cardiology can have this happen, and I picked some of those to walk through. But you could pick just about any specialty and do the same thing. And then we'll discuss how different models are designed or happen organically, in the case of DPC, to try to get rid of some of these conflicts. And there's one more outline. I kind of went through some of that. We'll look at some alternatives to fee-for-service. So fee-for-service has the regular kind of overuse conflict and the utilization management conflicts that seem to come up there as both the patient and the physician are incentivized to sort of do more, do more, do more. And then you have a payer saying no, don't do that, no, don't do that. Different models change from fee-for-service to some sort of monthly payment or capitated payment. The PACE there stands for Program for All-Inclusive Care of the Elderly. That's one example. And those patients are trying to stay out of nursing homes, and they do all their primary care for a monthly fee that's paid through some combination of Medicaid and Medicare, typically. But each of these things has its drawbacks and advantages, and we'll dig into that. So if you look at different principles of medical ethics, if you've taken a class on this, these words will be familiar to you. You've got autonomy, beneficence, non-maleficence, and justice. And these things are all important, and when you play them out, they all can conflict in various ways. On the surface, they're supposed to be equal. But in different health care models, some are held in more esteem than others. Autonomy means that you're respecting the patient's right to make their own choices. And that right includes, of course, decisions about their own health care. And in the United States, at least I would argue, this has been the one that we have listed as the most important when we're forced to put things in a hierarchy. There's beneficence, duty to do good, creating environments and practices that help people achieve their best health. Then you've got, of course, non-maleficence, first do no harm. Justice means treating people equally and fairly regardless of their health status, or maybe in the United States, regardless of whether or not they have insurance or ability to pay. All of those things are important. Is autonomy greater than beneficence, non-maleficence, and justice? In the United States, I would say that we switched from a system where non-maleficence was maybe the highest to autonomy. And you can think of many clinical examples of that, but the most common one might be that you have patients show up in an urgent care, convinced that they have some sort of infection that requires an antibiotic. The physician might be convinced otherwise. And instead of taking all the time to explain that or hopefully get somewhere, they'd sort of give up in a sense and prescribe the antibiotic because that's the easiest way to end the visit and move on and see another patient. And there's a long group of people in the lobby. When you do something like that, that's an example of favoring autonomy, this is what the patient wants, over non-maleficence, which is first do no harm since you might be causing diarrhea or a yeast infection or who knows what else from an unnecessary antibiotic such as resistance. So in other countries, you may see things play out differently. What's wrong with too much autonomy? So I just gave you one example. You might just have worse care in some circumstances when you're doing what somebody wants and not what they need. You can have, you know, ignorance can play out in ways that are frustrating. You can have distrust play out where you have short interactions where you can't build this follow up into it that would maybe solve the example I just gave you. Direct primary care practice has an advantage over an urgent care practice there because they can say, hey, this didn't cost you anything to come in today. If you still think I'm wrong tomorrow, come on back. It won't cost you anything then either. You know, urgent cares aren't designed for that kind of follow up. Many Americans may think they have rights to different things at different times and there's an almost an obligation if you read the ICU literature and the hospice literature where we have this hierarchy of things that tend to happen at the end of life that maybe wouldn't happen if we really went through and gave a longer informed consent process. But they do happen because we're short of time. People are frustrated and scared and we are valuing autonomy higher than any other of the medical ethics that we just walk through. So one way that plays out is people sort of expect a breathing machine. They expect beating tubes. They expect you to run a code. They expect dialysis. All these things are sort of requirements for end of life in some places because that's everybody's pattern. And a lot of times we're doing those things and prolonging somebody's life by two weeks and when we could have maybe had them have better quality of life in another environment. So I kind of got ahead of myself here. We don't really have, you know, a lot of physicians would say, we don't have time for these long talks. I've tried to have the conversation and I get somewhere with one family member and then the other four kids show up and want something else. You can't ask hospital administration to fix this. We're the ones who have to have these conversations. We're the ones who have to educate patients and we're the ones who have to take the time for it. So make sure that's baked into the model, whatever model you're using, that you can have these educational conversations. If we, quote, do everything, then the hospital might be happy. Remember, they're paid on fee for service so they get to charge the patient and their family more. And the family might be less likely to complain because that's kind of what they ask for. And we never discuss price because that might have been insulting or have taken more time. And since most of that gets dumped on some third party payer, maybe the family won't even notice or complain. All these things are a problem and create more conflicts of interest. If we prioritize beneficence, then maybe we'd read, readdress things like the farm bill that's, that's been unsubsidizing unhealthy, excuse me, that's been subsidizing unhealthy food for several decades. So traditional fee for service conflicts of interest. We'll dig into more examples here. You can have insurance companies that are dictating what care occurs. They have lots of protections through ERISA. If the plan was purchased by the employer, which it usually is, and they have ERISA protections, even if they deny a requested MRI and then the MRI doesn't done and then there's a bad outcome, then in subsequent litigation, that patient could file a lawsuit against the hospital and or the physician for a big number in damages down the road. The only thing they can really sue that insurance company for up front is the MRI that they should have paid for. So ERISA limits the damages in a big way that makes the insurance industry kind of bold and emboldened, I should say, in dictating care and in denying certain requests or delaying certain requests because they don't, they're not going to be held financially responsible for the most part. We, we overpay for wasteful diagnostics and procedures. We underpay for things that are not procedures like thinking, which is why a lot of primary care specialties have been paid less than specialties that are doing lots of procedures. So if you move away from that model, we'll see how that can play out later. Patients can be frustrated by this fee-for-service model too. They get fractured urgent care style care regardless of where they go. They're probably going to have a 10-minute appointment even with a lot of specialists. And when we have no way for patients or often for primary care physicians, if they're not thinking too hard about it, we don't really have a way to say go to this specialist versus that one. We have anecdotal evidence from, from patients coming back, maybe giving us a really good review of one physician relative to another. And we might make a note of that or even try to keep a book of, of names that seem to be consistently praised. But we don't have really good data about who has higher post-surgical infections, which back surgeries need to be revised more. That kind of thing is hard to find and act on. And since we don't have that data, not only in healthcare, but in several other industries, we, we wind up with this Veblen good mentality. And the, and the problem there is price becomes a proxy for quality because we don't know what else to look at. So imagine you walked into a shopping mall and you needed to buy a suitcase for your next trip and you couldn't look at Amazon or Walmart or wherever you would normally buy or go for reviews. You, you can't see any reviews of any luggage. You have no way to try to get more data. And you see five pieces of luggage ranging from 20 to 40 to 60 to 80 to $100. And you're thinking to yourself, my last one broke apart and my clothes were spewing all over the airport. I don't want that to happen again. A lot of people might just buy the hundred dollar piece of luggage because they want the best quality item. And they're assuming it's the highest quality because they have no other data to go on. They can't read reviews. They can't talk to anybody. That's sort of a silly example, but it draws the point home that in certain specialties, we, we have that taking place in medicine. Classic examples, plastic surgery. If you see somebody advertising plastic surgery, that's at a steep discount, people are less likely to go get it because they assume that particular plastic surgeon isn't busy because she or he is not any good. What do employers do here? Well, they try to get data and sometimes they get phony data or irrelevant data from, from different brokers or third party administrators. So that can be a challenge as well. They may use a low deductible plan to try to attract employees and then wind up with employees that want to spend more. Cardiology, how does this play out if it's sort of fee for service conflicts in cardiology? Will, will these things that you order or that they order change your patient's management or excuse me, change your management of the patient's coronary artery disease? So this is, this is kind of there as a reference and I've got a curbsider's reference at the bottom. These are some common cardiology tests that you might order. Most primary care docs are doing the EKG in their office and it's easy to do a baseline. The exercise stress testing done in different occupational settings, less and less so outside those settings. We're more likely to do a coronary artery calcium scoring. So this is there as a set of a background and then we'll walk through some examples here. If a patient comes in with stable angina, the, you know, are our interventions making a difference in how long this patient's live? In other words, is there a mortality benefit to some of the things that we're trying? And if you look at the data from the ischemia trial, if you have somebody with stable angina, stenting has no mortality benefit. A percutaneous intervention shows no clear benefit and optimal medical therapy with or without percutaneous coronary intervention showed no difference in outcomes. That's the orbiter trial. So you've got these two trials that say, hey, I'm putting that stent in there to resolve the chest pain when they weren't having a heart attack, didn't make them live any longer. So you're treating pain basically in a really expensive manner with the stent. And if the patient were aware in such a blunt format, shall we say, if they were really informed, would they want to spend 10, $20,000, whatever it is to treat that pain? Does it bother them that much? And have they tried medications that are affordable to treat the pain rather than the stent? So most people equate one kind of stent with another. They equate the stent that somebody got during a heart attack with the one that they got to relieve their pain. And they don't realize that in one instance the patient is living longer as a consequence and in the other we have no data that the patient's actually living longer. But we persist in this. So what if the patient has multivessel disease? Do they just wait for a heart attack to happen so that they can stop smoking, stop eating carbs, exercise? There are lots of different interventions you can do that of course will make a difference there. And we need to walk through all these. I like using the number needed to treat. I think it cuts through a lot of the statistic speak that patients often don't understand. And I would say even we as physicians are often not as savvy there as we'd like to be. And it's really easy to mince words and create the wrong impression when you're speaking about relative risk reduction. What about unstable angina? So here you've got something more acute and the stent does increase the life expectancy in an acute ST elevation myocardial infarction. But in the other example it didn't. So we need to draw this clear distinction with patients. So what about aspirin for primary prevention? If you look at the NNT data it really isn't making that big of a difference. For a while we thought it might reduce colon cancer risk. Now that seems to be debated. So it's real hard to tell patients what to do when it comes to taking aspirin or not. Fortunately it's not an expensive intervention. So if they don't have a history of bleeding you might walk through these scores with them and let them decide. Similarly statins for primary prevention, the NNT data is not great. One in 104 to prevent a non-fatal heart attack. But one in every 50 that you give it to are going to develop diabetes that otherwise may not have. Once they've had a heart attack then the data changes. The data for statins is excellent then. The number needed to treat falls and the number needed to harm was pretty similar. So you can see that and that's there for your reference. So what's the point of all this? That sometimes the data surprises you and that we really need to focus on informed consent. And especially if we're going to leave autonomy highest in the hierarchy of ethics among the four, then we better do a heck of a job with informed consent and we're not taking the time to do that. So if you look at this quote from Random Acts of Medicine, which is an excellent book on different examples of how statistics can play out in healthcare by both a physician and an economist, a pair of them. Mortality data was significantly lower when patients were hospitalized during the dates of a national cardiology meeting compared with the non-meeting dates. High risk heart failure patients had 30 day mortality of about 25% on non-meeting dates and it dropped to 17% on meeting dates. They dug into it a little more. It turns out the use of cardiac stenting fell from 28.2% of high risk patients on non-meeting dates to 20.8% of patients on meeting dates. This was mainly noticed at academic medical centers. So those who were cared for at community hospitals, they found no difference in mortality rates between the meeting and non-meeting groups. So they expected to see the reverse and this was a surprising finding that was in the data. And the obvious implication is that at least at academic centers, the cardiologists who were attending the meetings were more aggressive when they were there with intervention. This notion of, you know, do more, do more, do more, it must be better, doesn't always play out in reality. Patients show that they had non-STEMIs where the decision to perform the procedure was more subjective. They were less likely to receive cardiac stenting and had lower mortality rates during interventional cardiology meetings. This was equivalent to a two-percentage point reduction in mortality, similar to the magnitude of reduction that you see with some of the other medications that we talked about earlier in terms of thrombolytics. So one more cardiology example, what about ablation for atrial fibrillation? You've got to pick those patients carefully. Atrial flutter is very different than atrial fibrillation. Atrial fibrillation comes from many different spots in the atria and the ablations don't seem to hold long-term the way they would in flutter. And if you look at the study that included 2,272 patients with atrial fibrillation and heart failure with an LVF of around 28 percent, there was a 48 percent risk reduction in all-cause mortality. The number needed to treat was around 10. So cardiology fee-for-service conflict areas that we pointed out here, chest pain, it's tough to stay rational when you have chest pain, even if it's deemed not an emergency, not a STEMI, and somebody's offering to put a stent in and get rid of the pain, then most patients are likely to quickly say yes and really not fully investigate that. So we better make sure they're fully informed. Fee-for-service in general incentivizes you to do more to get paid more, especially with procedures. And patients perceive this as more care as well, and they're probably less likely to have some litigation. So not only are you doing more and getting paid more, you're maybe decreasing the chance of malpractice lawsuit. So all these things incentivize overuse. Stanford is a bit of that. I've got the link in the slide deck there for you. About a half a million stents a year at $67,000 apiece for Stabalangina. And so you can see the Vox Write-Up or USA Today article. And the medications to treat that Stabalangina are not nearly that expensive. I've got a couple examples right there. So Veblen, we already talked about this. It's a good that sort of violates the laws of economics. These are luxury goods where the higher you make the price, the more the demand goes up. And that often happens in medicine because we don't have better ideas of quality other than the signal that's coming from price. And because we often have a third-party payer problem. If you've already met your deductible, then you're not the one paying. So the thing that's more expensive is probably where you want to stay. It's the same thing that happens for businesses if they send patients or send, excuse me, employees to a conference. And they say, we'll pay for the conference. Don't worry about it. We'll cover everything. Then you have people who buy the first-class ticket to stay at the most expensive hotel they can find that wouldn't do that if they were the one paying. There's a next hospital syndrome that can occur pretty much anywhere across the country. No matter where you are, if you're in a town of 100,000 and there's a town of 500,000 a half hour away, people might want to go over there. And then there might be a smaller town next to you that has 20,000 people in it. And people from that town want to come to your hospital. So there's this assumption that bigger must be better. And that doesn't always play out if you can get the data. So how does the political system react to some of these conflicts of interest? Well, it's happened in many different ways. So in Texas, you had occupational health centers that were dispensing medications, presumably for patient convenience, because they didn't want them to have to go to a pharmacy to go pick stuff up after work health injuries. And they were overcharging. And they got away with that because the workers' comp system was paying for all of these medications. Rather than requiring price transparency or simply addressing that in some direct way, we had we wound up with a medication dispensing ban across the entire state of Texas. And it's one of five states where physicians aren't allowed to dispense medications. Fee splitting. The states and the federal government don't want you splitting fees with non-physicians. And that can play out in weird ways. Corporate practice of medicine was designed on its face to tell physicians that you have autonomy and that you can't blame a corporation for what's going on and that the corporation shouldn't be ordering you around. Even if you do work for one, they better give you your own clinical autonomy. And the irony is the exceptions in that law are for the groups that committed this offense the most. So it wasn't, for example, if a physician had a wealthy sibling that was a non-physician who wanted to finance the practice, those folks tended to be pretty hands off. And that wasn't the hypothetical that was problematic. But that kind of practice structure is legally more expensive than it used to be in most states. And the groups that we were most worried about, namely HMOs, large hospital systems, are typically exempted from CPOM laws. So you have these unintended consequences that can happen. Pathology billing restrictions. There were direct billing laws in the pathology sector that required some pathologists to directly bill the patient rather than billing the practice because the practice would take that bill, mark it up, and then pass it on to the patient and not disclose it. Sunshine Acts were designed to have an open payment system that would say if physicians were getting certain benefits from pharmaceutical companies. They used to, decades ago, take people to fancy resorts, golf outings, pay for all this stuff, and really not disclose it. Most of that is outright prohibited now. And then the things that are allowed, such as meals and that kind of thing, are recorded. Or speaker fees would be the biggest example. Those things are recorded. And you can go to that website. It's linked there. And you can look up any physician and see how much compensation they've received as a speaker or in meal format. Then you've got a long list of false claims act and stark laws that affect how physicians are able to have any ancillary downstream revenue from their own practice. That can be very complicated. And then, of course, HIPAA is the P in there is for portability. It describes how information is shared. And then you do have a privacy and security rule that you need to be trained on every year. And there are steep fines for violations. Most people are unaware of the high-tech part of HIPAA, which allows any patient with limited exceptions in Medicaid. But otherwise, any patient can pursue cash transparent pricing. So we've got the medication dispensing ban in Texas. These are a little more details there for you with the citation. So the Texas legislature did the wrong thing here. They said, well, there's some malfeasance here. Rather than requiring transparent pricing, we're just going to block the entire ability for practices to dispense medications. And we're going to have all this collateral damage on groups that had nothing to do with the malfeasance that was occurring in the occupational medicine space. And you can look at another law in North Dakota, which I thought was interesting. So North Dakota, as far as I know, is the only state that strictly prohibits, shall we say, the corporate practice of pharmacy. So unless things have changed, you can go to North Dakota and you won't see any of the national pharmacy chains, the CVS, Walgreens, Walmart, all those big players don't operate up there. Every pharmacy in North Dakota is owned by an independent pharmacist. So how does dispensing break out across the United States? This is an example of how that plays out. And there's lots of different restrictions that apply in different places. But the big takeaway here is that you can do it most places. You can do it in about 45 states. The ones in red are a problem. Arguably, Utah is not worth doing it either. But there you go. That's there for your reference. And fee splitting, we talked about. It affects how you can compensate others that are involved in bringing patients to your practice. And corporate practice of medicine, I spoke about this as well. So it affects how the practice is owned and structured financially and then focuses, of course, on physician autonomy. And some states are very strict about this. Others have basically gotten rid of it because they said that the law wasn't really having a meaningful effect. And this is your pathology summary. So some states allow for practices to pass through at cost. Some allow you to go ahead and mark it up as long as you disclose it. Those would be the ones in orange. Some really don't have any law on the books one way or the other. And then the ones in red, even if you wanted to get to save the pathologist some trouble and collect the fee for pathology at the time you did the biopsy, they're not going to let you do it. They're going to make the pathologist bill them and track them down. And of course, that's going to increase the price. And we already talked about the Sunshine Act as well. And we talked about that. OK, so if we look at some occupational medicine examples, there are tradeoffs here. They may not even use the word patient. So some places, they're supposed to do an objective review of the history. It might be 10 pages or it might be several thousand pages of records in a complicated case. And then they conduct their own history based on questions that they develop from reviewing the record. And then they do an objective exam and list that assessment. And they're not really supposed to have, when they're doing these independent medical exams, IMEs, as they're known, they're not really supposed to have a prior clinical relationship of any kind that could bias them one way or the other. So that's the most objective form of occupational medicine. And there are many other varieties where they might work on site for a large employer and they're not doing that IME work. But when they're doing that, it's a different kind of clinical skill and different kind of medicine than what we're all used to, where you're the advocate for the patient. And in those situations, you're more of an arbiter in the middle. Okay. And there are many different guidelines that they might look to in site. And it's just a different process, whether that's OSHA and IOSH, different workers' compensation regulations. And then if they're gauging the level of impairment with an IME, then there's a set of books called the AMA guides that are referenced. And there are many different editions and different states are using different editions. What about capitation? If you're in one of the older capitated models, how does that affect your conflict of interest? Well, it gets rid of some of the fee-for-service conflicts, where you're incentivized to do more, do more, do more to get paid more. But you do have a problem here where you might be incentivized to do less because you're already getting paid the same amount. So maybe you don't spend the amount of time with the patient you should. Maybe you don't switch a medication that you could because it's more work. And then you're hoping things will be just as well off. But you do have an arranged marriage problem with some of these models. So you try to counter that by having choice within them. If it's large enough, if you've got a larger PACE program and there are five different positions, then if people don't like the first position they get, they can switch. If it's small and there's only one, or if you're at a small jail or a small prison and there's only one person treating patients, then you obviously don't have much choice. You've got what you've got. There are conflicts that can happen on the insurance side here, just like with fee-for-service. Utilization management might be similarly aggressive in what they approve or don't approve. And the appeals process is not always as transparent as the physician or patient would like it to be. Medicare Advantage, they do get paid more overall for care than you would get under a Medicare setup. And they often have capitated arrangements for primary care in front of the rest of the fee-for-service system, at least attempting to save money. Here's a map of where the PACE programs were at the time that I put this together in case you want to explore those. And then, of course, direct primary care, which is where I've focused for the past decade. You've got newer conflicts of interest, but fewer of them overall, I would argue. And because there are less conflicts of interest, generally speaking, the physicians are happier and the patients are happier, and there's less burnout. So if traditional capitation that I mentioned earlier was an arranged marriage, then DPC is something closer to a selected marriage. And the person doing the selection, generally speaking, is the patient. They are finding the DPC physician and signing up on their own. They often have many different health issues. There's an insult sometimes that DPC physicians are cherry-picking, but typically it's the reverse. The patients are cherry-picking the doctor, and most of the time they have something they want to discuss. There aren't a lot of people who are perfectly healthy, 30 years old, knocking down the door of a DPC practice when they're not on any medications and don't have any chronic conditions yet. So in this arrangement, the patient can hire or fire the physician at any time. So there are times where the employer might want to pay for this or incentivize it, and most DPC practices do permit that. And then you might have some patients who are a little less activated who are also members. You've got to make sure that the scope is clear to the patient when they join the practice. So what things are included in the monthly fee and what things might be an add-on. So some practices might include some of the simpler medications in the monthly fee, for example, like Lysenapril, because Lysenapril is routinely less than $4 a month. They might just throw it in there. Other practices consistently itemize those things. And as the price of Lysenapril goes from $293 to $542, then that invoice that the patient receives, assuming that they were getting the medication dispensed at the practice, is obviously going to vary as that price varies. It may vary as some of the labs that were drawn vary. Those things are often added on. But things like EKGs, where there really is not much incremental cost at all, typically are included. Maybe you have a Kenalog injection in a knee, and it was another $10 charge. So there's different ways that can play out. So you want to describe what you can do, what costs more, and what doesn't cost more, so that there aren't any surprises. Also, make it clear to patients when you're willing to do a Pryoroth and when you're not. I don't know what you all have experienced, but in my practice, we get more and more Pryoroths all the time. I've even had Pryoroths for medications that were $4 a month. And so we're simply not going to fill that out. That's really not saving the patient any money. In fact, it might be costing them money, because they might be paying more for the drug through the plan than they would using a transparent price directly from the pharmacy. Vacation or paid time off. If you try to take too much time at once in a DPC model, especially if you're solo, then you're going to have a big pile of work when you get back. And patients may feel like it was unfair for you to not be there, especially if it was longer than a week. You could have a risk that you have a physician who might become more apathetic. Maybe the practice gets full, and maybe they've got a few patients that are more work, that are griping a lot, or kind of just irritable people. And they think, well, go ahead and leave. I've already got a big long wait list anyway. And maybe they're not working as hard down the road as they were at the very beginning when they first built it. And so they're going to have to go back and they first built it where everybody was new, where they wanted to have lots of good impressions. And that can happen if they were to take on more work than they wanted to take on. All right. If they're working with large employers, so this is common in the direct primary care space, large, small employers, they may ask you questions that they think are perfectly fair that you're not able to answer or shouldn't answer. They can create extra work for you in a way that neither of you intended. So maybe they say, we've got 50 employees. We want you to treat these people and let them join your DPC practice. And if they have 50 employees who stay there year over year, then that's good. That's what you both wanted. If they have 50 employees, but on average, the employees only work there for 6 to 12 months and then they quit and find another job. Then you've got a high churn rate and you're taking on all these new patients. Everybody's consistently new. And you never get to benefit from that hard up front work that you do to stabilize and identify chronic conditions. What if they have a low deductible plan versus a high deductible plan? That's going to affect how patients go about getting the rest of their care in the system. So patients with a low deductible plan, they are not going to care about the price, even though you're ready to talk about it. Patients with a high deductible plan, it's obviously going to incentivize them to pay attention to that. And so those discussions that DPC physicians are used to having remain relevant. If you want to focus on prevention, but they might get in the way of that. They might be off guidelines. So an example would be firefighter physicals have been in situations where we were asked to do PSAs on male patients in their 20s and start trending things annually. So then you have all this extra dialogue and all this extra cost that isn't backed up by evidence. The start date, as simple as that sounds, they can be pushed forward, pushed back. And it can be challenging to time staffing for a new office based on when that start date is actually going to land. And then they're going to ask you things that are asking for aggregated clinical data that sometimes can be aggregated and blinded. And other times you're serving too small of a patient population and you really can't provide that data because the risk that it would be de-identified is simply too high. They may like the scope that you identify in your discussion with them, but then want a nurse practitioner or PA to do the work rather than a physician. And then you have to explain why that may not go well if they don't have the same amount of training. So placing consults, how do you do that if you're a DPC doc? So you try to build relationships here. You try to figure out who's good. You try to get some data on clinical outcomes, and then you try to aggregate pricing data. And doing that for medications in labs is pretty straightforward, requires some upfront work, but you can get an apples-to-apples comparison easily. Doing it for specialists is always a challenge and it's always a local endeavor. And I would caution anybody using a consultation service that's trying to do it online and trying to do it anonymously that that's not a real consult. And if you ask the medical board, it might not be a lawful relationship entirely, and that's a longer conversation. But anonymity is a red flag to me. You need to know the person's name. They need to be able to follow up with that person. Medicare does have codes that you can use, and I believe I've got those in the slide deck later, where the consultant can bill for their time and join you over telemed or simply bill for reviewing your write-up and then providing commentary about how to proceed. So is the consult going to happen with the physician or is it going to happen with someone else in their office, maybe before they get to them? Those are important questions as well, especially if you've already done a lot of upfront work and framed your clinical question in a clear manner, because the extra visit is extra costly and does delay things. So these are ways that you can try to hold the rest of the system that's got an urgent care mentality more accountable. What happens if you try to be a good guy? Sometimes you get punished for that. There was a case out of Minnesota that went to the Supreme Court there, Warren v. Denter, where a nurse practitioner called a hospitalist and presented a case over a brief phone call, and the hospitalist said, OK, sounds like some diabetic complications, but I don't think you need to admit this person. I don't think that they're going to die of an infection in the meantime. And then the same nurse practitioner spoke with the supervising physician named Dr. Baldwin, got the same answer that the nurse practitioner got from the hospitalist that was called. And, of course, this wouldn't be a case if something bad didn't happen, and the patient did ultimately die of staph aureus sepsis and, of course, wasn't sent to the hospital. The hospitalist said, hey, I did this as a courtesy. I didn't even know this patient's name. I'd never met this nurse practitioner. The nurse practitioner gave me information that was, let's say, insufficient, or I didn't know all the things that I could have known that would have made me say something different. So, judge, you should dismiss me from this malpractice case and leave it with the nurse practitioner and with Dr. Baldwin. And the reason I'm out is because you can't prove any duty. In malpractice cases, you've got to prove duty, breach, causation, and damages. I didn't have any duty. I didn't know this person. And in Minnesota, they said, no, we're going to overrule that district court and the court of appeals. And at the Supreme Court level, they said there was some foreseeability here, and we're going to extend duty to this hospitalist physician. And when you as a court system do that, you are incentivizing hospitalists to not do any direct admits, to not have any candid conversation about what they think, and just to tell everybody to go to the ER. The hospital makes more money that way, and they reduce their liability that way. So, sadly, that is how many systems have responded to cases like this one. It's another case of unintended consequences and maybe a place where the legislature could step in where the judiciary has failed. So if you're trying to have a broad scope mentality like many DPC physicians, you know, do the work up yourself. Take that time up front. Don't be limited to a 5- or 10-minute visit. And these are examples of how that could play out clinically. When can you do it in person versus remote? I thought this summary was helpful. Primary care docs might find it nice. So a lot of the things in green I found that we could do remotely, at least if we had good technology to use. Yellow, it was kind of a mixed bag. And for the referrals in red, I really didn't find that, at least at my practice, that we were able to do those things 100% remote. It typically required at least one in-person visit, and often many. You can see that a lot of those are surgery, surgical specialties, and specialties that are very likely doing a procedure. So make your list of favorite specialists and why, and get those prices next to them, and get the quality data, and hopefully you're able to share that with your patients. When you're asking to evaluate the quality, so after a follow-up happens, ask for feedback. If you don't ask, you're not going to get it, and you won't know where you should be going moving forward, because this is often our best way to start aggregating some information on who we're going to work with. I mentioned this briefly earlier, but it is here for your reference. So HIPAA was modified by HITECH several years later, and HITECH does have a provision in it, in this section that I've cited above, 164.522, that a covered entity, which is pretty much every hospital you're going to interact with, must agree to requested restrictions unless the disclosure is otherwise required by law, and for which the health care provider has been paid out of pocket in full. What does that mean in plain English? If a patient goes to a hospital 10 times this year, and the first nine times they want to use their insurance in time number 10, they decide they don't want to, they're allowed to make that determination. And even if the hospital wants to bill that insurer, and likes the price that they've negotiated with them, if the patient says, no, you are not allowed, I'm going to pay you out of pocket, and as a consequence, I'm retaining privacy of this particular 10th visit in the record, then the hospital has to do that. This is federal law. Even if they have a contract with that insurance company that says, we will always bill you for anybody who's insured by your company, patients are allowed to enact this right. And they might choose to do that genuinely for privacy purposes, which is the implication and why it was passed, but other times they might do it pretty quickly because the cash price for the MRI is $700, and the insurance price is $1,200, and they don't think they're going to hit their deductible. So there can be different motivations why the patient might do it, but ultimately the patient is allowed to pay cash at their own demand, and not have the information shared with their insurer. The demand to have a cash pay option does not guarantee a good price. They could get a really bad price. So there's no demand to the hospital that they offer a specific kind of price, but they always have to have that cash pay option available. Venture capital, when it gets involved in medicine, can create different conflicts of interest as well. $21,000 in the medical field over a 10-year period, 65% of those lost money. About 2.5% had a 10 to 20x return, which of course is what the venture capital groups are looking for. And then a real small minority had these massive returns, 20x or 50x what was invested. So $1 trillion in 8,000 different health care transactions over the past decade. And then this quote from Forbes. From 2013 to 2016, private equity firms acquired 355 physician practices. In the four years that followed, private equity acquired another 578. So lots of growth here. And the prices tend to grow as well. So you have consolidation. Courts not quite breaking up monopolies that would form in a subtle manner. And the price for various services would go up with those acquisitions, which are trying to have quick three- to five-year turnarounds typically. And if you look at the emergency medicine venture capital data, it sort of stands out for that. So the hospitals would outsource ERs to venture-backed staffing companies. And patients will typically go to the nearest facility. They don't have a chance to shop around. They're having a heart attack, so they're not going to sit there and try to negotiate. It's in a state of duress. And any contract they signed, which they may not realize this, but any contract they sign under duress is generally unenforceable, and they could litigate more often than they do. But at any rate, these venture capital companies would take on a lot of ER work. They often replaced physicians with PAs and NPs because it made financial sense. These groups of practitioners were cheaper to employ. They ordered more tests, which increased the venture capital revenue. And they were more likely to follow whatever protocol was in place, sort of thumbing their nose at the CPOM issues that we talked about earlier. So when you're speaking to patients, tell them how to uncover some of these conflicts. Don't pay unwarranted bills. If something happened in the ER and you get a really big surprise bill, litigate your way to fair market value. You can do that. It was under duress. It's not going to be enforceable. The No Surprises Act can give you some transparency into different conflicts that you could point out. You could report unnecessary care when it was either provided against your request or not provided in spite of your request. If something were denied by utilization management, you can go to the medical or nursing boards if you need to. The team health example with Blackstone 2016, Envision Healthcare by KKR in 2018. So these are some examples of some venture capital changes in the emergency medicine space. Forty-three percent of ER visits seen in ER staffed by companies with non-physician owners. Typically private equity investors. So the kind of thing that CPALM was designed to counter but doesn't really make a meaningful difference and ironically makes it harder for physicians to own their own small practices in many ways. Okay. So I've spoken about some of this already, but they do tend to take a more short-term view. There can be pressure to take on contracts that aren't the right fit, maybe the wrong population or in a location that's a challenge. So if venture capital were to be involved in more primary care, these are some of the conflicts I would foresee. That's how this should be titled. So you can see them kind of changing the model in ways that the patient and or the physician may not have wanted. Large entities can play bankruptcy games. So there's something nicknamed the Texas Two-Step where you have a second entity that's formed and the original entity rather than going through the normal bankruptcy process and restructure process does it in a way that is harsher and can leave people holding the bag. And this can be complicated for physician employees of health systems. Hahnemann Hospital is one example where they had a group claims-made policy with a built-in tail. This was out of Philadelphia. Venture Capital Group bought the hospital and then kind of siphoned money off and bankrupted it. And then this group claims-made policy was no longer being paid because the entity went bankrupt. So the tail that was supposed to be built in was no longer there. And a bunch of physicians that thought they wouldn't have to pay for tail coverage suddenly did. Ultimately, the bankruptcy judge allowed for payments to be made for that group tail, several million dollars. But in the 6 to 9 to 12 months, whatever it was in the middle, a lot of them had to buy their own policies and that may have cost them $10,000, $20,000, $30,000. So things like that that aren't discussed up front with patients can obviously be affected and so can physicians. Those are a problem. Those are undisclosed conflicts. These cause burnout. These are bad. So we need to be aware that the customer should stay the patient. Does the venture capital group agree with that, or is this more of a hostile takeover of sorts of whatever entity was already there? Okay. So whatever your model, if you don't want to burn out, number one, identify all the conflicts of interest you can find. Follow the money mentality. It needs to be something that you have. And mark it out and be able to share that information with your patients in a clean and efficient manner. And have price transparency any place that you can in that chain, whether it's medications, labs, durable medical equipment, referrals, display all that information. This price next to whatever's being done can help you eliminate as many conflicts of interest as possible. If you've got a third-party payer that's getting in the way by obfuscating the price or by otherwise being a problem, try to avoid them. Try not to interact with them. Try to minimize your prior auth burdens. You may have to abandon those traditional fee-for-service models in order to do that in a way that makes sense to you. Describe the conflicts of interest that you can't eliminate. So make sure patients know where your scope ends and where it starts. What are the things that you're good at? What are the things that you like to do? What are the things that you don't like to do? And how far are you going to partner with different groups, large employers, small employers, venture capital? Are they investments that you need that are going to be clinically benign and out of the way, or is working with a group to scale going to change the model that you wanted? So here's a quote to sort of finish off from a man in the arena. It's not the critic who counts, not the man who points out how the strong man stumbles or where the doer of deeds could have done them better. The credit belongs to the man who's actually in the arena, who comes short again and again. So his place shall never be with those cold and timid souls who know neither victory nor defeat. So don't be bashful. Don't be the one with your head down just trying to not totally burn out and not get anywhere here. If you're feeling conflicts of interest and you're feeling yourself getting burned out, you need to be real direct about identifying those things, deciding if identifying them and disclosing them to your patients and others is sufficient, or if when you identify and make a list of all these conflicts, if you simply need to change how you're practicing medicine. So hopefully that was useful to each of you, and happy to be available for questions via email, phil, so phil at dpcfrontier.com. Thank you. ♪

direct primary care

conflicts of interest

fee-for-service

ethical principles

autonomy

price transparency

venture capital

healthcare models

patient care

medical ethics

capitation models

patient-centered care

unnecessary prescriptions

physician burnout