Eric Kropp has an anecdote that he says epitomizes the difference between standard family practices and his new solo medical practice, the area’s first example of direct primary care.
“I’ve heard from patients that they’ll be texting me and people ask them what they are doing. They say ‘I’m texting my doctor’ and the reaction is” – here Kropp mimics an exaggerated double-take – “What? You’re texting your doctor?!”
Kropp’s patients can also phone him whenever they want (he says most are too polite to wake him at home unless it’s a real emergency) and during office hours can usually talk to him directly without having to go through the office manager – who is the only other employee of the practice and also Kropp’s wife, Meredith.
They might even get that rarest of modern medical commodities, a house call. Quite a surprise.
However, there are some less attractive reasons for people to be surprised at what Kropp’s patients do. For example, they have to pay Kropp a set fee every month, even if they haven’t seen him for ages, and it’s up to them to find and pay for other services like having an X-ray taken.
And while they never have to worry about annoying insurance forms and questions at his office, that’s only because there is no insurance: Patients pay for everything. But they still need to buy insurance for emergencies or to cover specialty work and to meet federal requirements.
It’s all part of direct primary care, or DPC, a small but growing model for family practices that is part throwback to an old type of doctoring and part window into new forms of medicine in the fact of new technology and the Affordable Care Act.
Kropp is a Bow resident who has been a family physician for a decade. Before he opened Active Choice Healthcare on Chennell Drive in February, he was part of Penacook Family Physicians, a group practice associated with Concord Hospital. He says he decided to try the DPC model because of dissatisfaction with the way traditional practice requires doctors to carry patient loads of several thousand people, leaving them little time for anything other than popping in and out of exam rooms and extensive data entry.
“This model allows doctors to be human again. It allows us to be doctors and it allows us to be human,” Kropp said. “My job is taking care of my patients. That’s what I signed up for when I became a doctor. . . . If I miss something with (my) kids because I’m taking care of patients, that’s okay and my kids get it. If I’m taking care of the computer and making sure I checked all the boxes, that’s not okay.”
DPC has been around in various forms for close to a decade but is relatively new to New England. Active Choice Healthcare appears to be only the third DPC practice in New Hampshire – a listing maintained by an advocacy group called DPC Frontier lists one in Hampton and one in Lebanon – although it’s hard to know for sure because there’s no central authority. One of the things Kropp is doing, in fact, is helping organize New England Direct Primary Care Alliance, to connect practices and doctors interested in the idea.
DPC is more prevalent in other parts of the country, especially the West, but it’s not common anywhere. The American Association of Family Practitioners said that a 2015 survey found 3 percent of its members “working in a DPC setting” with another 1 percent making the transition. The field is so new, in fact, that more than one-third of AAFP member doctors didn’t even know what the term meant.
Yet it does seem to be drawing interest, fueled by attempts to trim health-care costs as smaller companies (with 50 to 99 employees) now must provide health insurance and are looking for cheaper options. An April article in the journal Medical Economics noted that the state of New Jersey is testing a plan that will give 800,000 state workers access to a direct primary care plan, while health insurance giant United Healthcare is testing plans, and even some associated clinics, in Chicago and Atlanta.
Kropp says one way to think of direct primary care is like a medical version of a health club. You pay a monthly fee and use the service whenever you want, realizing that anything beyond basics will cost more and might require going elsewhere.
It’s similar to what is known as concierge medicine, except the latter tends to focus on more specialty services with fee-for-serve additions, while direct practice sticks with just the basics. A survey by The Direct Primary Care Journal found that families who use it tend to have household incomes of $95,000 or less.
Kropp charges each patient between $39 and $99 per month, depending on their age. Other physical factors – pre-existing conditions, smoking – don’t matter. If you’re a family you can add children for $19 a month, each. That payment covers everything Kropp does, including eye exams, blood-glucose tests, EKGs, and phone or office consultations as often as the patient wants.
Everything else, such as physical therapy or MRIs, is up to the patients, although Kropp often provides suggestion about where to go, made easier in this era of walk-in urgent care clinics.
“We spend time working with ancillary service providers to get the lowest prices. . . . That’s what restores competition to the market,” he said.
This is where insurance comes in, despite this no-insurance model. The Affordable Care Act specifically allows people to have this medical coverage as long as they also have high-deductible health insurance, or catastrophic plans, that can kick in for major expensive issues such as hospitalization or surgery. Kropp, like many DPC providers, does not accept Medicare or Medicaid.
DPC advocates say this model makes more financial sense for everybody, although that’s far from a unanimous opinion.
“We can make health insurance operate like every other insurance. You don’t use car insurance for every little expense. You should have insurance for expensive, less common items – surgery, hospitalization, cancer,” said Kropp.
There are legal questions that vary from state to state, in particular whether DPC should be regulated as if it was a form of medical insurance. The main concern is that without government oversight, DPC providers might take on more patients than they can handle, leaving some of those patients stranded or ripped off, just as if the firm providing their health insurance coverage had gone under.
New Hampshire has no laws on this subject. A bill was proposed in 2015 that said DPC doctors would be “not subject to the insurance laws, provided that certain conditions are met,” but it was shelved. Kropp says treating DPC as if it was health insurance would impose costs and restrictions that would probably put him out of business.
Although it’s not clear how much, if anything, DPC would save most patients in money compared to insurance coverage at a traditional practice, DPC advocates say a major draw is that it can create a connection between doctor and patient that is often lost in the modern system.
“Most of the time, it’s somebody who doesn’t feel they’re being listened to, or their concerns aren’t being addressed in the office. . . . They say ‘I can’t see my own doctor for four weeks, I’ve talked to three nurses, four nurse-practitioners, nobody knows who I am or what I need,’ ” Kropp said.
But it’s one thing to want to be part of a particular business, another thing to make the finances work.
“My goal is to have (income) similar to being an employed physician,” Kropp said.
Kropp hopes to sign up as many as 600 patients. If he does and every single one pays the maximum $99 a month fee – meaning they are all over age 55 – it would produce about $700,000 annual gross income. If he gets 500 patients at $79 a month, which seems more realistic, that’s about $480,000 gross income.
The median income for a family physician in the U.S. is about $185,000, according to federal figures, and it seems possible to carve out such a salary from these gross income estimates, particularly with just one staff member and low costs. Kropp, for example, does not handle any controlled drugs, and notes that he outfitted his 1,400-square-foot office with a lot of used furniture: “EBay is my friend.”
But it’s not easy, part of the reason why the American Association of Family Practitioners found that one-third of doctors had considered DPC but rejected it.
Notably, it’s not easy finding new patients if you aren’t part of an insurance network or associated with a hospital – Kropp says a number of patients he knew from his previous practice followed him. Futher, doctors face special costs, including often hefty medical school loans and always hefty liability insurance premiums.
“Ah. Yes. Liability insurance,” Kropp wrote in a email when asked about this. “Well, with the reduced size of the patient panel, many insurers consider it equivalent to a part-time practice, so the rates are lower. Additionally, some insurers are recognizing that the likelihood of a DPC doctor being sued is probably significantly less because of the nature of the high level of personalized care and attention that is given.”
But that’s still developing, as is much in this field. Whether it can become a major part of American medicine remains to be seen.
“I talk to (other) doctors. Everybody’s interested in this, everybody’s excited about this. I think a lot of us want to see it succeed,” Kropp said.
(David Brooks can be reached at 369-3313, or dbrooks@cmonitor.com or on Twitter @GraniteGeek.)
