Wednesday, February 3, 2016

Reducing Healthcare Costs Through Company Wellness Plans


Employers have seen their health care costs rise dramatically over the years. To compensate, they have expected employees to pay an increasing portion of the healthcare insurance premium, expected employees to pay significant co-pays with each physician visit and have purchased policies that restrict individuals to a narrow network of doctors and hospitals. Largely these have not worked. They have offset some of the expenditures but it has not done much to slow the inexorable rise of health care costs. The reason is because they attack the wrong “problem.” What is needed is to institute approaches to improve health and maintain wellness of the employee (and the employee’s family) and to assure that the employee (and family) get outstanding primary care including proactive population-style health care. Add to this patient engagement – a stake in the financial arrangement. That combination will reduce costs considerably. Here is one approach that progressive companies are following.
Large companies such as General Mills and Safeway have demonstrated the utility of wellness programs. Employees are invited to voluntarily participate in company sponsored programs that are designed for behavior modification such as nutrition, fitness, chronic stress reduction and smoking cessation. The employee (and sometimes the employee’s family members) who participate are rewarded with a reduction in their share of the health care premium. Given that employers are continually increasing employee share, this reduction can be a real benefit to a person’s paycheck. Large corporations often create these programs in house but smaller and many larger companies can turn to wellness companies such as Orriant that will do a turnkey approach for a single larger company or a group of smaller companies in a defined geographic region. Workplace wellness programs logically should improve employee health but until now results were mostly anecdotal; there was no definitive proof. Now, evidence has been published in the International Journal of Workplace Health Management that an opt-in program encompassing biometric testing and a personal wellness profile to guide individualized telephonic health coaching combined with financial incentives led to improved health parameters, improved health age and reduced healthcare costs. The authors concluded that “health coaching effectively improved biometric scores among high-risk individuals and narrowed the difference between current health age and achievable age, more so among those with the greatest health risks at baseline.”

Here are some of the specific findings: Compared to nonparticipants, the participant’s claims paid increased at a lower rate and they had fewer claims per person. For those with elevated blood pressure, the average systolic pressure was 170 mmHg which was reduced by 34 over the three year study; for diastolic it was 105 down by 18 mmHg. For those with elevated glucose the starting average was 164.4 and dropped by 31(58%) over the three years. Those at the greatest risk for cancer improved their lifestyle score by nearly 32 points, or 41%.

According to those in the company wellness field, there are few key ingredients that make for a successful wellness program. The majority of employees (and spouses) need to be working one-on-one with a health coach to develop their own self-directed plan for behavioral improvement. Individual care and concern by the health coach is the most effective intervention. Employees need to like their coach (which I interpret to mean they trust their coach.) Coaches need to be well trained with a significant healthcare background. Individual accountability needs to be an integral part of the program. This implies that the participant needs to call the coach; not the other way around. That is part of accountability. The focus needs to be on those with health risks, which most Americans have. Getting the men in the company involved is important; women are more likely to volunteer early so there has to be extra effort to attract the men.

Some readers will not like the idea of health coaches “meddling in their affairs.” But no
one is obliged to join into the wellness plan; it is always an option although for
sure the employer often offers a financial incentive to do so. Whether in a
wellness plan or affiliated with your PCPs office, health coaches (when properly trained and focused) have been found to be powerful advocates for improved health.

Major health risks from life style factors are being overweight (two thirds of the American population), lack of adequate exercise (probably more than half of people), chronic stress (it seems like everyone is stressed today) and smoking (still about 20%.). High blood pressure can be in part lifestyle directed as is obesity. These in turn lead to chronic illnesses such as heart disease, stroke, chronic lung and kidney disease – just the diseases that account 75-85% of all claims paid by healthcare insurance.

The cost of wellness programs, whether done in house or with a consultant, can be self-funding, i.e., those who opt in get lower premiums and those that do not have higher premiums. But the larger more valuable benefits accrue to both the employer and employee. Staff become healthier – that is good for them. But healthier employees use less total healthcare resources. This in turn lowers company insurance costs or at least slows the growth of premiums, often dramatically. The employee benefits from better health, will likely be more productive, will have less absenteeism and will have greater job satisfaction. That is a win-win for employee and employer alike.

My next few blogs will relate what some companies are doing to offer a complete package of wellness, prevention, consumer-directed insurance, on site primary care clinics, prefunding a HSA or HRA, price transparency and more to manage costs while improving employee health.

[Note: A look at the Orriant web site will show that I am quoted. I am a proponent of wellness programs but I have no financial or other association with the company. If you go to the link for the article on wellness plans noted above you will find that you need to pay to read more than the abstract. I read it and thought it was useful information which why I used it here. You can also find the details on the Orriant web site. As with any study there can be criticisms but I think it was pretty well done. The graph is  claims paid per participant]

Thursday, January 28, 2016

A Business Approach To Reducing Healthcare Costs


“Helping employees improve their health is right for the company’s bottom line and is doing right by our employees.  Healthier employees are happier, demonstrate less absenteeism and presenteesism, and are more productive.  This is a win for everyone involved.”  Quoted from John Torinus, Jr., in The Grassroots Healthcare Revolution; he is retired CEO and current board chair of Serigraph, Inc., a mid-sized Wisconsin company with about 500 employees in the USA.

In my earlier posts in this series I have written primarily from the perspective of what primary care physicians can do to not only improve the health of their patients while reducing total costs of care yet also reclaim their right to practice in a non-frustrating environment with a limited number of patient visits per day. Torinus approaches improving health care from the perspective of a business leader faced with rising health care costs. Here I will quote and paraphrase from Torinus’ book and, since I basically agree with his recommendations, will amplify with some of my own thoughts.

He argues that company CEOs must make health care a strategic priority since it is one of the top three costs for any company. Healthcare costs can make the company noncompetitive if not managed aggressively. However, strategic priority to him also means it is essential for the company to attend in a proactive manner to the health and wellness of its employees, not just be the provider of an insurance plan.

CEOs need to think of the long term for their companies and therefore for their employees. The company and the employee together spend about $16,000 per year for a family for insurance today.  An employee who works for a company for 25-40 years represents an insurance expenditure over a lifetime career that could be as much as $400,000 to $640,000 in today’s dollars.  This drives home the point that it obviously only makes sense to have a long term view of employee health beginning with an aggressive approach to maintain wellness, actively reduce risk factors and  manage disease as it occurs.

He observes that the current health care system focuses on specialty care whereas it needs to focus on the care recipient with high quality primary care – the patient/consumer/employee.  But to be effective, the patient/consumer/employee needs to be engaged.  The current healthcare system disengages the patient – it removes responsibility because the patient is not the customer of the doctor.

In his company, expenses were rising to double digits by 2003 but with their new plan in place, it dropped to 2% or less per year.
Torinus’ “prescription” for all companies (and what his company initiated beginning in 2004) follows:  First, every company, including small companies, should self-insure with an added stop-loss catastrophic policy.  Second, employees should be offered only a consumer directed healthcare policy (CDHP), in essence a high deductible plan (often about $2500) with either an associated health savings account (HSA) or a health related account (HRA.)   The company should prefund the account with an amount (often about $1500) that the individual can use for any health care needs with the assumption that since it is now the individual’s money, he or she will spend it more wisely – employee/patient engagement.
Third, the company should insist that each provider have price transparency. Since that’s often difficult to obtain Serigraph uses various companies like Alithias Inc. to provide that for them so that they can compare one provider to another.  For example, they determine the all-inclusive (gastroenterologist, anesthesiologist and facility fee) price along with quality data of colonoscopies at the nearest five centers and then rank them. The employee or family member who needs the colonoscopy is told that, for example, the company sees it as appropriate preventive care and so will cover the cost, in this case up to $1,500.  [His book appeared before the ACA became law so colonoscopy would be covered now by the insurance component but the principle is still valid.] This is an amount that will pay for say, four of the five local centers; but if he or she selects a provider that charges more, they are on the hook for the remainder. 
Fourth, if the company is large enough, it should provide an on-site primary care clinic at no cost to the individual.  At Serigraph, the clinic includes a concierge-type physician (meaning that the physician is salaried, has a low number of patients under care and gives extensive time and energy to each employee/family member patient consistent with some of my previous posts) plus a nurse practitioner, a health coach, a dietician, and a chiropractor.  If the company is too small to justify a full-fledged clinic then the company can pay the retainer for a nearby direct primary care/membership/concierge physician who works with others such as the health coach.  Fifth, the clinic, with special attention by the health coach, gives all employees a health risk assessment annually and then works one-on-one with each employee (and family member) at no cost to maintain wellness and health including the use of behavioral change programs around diet, nutrition, exercise, stress management and smoking cessation.
Sixth, there is very intense management of chronic diseases by the clinic staff and coordination of specialist visits when needed.  Seventh, Serigraph uses what Torinus calls Centers of Value for procedures beyond those that are done by the primary care physician. These are doctors/institutions that have outstanding quality records yet a competitive price for, say, a knee replacement. Serigraph gives their employees $2,000 toward the deductible or totally covers the deductible for the surgery when they make use of these Centers of Value.  Seventh, his company gives (and he recommends others do likewise) generic drugs for free and all of the above prevention and wellness programs are supplied free of charge.  Finally, the company makes free counseling available for developing advanced directives and in the event that an individual requires end of life care, hospice is available free of charge.

I notice that his company spends considerably on extensive/comprehensive primary care including wellness maintenance, proactive prevention and chronic care management but it is rewarded in return with lower total costs and healthier workers.

Given that healthcare has become a company strategic priority, then it needs to be managed and that requires data. Hence, he urges all companies to develop health-related management dashboards including both a financial dashboard (how much is the company spending) and a health dashboard (how many individuals in the company have uncontrolled blood pressure, uncontrolled asthma, uncontrolled cholesterol, have not had appropriate mammography or colonoscopy, etc. – all information collected from the clinic in an unidentified manner to protect individual privacy). 

These approaches are based on fundamental principles including individual responsibility; market place discipline – installing consumerism, steering business to the best quality and price (“do good work and you get our business”); proactive care – maintain employees’ health and wellness and give extensive care to those with chronic illnesses; and sound management – putting those who pay, i.e., the employer and the employee, in charge. 

Torinus suggests there are multiple rewards for following this basic approach (I added number 2 since he implied but did not write it.)

1)     The reward for business is a healthier work force and more affordable healthcare expenditures. 

2)     The reward for individuals is more health and wellness, less illness and fewer dollars spent. 

3)     The reward for high value providers is more business.

4)     The reward for entrepreneurs comes if they innovate with better care provided at lower cost

5)     There could be a reward for tax payers - if government (federal, state and local) were to utilize these approaches

Sound advice.  Your thoughts?

The next post will delve into company wellness programs.

Monday, January 18, 2016

Direct Primary Care – A Response To Your Comments



Over the past few months KevinMD has posted a series of articles by me on what I call the “Crisis in Primary Care.”  (BTW, I was not a PCP.) Most recently have been a few posts related to direct primary care. They have generated many comments – some pro and some con. I have greatly appreciated everyone’s interest; it makes it worth the time to write. So thanks.

My fundamental belief, contrary to some comments, is that PCPs are much more than providers of “simple” stuff. They are more correctly specialists that deal with the very complex. Comprehensive primary care includes wellness and health maintenance, prevention and risk management strategies, attending to the episodic events that occur in life, and the care of those with complex chronic illnesses including coordination of care when a specialist is needed. It also includes developing a strong relationship between doctor and patient, building trust along the way and offering true healing. This means that the PCP can competently handle the vast majority of our health needs. 

But all of this takes time and when the current practice business model forces the PCP to see 25 or more patients per day, there is just not enough time. Direct primary care (DPC) is one way to regain that time. It is not the only way. I plan to discuss some other approaches in later posts. 
 
A few themes have arisen repeatedly in comments from these posts about direct primary care. One is that there is a difference among the terms DPC, membership, retainer, and concierge.  But to me, they all mean essentially the same thing - fewer patients per doctor and therefore more time for the patient with the doctor which equates to better care.  There does seem to be a degree of concurrence that DPC and membership are terms most often used for those practices that cost less per month or year and retainer and concierge for those that cost more. (There are a very few that charge a huge fee; I discount these as giving the term “concierge” a negative connotation to many.) 

Among the most common other themes from the perspective of a patient are: DPC is too expensive, especially for those of lesser means. DPC is an added expense if you already have primary care coverage by your insurance (e.g., Medicare or company policy). The PCP “abandons” patients when converting to DPC and does it because he or she is greedy. And the question - Is the care quality really better and are costs really lowered? Some thoughts on each.

First, DPC is certainly not for everyone – patient or doctor. But it is one model and it has proven very effective for some. 

Expensive? It’s relative. The average American family spends $2237 per year for cable TV, internet and phone. A Starbucks a day adds up. A parking space per month in a downtown lot is probably more than the DPC doctor. It is about prioritizing our personal expenditures. I also posted an article using as examples three practices that have been termed “blue collar” in the popular press because the costs per month are relatively low, the service is high and with the added benefit of generic drugs at wholesale prices many patients can save handsomely. Two of them have noted that they have many uninsured patients. These practices are cheaper than urgent care clinics and much cheaper than the ER. One person commented that I cherry picked cheap Midwest practices; DPC in urban areas cost much more. That is likely true if only because rent and staff cost more. Here is a chart from Concierge Medicine Today related to costs across the USA.


Why sign up if you already have insurance that covers primary care? The question to answer for each person is whether it is worth the extra money to get more time with your PCP? A lot more time. My PCP converted about five years ago. I was ticked off that I had to pay an extra $1500 a year since I am on Medicare and primary care is mostly covered. Some of my friends decided to not convert with him. Others decided as I did to pay up. My wife’s PCP converted to a retainer approach a few years ago. Same thoughts. But it has been worth the price – to us. But probably not for everybody. Again, it is a question of your priorities.

What about abandonment? It is another of those questions where the answer depends on your perspective. A group practice I know planned to convert and announced it to their patients. Soon articles appeared in the local paper about “greedy” doctors and patients who would be left without a doctor. But everyone who wanted to find a new PCP did so quickly – often with help of their former PCP who guided them to an appropriate doctor. Of course, in say a rural community where there is just one provider, it would be a different story. An analogy given me by Dr Josh Umbehr might be useful. Consider a 60 watt bulb. Try to push more voltage through it and it will burn out and there is no longer any light at all. Run it as it is supposed to be and it will last a long time. If the doctor is burned out and gets sick or just quits, that is not abandonment. It is actually worse. 

And the greedy doctor issue? When a PCP with a busy practice converts, they often end up with a much lower income, at least at first. Read some of Dr Rob Lamperts posts about what happened to his income including a one about his application for health insurance and for Medicaid. Later their income may rise and sometimes it will be more than before. From that same Concierge Medicine Today article – 73% of concierge or DPC physicians earn less than $200,000 per year. But it is really not about more money; it is about more time for each patient.

Quality up and total costs down? I wrote about this in my last post; here is a summary. It is hard to find other than anecdotal data with individual practices or even group practices. MDVIP [which is not a DPC practice since it still takes insurance in addition to a retainer] is a practice model that lowers the number of patients to doctor to about 500:1. Among the about 700 affiliated doctors there are about 215,000 patient members, enough to do some observational studies. They have found that quality measures like blood pressure control, diabetes control, immunization percentage, screening for cancer, etc. are substantially better than a comparable group of individuals not in their network. Similarly, there is a very substantial reduction in total medical care costs of $2551 per capita as a result of fewer referrals to specialists, fewer prescriptions, fewer hospitalization and fewer trips to the ER. As to satisfaction, perhaps the most important marker is that few individuals leave the practice. 

Similarly, Iora Health, Qliance and AbsoluteCARE, organizations that like DPC practices lower the number of patients per provider, can demonstrate better outcomes with lower total costs. Here again the cost reduction is from fewer specialist visits, fewer hospitalizations and fewer ER visits among other parameters. Qliance, for example, has noted 35% fewer hospitalizations, 65% fewer emergency department visits, 66% fewer specialist visits, and 82% fewer surgeries than simi­lar populations. (And before you tell me, I know that this reduction in costs may not directly accrue to the patient although it could convert into a substantial dollar savings for those with a high deductible policy. My point however is that fewer patients means better care which in turn means lower total costs.) 

What about doctors? Is DPC for every PCP? I doubt it. When a practice is converted a lot fewer patients convert with it than might be expected – maybe 15-20%. Income will probably go down, at least initially. Some patients will feel the doctor is being greedy as noted above. There can be legal issues; the insurance commissioner may say it is essentially an insurance policy for primary care; a doctor is not an insurance company. Some sound advice would be important before embarking.  Doctors are a cautious bunch; this is a big change. My bet is that, until patients actually start demanding more time and agreeing that this is a sensible approach, the total numbers of PCPs who convert will be modest.

Next time will be a different topic; what employers are doing to assure better care yet lower company costs. In many cases it too amounts to getting the PCP more time.

Monday, December 14, 2015

Direct Primary Care – Isn’t It Too Expensive?



A common criticism of direct primary care (membership/retainer/concierge practices) is the added expense – “isn’t it too expensive?” Ways to think about the cost are to prioritize expenditures and to consider potential savings that make it cost effective.

I gave examples of three direct primary care practices in an earlier post. Here is a recap of costs.
AtlasMD’s annual fee is $600 for a young adult and about $1400 for a family of four; Dr Neuhofel’s fee is $360-$600 annually for an individual and $1200 for a family of four and Drs Izbicki charge $780 per year per individual. All can be paid monthly.

As Jon Izbicki puts it, “Our monthly fee is less than what it costs to rent a parking space downtown for the month.” Even the more expensive retainer practices are still within reason for many.  $1500 is about $4 per day; $2000 is about $5.50. How many people spend that much per day at Starbucks? Or, consider the monthly/annual cost of a smart phone data contract with ATT or Verizon. According to the Wall Street Journal and quoting from a Department of Labor study, the average American family spends $2237 per year for internet, pay TV and telephone service. So, perhaps $1500 or $2000 - which is certainly real money - is not such an onerous expense when thinking in terms of prioritizing healthcare expenses relative to other expenses. Of course, it is an added expense if you already have typical insurance.

But if you have a high deductible plan with a health savings account (HSA), you can pay for the membership/retainer with tax advantaged dollars and save considerably. And since the PCP will likely help you avoid expensive trips to the specialist, you will save those dollars as well.

I predict that (absent a significant change in insurer behavior) direct primary care will likely be the future of primary care payment. In each of them, it means that the patient will obtain real assistance to first prevent chronic illnesses from occurring; second, episodic care for those issues that pop up during the year; third, careful care of complex chronic illnesses and fourth, thorough coordination of the care of chronic illnesses, all at a reasonable cost which will be transparent. Fifth and importantly, a PCP who has the time to listen – to listen deeply with a return to relationship medicine.

Those who already have typical limited deductible insurance – commercial or Medicare – might argue that these various direct primary care models represent an added expense, not a savings. Correct, although the potential savings can actually be quite substantial. For example, each of the three practices referred to above make generic medications available at wholesale prices; considerable savings for many individuals.

Those who have no insurance – for whatever reason – will find that they can obtain good quality primary care at a reasonable price from one of the direct pay or membership practices. It will cost a lot less than going to an urgent care center or an ER. Recall from my earlier post that Dr Neuhofel’s practice has more than two thirds with no insurance.

Perhaps Medicare and Medicaid will decide that it makes eminently good sense to pay the retainer for their enrollees and thus ensure that their members gets superior primary care at a reasonable cost and meantime save Medicare and Medicaid enormous total dollars.

This concept applies equally to commercial insurers who have largely avoided paying the retainer. Some are collaborating with the insurer paying the retainer out of its premium.

What about employers? Many are converting their health insurance policies to high deductible, often with a deductible as high as $10,000 per person or family per year. For a family with members that have chronic illnesses, the costs of healthcare will be very substantial indeed at this level. Employees will arguably feel that their employer has walked away from them and saddled them with costs that they simply cannot bear. The company can partially offset the inherent anger this generates among its employees by paying the fee for a direct primary care practice. It is especially valuable for the individual with multiple chronic illnesses since quality primary care can mean much better health, many fewer tests, prescriptions, specialist referrals and hospitalizations.

I suspect that employers will be the major reason for direct primary care membership/retainer-based practice growth in the coming years as they will essentially demand that level of service for their employees – and in so doing they will be reducing their company health care costs as a result of high quality primary care.

The exact number of physicians in DPC practices is unclear but an estimate by Concierge Medicine Today in early 2014 pegs the known number at about 4000 with about 8000 others doing so but without fanfare. CMT also notes that many combine insurance with membership fees; not exactly DPC anymore but still an ability to limit the number of patients and give more attention to each.

More doctors will convert once the general population understands the advantages and begins to ask for it. There are many good reasons for an individual to connect with a direct primary care physician - better quality care, a return to relationship medicine and often a significant cost savings despite the fee.

TAGS  Direct primary care, primary care, primary care physicians, health insurance, healthcare costs, relationship medicine, concierge medicine, retainer based medicine

Sunday, July 12, 2015

Concierge Medicine – For the Masses or the Elite?


Is concierge medicine (also known as direct primary care, retainer-based, membership) for everyone or is it just for the rich, the 1%? Most people assume it is for the elite and cannot be afforded by the common man, the masses. That is unfortunate because in many cases it can be quite affordable. Here are three examples.

AtlasMD in Kansas City and others like it think of themselves as “blue collar” concierge practices. According to AtlasMD physician Dr Doug Nunamaker “We realized that insurance paying for primary care is akin to using car insurance to try to pay for gasoline. ‘It’s something that’s otherwise fairly affordable until you try to pay for it with insurance: My premiums would be much higher because they wouldn’t know how much gas I would need, they would tell me where to get gas, and I’d have to preauthorize trips out of town.” AtlasMD physicians have 600 patients each. Monthly fees: 20 to 44 years - $50 a month, 45 to 64 - $75 a month, 65 and older - $100 a month, children to 19 years - $10 a month. Generic medicines are available at wholesale prices.

In Erie, a working class city in northwestern Pennsylvania, the Izbicki brothers also began such a “blue collar” membership practice. Just out of training in Family Medicine in 2005, they first worked for another practicing physician and then the local hospital, in each case being frustrated that they could not spend enough time with each patient.  They started their own practice using the typical insurance-based business model and soon had about 4000 patients between them. They were back to seeing too many patients for too short a time each. Dr. Jon Izbicki told me, “We were bitter, frustrated. We were in a failed profession. It was so bad that we really had to take a risk. We knew that what patients want more than anything else is uninterrupted time with their PCP and with that to build a level of confidence. They want relationship-centered care.”

They converted in June, 2013. They chose to call their practice direct primary care given the fiscal conservatism of Erie. Not all of their patients were pleased; less than 20% joined initially. But over time their practice numbers have climbed.

The Izbicki brothers charge $780 per year for unlimited primary care, payable as $65 monthly or annually with a discount. Visits are as long as needed and usually the same or the next day. They have developed contracts with clinical laboratories for highly discounted testing and radiology. They purchase generic drugs at wholesale prices and sell them to their patients at the same price. For many patients, especially those with multiple chronic illnesses who are taking 5-7 prescription medications, this can save as much or more than the annual membership fee. It is this latter factor that especially encourages Medicare enrollees to join.

Dr Jon Izbicki put it this way, “Perhaps the term ‘complex care physician’ would be better than primary care physician as it more closely relates the work of the doctor, especially with these patients with highly complex, serious illnesses.”

Not everyone has a sizable practice from which to convert. For younger physicians, with no base of patients to draw from, it can be a challenge to get started. In Lawrence, Kansas, Dr Ryan Neuhofel began a membership practice called NeuCare right out of his residency training in 2012. He had decided while in medical school and residency that he did not want to be in a typical insurance-based practice. He told me, “I saw that most PCPs did not have fulfilling careers; they spent enormous time in administrative tasks rather than actually working with their patients. I knew I wanted to do primary care but it had to be in a model that let me earn a decent living yet let me give real quality care in a compassionate manner.

“It was a real gamble to go straight into this. I had no patients and no reputation in Lawrence. My practice built slowly at first but is gaining momentum now.” The demographics of his locale are individuals with less than the national median income so his practice is “more like a safety net clinic.” About 70-80% are uninsured and a very large number have complex, chronic illnesses – “a lot more than I anticipated.” His monthly fee is $30 and $40 rising to $50 for those over age 60; he charges $100 for a family of four with $10 more for each extra child. He buys medications from wholesalers. He finds that the savings for some of his patients with multiple prescriptions can be literally hundreds of dollars per month for a family, far outweighing the monthly membership fee. Now a few employers have noticed and decided to offer his services as a benefit to their employees who take out a high deductible policy. “I see this as a real source of growth for my practice and the real long term growth for the whole direct primary care concept. It allows employers to initiate a high deductible policy yet give the employee access to quality primary care at no added cost. This is especially important for the person with lots of chronic illnesses personally or in the family.”

Asked about income once his practice is filled out, “I will be earning about average for a family practice physician in this area and that is just fine with me.”

These three practices demonstrate that direct primary care by whatever name can be affordable to most individuals and families and in many cases actually save money – not to mention a return to relationship-based medicine.

Praise for Dr Schimpff

The craft of science writing requires skills that are arguably the most underestimated and misunderstood in the media world. Dumbing down all too often gets mistaken for clarity. Showmanship frequently masks a poor presentation of scientific issues. Factoids are paraded in lieu of ideas. Answers are marketed at the expense of searching questions. By contrast, Steve Schimpff provides a fine combination of enlightenment and reading satisfaction. As a medical scientist he brings his readers encyclopedic knowledge of his subject. As a teacher and as a medical ambassador to other disciplines he's learned how to explain medical breakthroughs without unnecessary jargon. As an advisor to policymakers he's acquired the knack of cutting directly to the practical effects, showing how advances in medical science affect the big lifestyle and economic questions that concern us all. But Schimpff's greatest strength as a writer is that he's a physician through and through, caring above all for the person. His engaging conversational style, insights and fascinating treasury of cutting-edge information leave both lay readers and medical professionals turning his pages. In his hands the impact of new medical technologies and discoveries becomes an engrossing story about what lies ahead for us in the 21st century: as healthy people, as patients of all ages, as children, as parents, as taxpayers, as both consumers and providers of health services. There can be few greater stories than the adventure of what awaits our minds, bodies, budgets, lifespans and societies as new technologies change our world. Schimpff tells it with passion, vision, sweep, intelligence and an urgency that none of us can ignore.

-- N.J. Slabbert, science writer, co-author of Innovation, The Key to Prosperity: Technology & America's Role in the 21st Century Global Economy (with Aris Melissaratos, director of technology enterprise at the John Hopkins University).