SPRINGFIELD, Mo. (AP) - With the start of October, the number of specific codes doctors use when diagnosing patients increased five-fold, to about 70,000.
Doctors use the codes to classify the care they provide when billing government programs and private insurance companies. The addition of the more specific codes will result in an influx of new data, which the federal government hopes to analyze to improve health care. But the additional codes will also further complicate the workload for the nation's doctors.
A group of local primary care doctors, however, aren't affected by the change. And their numbers, while small, are growing.
They don't accept insurance. But they'd be happy to see you for a standard monthly fee - although you can also just text. In return, they say you'll get longer, more personal visits, and quicker turnaround for appointments.
"The classic analogy of direct primary care is auto insurance," said Dr. Shelby Smith, who will open Equality Healthcare with two fellow doctors in December. "Everybody needs auto insurance for a car wreck. You don't use auto insurance for a car wash, or an oil change or new tires. Sort of what we're doing in the primary care realm is saying that primary care in this country should be accessible, it should be affordable and the pricing should be very transparent."
At the beginning of 2014, there was one local practice open to the public locally that classified itself as direct primary care. Now there are five in Greene and Christian counties. And three more plan to open by the end of the year.
Direct primary care operations are an alternative to traditional providers - and thus naturally somewhat of a critique of them.
Direct primary care is an umbrella term, which can be applied to multiple styles of health care delivery. The model has been around for about two decades, with the first operations targeting wealthy people willing to pay high sums for personalized care.
Among the practices in the Springfield area, monthly membership fees for an individual range from $39 to $150 a month. Each operation differs slightly in what is included in the fee. Ascent Direct Primary Care, for example, will have one of the lowest monthly fees locally when it opens in Nixa, but will charge $20 per office visit. Membership at other operations includes unlimited office visits. Some practices also have pricing per couple or family, and allow non-members to pay per visit.
Practices generally recommend that a direct primary care membership be paired with a basic level of health insurance - more spartan than what individuals might otherwise choose - to cover hospitalization and more serious medical issues.
With the exception of Equality Healthcare, which will have three doctors when it opens in downtown Springfield's College Station in December, all of the local operations revolve around one physician, who is typically supported by one or two staff members. Because of the fairly recent emergence of the model locally, most doctors who have become involved spent years working for operations affiliated with one of the city's major health care systems beforehand.
The average primary care doctor locally has about 2,500 patients, and he or she might see 25 to 35 of them a day. Most local direct primary care doctors interviewed said they're aiming for about 600 members in their new practices.
"It's difficult to provide adequate care for someone with three or four chronic conditions in a 10- to 15-minute office visit," Smith said.
Not dealing with insurance and billing allows direct primary care practices to cut down on staff costs, and the membership fees give the practices regular income. That leads to what the doctors feel is a more patient-friendly focus.
"It allows us to just see people, and it doesn't depend on how much we do as far as there being reimbursement for that," Smith said. "A lot of what is seen in a primary care office doesn't need to be seen there. On any particular day, say 30 to 50 percent of what we see in the (Cox) clinic could have been dealt with over the phone, text, email, Facetime."
Direct primary care operations generally encourage electronic communication, because the doctors earn the same whether patients see them in person or not.
Dr. Martie Gravitt, the only local pediatrician in the direct primary care space, doesn't even have an office. He makes house calls when needed, and said "80 percent of what I do is texting." Gravitt describes his practice with the term "concierge medicine," which he feels better communicates his ability to be reached 24 hours a day, seven days a week.
The model is also attracting some physicians at the beginning of their careers. Dr. Luke Van Kirk, who completed his residency at Cox Family Medicine in June, plans to open Command Family Medicine in southeast Springfield in December. He said he became familiar with direct primary care because he has a cousin who works in one such operation in Wichita, Kansas.
"I started talking with him my first year in residency and realized direct primary care was the only way I would ever want to practice," he said. "Traditional practice was something I never even considered because I saw how burnt out everyone in that system was."
Mercy Springfield spokeswoman Sonya Kullmann told the Springfield News-Leader (http://sgfnow.co/1QtSLZL ) that the direct primary care model "does not fit with what we believe is the future of health care, where a patient's entire care team is increasingly connected to them and each other through technology."
"This allows for better patient access as well as coordinated care among multiple providers," Kullmann said. "We believe that will produce greater overall health for patients as well as reduced costs. However, we are anxious to see how patients in Springfield react to these new offerings."
Mercy Health recently opened a $54 million "virtual care center" in Chesterfield. The facility is a central hub for the system's telemedicine programs, which allow patients to see their doctors via computer for certain conditions; staff members at the care center also provide remote monitoring for patients in hospitals across the Mercy system.
CoxHealth declined to comment for this story.
The growth of direct primary care occurs in the midst of what is seen as a shortage of primary care doctors in the country - a shortage that will reach 45,000 by 2020, according to the Association of American Medical Colleges.
A high number of physicians who had seen thousands now seeing hundreds would naturally exacerbate the shortage in the short term. But in the long term, direct primary care physicians hope that if physicians are happier in their new practice, medical students will see that, and more will decide to focus on primary care.
"I would say a large part of the situation we're in is due to the dissatisfaction of primary care physicians with how they're able to care for patients in the system they're in," said Dr. Matthew Green, of Ascent Direct Primary Care in Nixa.
Tim Fursa, a former program director of the Cox Family Medicine Residency now working to promote local direct primary care practices, said such practices are still in the "gathering members" stage, so it's too early to assess success. He figures it takes two to three years for a doctor to get established. An average family physician in the area might make $180,000, Fursa estimated, and he or she has the potential to exceed that in a successful direct primary care practice.
About 18 months after launching Gesundheit Pediatrics, Gravitt said he has about 50 members - about half what he figured he'd have by now, and well short of the 300 he'd eventually like to see. That makes him slightly concerned about the influx of new practices similar to his.
"I don't know that we're all going to make it," he said. "I don't know the Midwest is quite ready yet."
But William Graham, the first direct primary care practitioner locally, doesn't share the same concern. Graham launched Bethesda Medical Care in October 2011, and his downtown Springfield office opened a few months later. He currently has about 450 members, and said he'll generally see another 450 people during the year for one-time visits. He's one of only two aviation medical examiners in Springfield, for example, so he sees pilots that need medical certification.
Graham said he's making less than he did in his previous roles, but he's happier. He wishes he had discovered direct primary care a decade earlier.
Billy Holt, who opened VIP Medical Services in Ozark in April 2014, said his biggest challenge in the past 18 months has been educating people on the model, because consumers are so used to dealing with insurance.
"It's a new concept, trying to educate people - yes, you do have insurance, but I can give you this on top of it - when they're used to kind of the normal rat race of the hour wait for the six-minute visit, and then being referred to three different specialists," said Holt, who declined to quantify his membership.
Another challenge for doctors, according to Graham: "Usually in family medicine, residency training has not emphasized a lot about running a small business."
While Van Kirk will be the only doctor at Command when it opens in December, he hopes to bring on others when his membership base gets large enough - attracting doctors who might be wary of starting out on their own.
"I've found most doctors' resistance to doing DPC (direct primary care) is they don't want to go through the transition period where they make less money, especially with student loan payments and families to feed," Van Kirk said. "If I can eliminate that transition period for them, then I can help more doctors enjoy the practice of medicine and in turn help them be able to take care of patients the way they've always wanted to."
Most direct primary care practices locally add members one individual at a time. But Fursa, the former residency program director, hopes to get practices a larger chunk of business.
Fursa runs Innovation Family Medical Care, a local company that is hoping to spur the demand for the direct primary care model in the Springfield area by working with local employers.
Employers might be reluctant to contract with a direct primary care practice, Fursa said, because primary care is only one aspect of the health benefits they provide to their employee. So Innovation is working to create a health care plan that combines a basic version of health insurance, an employee wellness program and an arrangement with a direct primary care practice. He's targeting employers that are highly interested in employee wellness.
"The approach that I'm working with my partners is bringing the whole package to employers," Fursa said.
An arrangement with an employer, who would pay for memberships for its employees, would be a sort of "golden prize" for a practice, Fursa said, guaranteeing a solid base of business.
Fursa believes the existing and planned operations are being watched closely by those in the medical community locally.
"I have doctors approaching me fairly frequently that are currently employed in the health systems in town that are considering this care. There's kind of this shadow network of doctors who might do it."
Information from: Springfield News-Leader, http://www.news-leader.com