Wow… this was unexpected! Almost a year ago, Lifespan and Care New England, along with Brown University, announced a proposed merger. At that time, I wrote a blog about why this was such a horrible idea. While the physicians at Direct Doctors completely understood the downsides of such a merger, especially in this small state, we did not think Rhode Island would get this right! Well today, the Attorney General denied the merger while at the same time an FTC advisory board voted 4-0 to file a joint lawsuit to do the same. While news organizations are calling this “stunning,” this is likely only because we tend to get these decisions wrong all the time. There is not necessarily anything stunning about realizing that having one organization in charge of 80% of inpatient care in a state is a bad idea! It seems obvious to us, given the mountain of evidence that AG Neronha cites, that health care monopolies cause prices to go up, access to go down without any appreciable change in care.
Now, Rhode Island still has a long way to go to fix our broken health care system. We need to focus more on primary care including incentivizing more primary care physicians to practice here. We need to give innovative practices (like Direct Primary Care) more of an opportunity to thrive. We have to work on giving patients more choice while also lowering costs. We are doing that here at Direct Doctors and will continue to do so as we grow in the future.
Dr. Ashley Lakin DO is "over the moon" to be starting her own branch of Direct Primary Care with the help of her friends at Direct Doctors. Dr. Lakin, trained at Brown with Drs. Turshen & Hedde. As a fellowship trained Maternal-Child Health Family Physician, Dr. Lakin is excited to add prenatal care and lactation medicine to Direct Doctors. With a special interest in primary care for newborns and whole families, Dr. Lakin is a great addition to the Direct Doctors' family. Drs. Hedde & Turshen "are so excited to have a colleague joining us as we expand the services and locations of Direct Doctors direct primary care practices in Rhode Island. Dr. Lakin is a long-time colleague & friend as well as a phenomenal and caring physician." Dr. Lakin is currently accepting new patients and will be working out of the East Greenwich office until her new practice location is up and ready in Riverside, RI where she plans to stay long-term.
This recent Wall Street Journal article may have hit the nail on the head. During the early months of the COVID-19 pandemic, insurance companies and state & federal regulators really reduced the requirements surrounding telehealth. This allowed patients who were sick or in need of prevention-related care from their primary care doctors or specialists to reach the doctor without going in for a visit. Care was able to continue for many things that did not have an essential in-person component and patients were happy to continue to receive what they needed in a trying time.
In 2019 we discussed the basics of why patients wait a long time to hear back, get through on the phone lines, or be seen with a primary care doctor. Unfortunately, this problem seems to have worsened acutely with the COVID epidemic. As an update to that blog, we want to begin by highlighting again that according to Merritt Hawkins, the average wait time for a new patient appointment with a primary care doctor is 29 days, up 50% from 2014. In Rhode Island, the wait continues to be much longer. We’ve heard of patients quoted a six to twelve month wait period before they can see a doctor as a new patient!
As the COVID-19 situation in RI takes a turn for the worse (yet again) we find ourselves in a predicament as patients. The hospitals in RI are over 90% capacity for inpatient beds and ICUs are at more than 80%. This has been true on and off for a majority of the COVID pandemic. In states like FL, which are extremely hard hit right now, some ICUs and hospitals are unable to accept any patients. A nationwide news story recently revealed patients have died because they cannot get non-COVID-related hospital care when they need it and their local hospital is full.
Why am I telling you all this? Not because I am trying to scare you out of going to the hospital when you need it or to make you think all is lost. I am telling you this to emphasize NOW is a more important time than there ever was to get yourself a trusted Primary Care Doctor (PCP). PCPs can address your needs before you become very sick, can order testing as an outpatient to avoid waiting in the ER or urgent care, and we can help you identify illnesses and treat them quickly.
The Direct Primary Care movement has picked up steam over the last seven years since we started Direct Doctors in RI. According to DPC Frontier, a site owned by a DPC physician/lawyer who was a founder of the movement, there are now over 1500 clinics doing pure Direct Care across the nation. There are likely many more than have been officially labeled on the map. Looking back to 2014, when we began, there were less than 100.
Seven Years on an Island
Direct Doctors will be celebrating our 7 year anniversary this August! Over that time, we’ve come to really appreciate the direct primary care model that we are using to deliver efficient, evidence based and personal care to our almost 1,000 patients. Like many of the other DPC practices across the country, we’ve noticed many benefits (for both the patient and physician), while also discovering a few barriers.
The two most common types of health insurances that we see today (outside of medicare and medicaid) are called PPOs and HMOs.
The majority of our blogs focus on the healthcare system in general, and how direct primary care can help fill in some of the gaps. Currently, I’d like to highlight some concerns with a more local healthcare issue that has been in the news lately. If you haven’t heard, the long anticipated merger between Lifespan and Care New England has been announced. This deal also involves Brown University who only noted the positive aspects of such a merger in their press release. The Providence Journal conversely, ran a much more balanced assessment article .
Every time large health organizations merge or consolidate, the purported benefits are advertised far and wide: continuity of care will improve, costs will go down, quality of care will go up and the health ecosystem will dramatically change. In this case, we are told that all of Rhode Island will be better off with the two largest healthcare organizations combining powers to produce a health care utopia.... except all the data we have to date shows the exact opposite.
We have mountains of evidence that whenever this happens, costs go up! When there is a monopoly on services and reduced choice for consumers, patients (or their insurers which eventually trickles down) end up getting charged more for the same services. There is evidence that the same thing happens when physician practices merge or get bought by larger organizations. You want more data? Here’s an article from 2018 showing that though hospital operating costs are reduced 15-30% by this kind of merger, costs still go up! And how about that “increase in patient care” that is touted. Here’s an article from Harvard just last year that indicates that hospital performance does not improve and patient satisfaction actually goes down.
Interestingly, we do know that one of the only things that does decrease health care costs is access to good primary care. Neither Lifespan nor CNE have ever prioritized primary care, which is consistent among most large health care providers.
What is the incentive for large hospitals to have great primary care that keeps patients away from their biggest revenue generators?
Care New England allowed Memorial Hospital to close, displacing the main Family Medicine Residency in the state, which disproportionately affected the large minority population in the Pawtucket/Central Falls area (despite everyone's calls to improve health disparities). Brown Medical School, like many large academic institutions, loves to highlight their students who go into flashy specialties as opposed to holding those who love primary care in similar esteem. So those who are interested in primary care medicine are really exposed only to corporate medicine, PCMH and the types of practices we think need to be changed in the first place.
Rhode Island, as a whole, already has a primary care shortage due to many factors which drives more patients to urgent care and ER facilities subsequently driving up costs for everyone. To combat this, these large organizations are turning more to mid-level providers (PAs and NPs) in their primary care setting. These providers historically order more tests, refer more to specialists, etc… which, you guessed it, also drive up costs. To assist with all of this “continuity,” these large organizations turn to bloated, insanely expensive, electronic medical record and billing software. Then to make up for these costs, primary care doctors are forced to see more patients, leaving little time for good medicine or pension for over prescribing, ordering and referring (as we’ve mentioned in the past)
We do understand that there can certainly be an increase in academic research and improved specialty consultation within these institutions, so it’s not all bad. But in the end, the combination of poor primary care, hospital monopolies and the introduction of more HMO plans into the mix are setting our Rhode Island health care system up for increasing costs, decreasing patient choice without any change in outcomes or patient satisfaction. At Direct Doctors, we will continue to do our part in assisting patients with quality primary care access, lowering their medical costs and improving their overall care!
During the COVID pandemic, as many insurances started to see the necessity of telemedicine (i.e. video and telephone calls in place of in-person visits), many types of “healthcare providers” and services jumped to the forefront for these types of visits. Services like Teladoc, having been around a long time, started getting more notoriety for the virtual service they offer. It’s important to understand the differences between telehealth and virtual services and telemedicine appointments with your own doctor.
Lauren Hedde, DO; James Hedde, DO and Mark Turshen, MD are Family Physicians and Co- Founders of Direct Doctors, Inc. a Direct Primary Care Practice.