Why It Matters
Erika Bliss, MD, wants to help remake primary care in the US. Getting chronically ill Medicaid patients healthy and back into the workforce is just one way she hopes to do it.
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The Old-Fashioned Way to Reinvent Primary Care

By Jo Ann Endo | Friday, April 7, 2017
The Old-Fashioned Way to Reinvent Primary Care

Erika Bliss, MD, is founder and CEO of Qliance, a health services startup that operates direct primary and preventative health care clinics in the Seattle area.

What is “direct primary care” and how does it compare to the standard primary care model in the US?

Our patients pay a recurring monthly fee and no co-pay per visit. The monthly fee allows us to charge what we need to provide the kind of care that we want to provide, and that we believe our patients want.

Direct primary care was born out of frustration. Primary care providers felt they weren’t using their training to do what was right for patients. They felt very unsatisfied. Patients were not satisfied. Nobody was getting what they needed because primary care providers couldn’t spend enough time with their patients.

Everyone blamed insurance hassles, but the real issue was the per unit payment for care — it was too low. So, in order to make up the difference, practices had to see more patients. You couldn’t make a living spending half an hour with a patient and taking care of all his or her problems at once. You had to tell the person, “Sorry, I can only deal with one or two problems per visit.” The patient would have to make another appointment to address other problems. 

It obviously wasn’t efficient, and it was terrible for the patient. You had to blaze in and out of the room, and you ended up jumping to conclusions. You couldn’t really do your job as a doctor.

Some people talked about convincing the insurance companies and the country as a whole to value primary care more highly, or to pay for it differently. Finally, folks like us said, “We can’t wait. We’re going to have to do this ourselves.”

We decided to go direct to the public and try to sell our wares the old-fashioned way. It’s basically hanging out your shingle saying, “Hey, folks, this is what I have to offer. This is my price, and if this is something you’d like, then you can come by.”

There are no additional charges for anything, so there’s no disincentive to come in for care. To me, that sets up the person for success. You’re basically saying to him or her, “I want you to come in. I want you to call me. I want you to email me. Let’s keep you out of trouble. Let’s keep you healthy, so you don’t need specialists, and you don’t need to go to the hospital. We can take care of your diabetes and hypertension. And, eventually, maybe you won’t even need me!” That would be a great thing.

It sounds like you’re trying to put yourself out of business.

Exactly! It’s funny you say that because that’s what I’ve been starting to say because, ultimately, self-respecting doctors should be trying to put themselves out of business. We shouldn’t be trying to make more business for ourselves.

What are the advantages of direct primary care for patients and primary care providers?

This model frees me up to do what’s right for patients. I could, for example, open a clinic tomorrow, and charge $100 a month and spend two hours with a patient during the first visit because that’s how much time I decide I need to really get to know him or her. At the next visit, I’ll spend 30 minutes with the person. I could set up a practice that way. I just have to have enough people to cover my costs, make sure that I make a living, and pay my staff. This puts me in a position to tailor the care to the population I’m serving, rather than expecting that population to fit me. I make sure that I’m meeting the quality standards, but I also get a chance to get to know a person as an individual, and find out what approach will work for him or her.

Is there a patient story you can share that helps illustrate the difference direct primary care can make? 

There are so many, but let me start by talking about the difference it makes for my staff. They are so engaged and happy and passionate about what we’re doing. When we’ve gone through lean times, they’ve said things like, “I just want you to know that I’m with Qliance until the end, until the wheels fall off.” Who says that to their boss? That’s a big deal. This is important because there’s burnout among all levels of health care providers, not just physicians. It’s a really critical problem because if my medical assistant, nurse, front desk staff, or physicians suffer from burnout, care is going to suffer.

My favorite patient story is about someone who got his life back. The Medicaid plan called us one day and said, “Would you please, please, please see this patient? His care has been so poorly managed. You guys seem to be very good with complex patients. Will you see him?”

We got him in on a Tuesday. He had been in the hospital every two weeks. His care was costing Medicaid hundreds of thousands of dollars a year. It was too late to prevent the next hospitalization. He had to go in the next day because he was so sick, but that was his last hospitalization. He didn’t go back to the hospital, ER — nothing. We got all his care organized and helped him get healthier. 

I heard about this patient because he came into the office six months later and asked to speak to the nurse. He wanted to talk about nutrition and exercise. He said, “Now that I have my life back, I really want to get healthy.” That just blew my mind.

We haven’t found an easy way of checking the data on this, but we [hear anecdotally] that we help a lot of people get off Medicaid and back into the workforce. Looking at the big picture, why aren’t we [in health care] trying harder to get people better and back to work?

What data are you tracking and what kinds of results are you seeing so far? 

We just looked at our 2016 data for our Medicaid population. We follow about 11 measures from Healthcare Effectiveness Data and Information Set (HEDIS) data. We use a patient satisfaction survey, and we get quarterly feedback from our clients.

On traditional quality measures, we got to at least the 75th percentile for 75 percent of them. We hit the 90th percentile for about 65 percent of them. On patient satisfaction, we get really high scores — 95 to 100 percent on patient satisfaction survey scores. 

When we look at health care utilization, our patients consistently end up using about 40–60 percent fewer hospital days than their comparison populations. Our number of days per stay is sometimes a little longer than the average for the comparison population, but that’s because when our patients do go to the hospital, it’s because they’re really sick and they need to. Our number of days per stay is about a day longer than everybody else, but our total days are about half as much.

What are the barriers to implementing the direct care model more widely?

Our approach ends up eliminating the need for a lot of care. Think about how threatening that is [to some people in health care]. And I’m not talking about [reducing the need for care] over five to seven years. We see these reductions within the first year. So, if we take on a population, and they end up needing 30 percent fewer advanced radiology, specialists, and hospital services, how do you think the hospitals feel about that?

Ultimately, it’s never easy to shift power and resources in a system, and systems that are deeply entrenched do not change easily, especially when many benefit from the way it’s currently built. It takes disruption, and disruption is painful. And it takes people being relentless and determined and finding the right allies to make it happen. The good thing is that our patients are our biggest supporters. They know this is the best way to do it, and they don’t want to give it up. 

I think that the health care system, and the different industries connected to it, need to do some soul searching. They need to look at the way the wind is blowing. Change is necessary, and if we reduce the need for some of these systems, they could be repurposed and contribute more to building long-term health and prosperity for the country.

Would you give me an example of what you mean?

Let’s think about all the health care needs we have in this country. Instead of building new hospitals, let’s say that every hospital dedicates a floor to a full-service primary care center. You could make the care so good that everybody wants to go to your hospital system to get the most fantastic primary care ever. You could compete on the basis of true quality and great patient outcomes.

The hospital could ask the government to back them. They could promise to return a certain amount of the money to the government if they don’t deliver superior outcomes. They could partner with folks like Qliance. Forget this pioneer ACO thing! We could show dramatic improvements in two years.

Note: This conversation was edited for length and clarity.

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