On Housecalls, and the Hope of Direct Primary Care

Yesterday afternoon, I had the privilege of speaking at the annual Pennsylvania Homecare Association conference, held at the Lancaster Convention Center at the Marriott. The Association invited me to talk about my experience being a physician that does housecalls. Below is the transcript of my 30-minute speech -- Dr. Rohal


I want to extend a sincere thank you to the Pennsylvania Homecare Association for having me this afternoon.  My name is Doctor Patrick Rohal.  I’m a family physician here in Lancaster.  I have the unenviable privilege of being the only thing standing between you and lunch, so I promise not to add one minute to the 2 hours the Association has allotted me (laughter).

I would like to begin with a true story.  It takes place on a sunny Summer morning in 2016, on the quiet roads of southern Lancaster County.  That morning, I’m on my way to a housecall.  This would be an unusual housecall.  One reason is that it’s taking place on a Saturday morning.  Another is that I’ve purposely not taken along my usual tools of the trade, the tell tale doctor bag organized with instruments and supplies.  That is because my express purpose this morning is to merely have a conversation with my patient and his wife.  The patient, I’ll call him Amos (though that is not his real name), is a sixty-one year-old Amish man.  He became my patient only about one month before.  At his intake physical, I took a careful history, performed a thorough physical exam, and checked some routine bloodwork.  The results of that bloodwork began a cascade of events that is culminating in my journey to his home this morning to speak to him and his wife.  You see, that bloodwork uncovered severe hyponatremia, or a significant depression of his body’s sodium level.  Now the serum sodium is one of the human body’s most tightly regulated levels.  And when it is out of alignment, especially to the degree that Amos’ level was out alignment, it could be a harbinger of some significant dysfunction somewhere in the body.  So when I received this lab value, I asked myself, where would I begin a search for the cause?  I thought, how could such a significantly depressed sodium level be present in a man that was otherwise healthy, at least outwardly.  As I began to put the pieces together, one aspect of his medical history that worried me was his smoking history.  We all know that smoking is a risk factor for lung cancer.  It turns out that one unusual feature of lung cancer is that it can hormonally depress the sodium level.  So as a first step in beginning to investigate his abnormal labs, I ordered a screening CAT scan of his chest.  It turned out that this CAT scan, whose results I had received just the evening before this housecall, found a 12 centimeter mass at the top of his right lung that, though it would need to be further characterized by more imaging and maybe even a biopsy, was almost certainly advanced lung cancer.  And so my journey that morning to Amos’ house was to deliver the news to him and his wife that he had lung cancer, that the tumor in his right lung was large and possibly inoperable, and that it therefore had pressing implications as to his health and survival even over the coming weeks and months.  So I sat in Amos’ living room, his wife sitting beside him.  I delivered that news in the most measured tones I could, and then I paused and I let there be silence.  And it was a long silence.  That morning, I very much appreciated, and I think my patient and his wife did as well, that I could deliver that news in the quiet of his home, away from a busy office, in in a way that was not time-limited, as too often things are in the modern family doctor’s office.  We outlined and arranged next steps.  Of course, their most pressing questions had to do with his prognosis.  I replied that I couldn’t comment on that at least until we brought Oncology into his care plan.  On the way home from that housecall, though I usually like to play a podcast or listen to music, I could only drive home in silence, as I think that was the only sound weighty enough to bear the events of this morning.  It turns out that Amos died of terminal lung cancer five months later.

I would like to talk to you this morning about housecalls.  Particulary, doctors doing housecalls.  I would also like to talk about the larger issues that the performance of housecalls (or lack thereof) highlights, namely, the state of the doctor-patient relationship in primary care, and the state of our modern healthcare system.  So first, I would like to ask you a rhetorical question, and that is, when was the last time your primary care physician saw you in your home?  Or when was the last time they saw you at your worksite?  I would wager that the response of most, if not all of you, would be “never.”  Now let me ask a couple of other broader questions, questions that also get to the heart of the plight of our modern healthcare system.  Those questions are:  Why is primary care so devalued in our healthcare system, despite lip service to the contrary?  And why is it that only 15% of graduating medical students choose a primary care residency?  Housecalls as a relic of a bygone era, the value of primary care in our healthcare system, the crisis that primary care residencies face in filling out their classes…though these may seem like disparate problems, I think they can have a unifying solution, a solution that I’ve implemented in my career, and which I’d like to share with you this morning.  But first, I’d like to tell you a little about my journey as a family doctor. 

Marcus Welby, M.D. (actor Robert Young)

Marcus Welby, M.D. (actor Robert Young)

I entered medical school at the University of Maryland in the year 2000 wanting to be the 21st century epitome of Marcus Welby.  It’s funny…when I’m talking about my medical practice in the community, I often begin by showing a picture of Marcus Welby, with the caption “Dr. Rohal, circa 2000”, and asking who in the audience knows who this is.  Invariably, what I’m ultimately asking the audience is who among them is old?   So yes, I entered medical school wanting to be a Welby-esque general practitioner, a doctor that offered ample time for his patients, that could perform housecalls, and that would be a fixture in the community over many years.  That’s not to say that, along the way at the University of Maryland, I wasn’t enthralled by other specialties like general surgery and dermatology.  But I sensed that the specialty of family medicine presented both the deepest challenges and the deepest rewards of any specialty.  Family doctors have to know a little of everything.  There couldn’t be more variety to what walks through our office door on any given day.  And we enjoy the privilege of caring for every member of the family, from birth to old age, and forging relationships that we hope would endure for years.  We aim to treat the whole person, to resist the tendency in modern medicine to look at the human body as a machine that can be divided into modules:  a cardiac module, a kidney module, and so forth.  We see patients as a complex unity of physical, emotional, spiritual, and communal aspects.  This is the ideal of family medicine.  While I do believe that this ideal is alive and well in the hearts and minds of many family doctors today, as it is with many of my family practice colleagues here in Lancaster, I think that this is so despite the culture of primary care that our modern healthcare system has handed us.

I began to sense storm clouds on the horizon during my family practice residency in the U.S. Air Force from 2004 to 2007.  In the military, doctors essentially practice in a single-payer system.  Active duty families enjoy Tricare, a health insurance benefit with very low premiums and virtually no deductibles or copays.  So while it seems that Tricare families enjoy the best that health insurance can offer, what kind of product do they get in their primary care experience, and by the same token, what kind of a product could a family practice doctor deliver in that environment?  Well, it looked like this:  15 to 20 minute appointments, 25 to 30 visits per day, a several-week wait for my patients to see me, a daily burden of constantly running behind on my packed scheduled, and very little room to innovate in order to make the primary care experience better for my patients — as in no options for my patients to communicate with me in secure and HIPAA-compliant ways, or to innovate beyond the context of the single time-limited office visit.  This is the lot of every primary care physician that works within the milieu of insurance-based fee-for-service, which is the payment model we’re all used to.  Because you see, the name of the game in the context of this model is…efficiency.  With reimbursement rates to primary care providers going ever downward, we have no recourse but to fill our schedules.  And what other problems emerge from that?  Well, with the pressure to be efficient comes the tendency to practice medicine exclusively according to an acute care model.  In such a model, a doctor collects a list of symptoms, and a list of objective findings via the physical exam, labwork, and imaging, and then she fits a diagnosis to that list.  Hopefully, that diagnosis leads to a quick and efficient treatment plan.  And nothing is more quick and efficient than prescribing a pill, or in writing a referral to a specialist that will take over in treating her patient’s high blood pressure, his diabetes, or his depression.  Yes, the name of the game in being a primary care physician in our healthcare system is to do quick data acquisition (at times even farming that data acquisition out to ancillary staff), to make quick diagnoses of medical problems, to prescribe a pill or make a referral, and then to do the best we can in applying these same acute care principles to the management of chronic disease.  This paradigm also carries with it a number of other downstream effects, such as the need for a primary care doctor to carry a patient panel numbering in the thousands.   Did you know that a typical family doctor cares for as many as 3000 to 4000 patients or more?  And what about the cost of care?  In every other service industry, professionals name prices and customers agree to pay those prices.  Prices are transparent and not hidden.  But in healthcare, it’s often the case that neither the physician nor the patient knows what the true cost of care is.  That’s because there is an ever present third party that is paying the bills.  And finally, and most importantly in my view, there’s the time factor.  Not every problem lends itself to a neat 15-minute office visit.  What do I when it’s mid morning, I’m already running 30 minutes behind, and my 43-year-old patient discloses that he is suffering from depression, and would rather talk about this than the sinus infection he ostensibly told my nurse was his chief complaint?  And what do I do when it would take me at least 30 minutes to teach my diabetic patient about a low carbohydrate diet, by far the most effective treatment for his problem, but one that requires, ideally, repeat visits every week to track his progress.  The pressure is immense to, instead, take 5 minutes to prescribe a pill.   

You might have heard of what’s called the Triple Aim of healthcare.  This is a framework developed by the Institute for Healthcare Improvement in 2007, in which they highlight three goals for improving healthcare performance.  Those goals are 1) improving the patient experience, 2) improving the health of populations, and 3) reducing the per capita cost of healthcare.  Primary care practices around the nation got to work on applying these aims, and many were quite successful.  But by 2014, 7 years after the emergence of the Triple Aim, a new epidemic began to emerge, and is still smoldering even as I speak, and that epidemic is physician burnout and suicide.  And so in 2014, it was recommended that the Triple Aim be expanded to a Quadruple Aim, adding as the fourth tenet “Improving the work life of health care clinicians and staff.”  But let me ask at this point, how is it possible to improve the work life of primary care clinicians and staff, while at the same time improving the patient experience and maximizing value in healthcare?  Doing so, I think, would require a radical shift in the way we pay for and execute primary care.  Such a radical shift might have to begin not at the ivory towers of medicine and healthcare, but at a grassroots level, patient by patient, doctor by doctor, and practice by practice.  Such a promising solution does indeed exist, and I believe that I have successfully implemented it in my practice in Lancaster.  I’ve done so on the shoulders of my physician colleagues, courageous innovators and pioneers, that first took the risk and went renegade in the early 2000’s.  This solution not only meets each tenet of the Quadruple Aim, in delivering a superior patient experience, value for their hard-earned dollar, and the rediscovery of the love of primary care among medical students, physicians, and nurses, but allows a reintroduction of those aspects of care we thought we would never see again…like housecalls.  This radical solution is called Direct Primary Care.  

My first introduction to the concept of Direct Primary Care (or DPC) came in 2007.  That year, I was an Air Force family physician, newly graduated from residency and facing a long career as a family practice doctor, not sure that I could sustain a whole career practicing on the treadmill of insurance-based fee for service.  So there I was one afternoon, sitting in my cubicle.  I was probably eating my lunch, and I was perusing my medical journals.  I came across an article that had quite a provocative title, “Breaking Even on Four Visits a Day.”  Really?  Four visits a day?  I had 25 patients on my schedule that day.  This doctor had implemented something called Direct Primary Care, in which he left behind all of his health insurance contracts, and instead contracted directly with his patients (hence the name Direct Primary Care), via a low monthly fee.  The model was a little like concierge medicine, which had already been in existence for some time.  But unlike concierge medicine, DPC greatly lowered the monthly fees, and made a complete break from billing health insurance.  Because he was not subject to insurance contracts, there were a number of things that this doctor could do to innovate the primary care experience not only for his own benefit, but ultimately for the benefit of his patients.  He could greatly reduce the volume of his day, seeing at most 10 patients.  He could offer his patients ample time with the doctor, lengthening appointments to 30 or even 60 minutes.  He could perform labwork at greatly discounted prices (again, not having insurance contracts means that we can price things outside of the insurance world, which often translates to incredible discounts).  He could dispense medication from his own pharmacy, again at greatly reduced prices.  And he could service a patient panel numbering not 3000 or 4000 patients, but at most 800.  Having a patient panel of 800 meant beginning each day with ample room in the schedule for acute same-day visits, and it meant having the ability to take call, 24 hours a day and 365 days per year, for all 800 of those patients, decreasing their usage of urgent care and the emergency room.  More time with his patients meant less referrals to specialists, decreasing the care fragmentation that is so common in our healthcare system.  This doctor, Brian Forrest in Raleigh, North Carolina, turned heads as he began writing about this Direct Primary Care model, and slowly, other physicians, physicians that were also burned out in an insurance-based fee-for-service model, and had patients that were burned out too, began opening their own DPC practices, and a revolution was born.  

But what about me?  Was such a radical practice change in my future?  Would I be able to give up the comfort of a salaried position with benefits to take the risk of starting my own practice with an unknown future, especially with a wife and three children depending on me?  And so for many years I kept my sights on the DPC movement, as I continued to slog along in fee-for-service.  And then something happened that accelerated the movement.  The Affordable Care Act was passed in 2009, which lead, over the next few years, to greatly skyrocketing health insurance premiums and deductibles.  Suddenly, every November the 1st, when state health insurance exchanges opened for business, there was an undercurrent of anger and desperation, as patients began grappling with ever more expensive health insurance products offering ever dwindling quality.  Patients began realizing that in order to survive they had to become consumers.  But just how would they do that?  Where would they look for the best value and highest quality in a healthcare offering.  Direct Primary Care provided this answer, and so DPC really began to hit its stride as patients realized that for about the price of cable, an entire family could purchase a product that served 90% of their healthcare needs.  

I’ll take a brief detour to describe another adventure in my family medicine career, and that was my employment at a clinic exclusively serving the Amish and Mennonite populations of Lancaster and the surrounding counties.  I began this job in the summer of 2012, and I felt like I was living a family doctor’s dream.  Although the practice model was still fee-for-service, is was cash fee-for-service, as we did not take insurance (our patients didn’t have insurance).  This allowed me, for the first time, to grasp the true cost of the care I was used to delivering.  For example, I had no idea that the migraine medicine I was used to prescribing cost $300 for 9 pills, as it was always paid for by an insurance company, who increasingly passed on the full cost to my patient, again without my knowledge.  I learned that there were incredible discounts available even to “English” patients if they simply asked to pay cash for an x-ray, for instance, rather than pull out their insurance card.  It meant $45 for an x-ray rather than the $300 to $400 insurance-negotiated price, which with high-deductible plans the patient would be paying anyway.  But despite the joy and the adventure of being a doctor for the Amish, and being liberated from the burden of health insurance, the practice model I was working under was still fee-for-service, with its 15 minute appointments and thousands of patients per provider.  I was quickly on my way to the burnout experienced by so many primary care physicians today.  

And so we come to the year 2015, when I finally made the decision to begin my own Direct Primary Care practice in Lancaster.  I decided to call this practice CovenantMD.  I launched my website in August of that year, well ahead of my anticipated opening in January 2016.  I also did some things that would help to bring the concept of DPC to the people of Lancaster.  I began holding townhall-type gatherings to talk about the concept.  I reached out to our local newspaper, LNP, who placed my picture and an article about DPC on the front page of their business section on a Sunday morning in November.  I was featured on the local TV news.  And I began a blog on my website.  With that blog, I started with three articles describing the concept of DPC.  I soon followed up with a blog post entitled, “How the Amish Made Me a Better Doctor,” describing my years as a doctor for the Amish.  I’ve written many blog posts since 2015, but the one that consistently garners the most attention, and the one that it turns out brought me to the attention of the PA Homecare Association and garnered an invitation to me to speak to you today, was this post about the Amish.  

And so my Direct Primary Care practice, that I decided to call CovenantMD, opened in Lancaster on January 4, 2016, with one doctor, one nurse, and 77 patients.  As the renovations on my office wouldn’t be completed until February, CovenantMD was exclusively a housecall practice for the first 6 weeks.  I charged a monthly fee of anywhere from $15 a month for children to $80 a month for seniors, and just $1 a month for any person 100 years of age or older.  We offered same-day visits, substantial discounts on labwork and medications, 24/7 call, and yes…housecalls.  To give you an idea as to the lab discounts we were able to offer:  comprehensive annual fasting bloodwork, that previously cost $300 to $400 according to insurance-negotiated prices, now cost our patients $17.  They also often left our office paying $2 a month for their blood pressure medicine, dispensed straight from our own in-office pharmacy.  CovenantMD grew over the ensuing months, doing so by word of mouth.  We also began forging relationships with local employers, who decided to purchase our services for their employees.  So now our 14 employer clients are finding that there is no better workplace wellness program than a physician’s office that is easily accessible, practices telemedicine everyday, and works hard to ensure that chronic diseases like diabetes or COPD don’t progress to time off from work.  I am happy to say that CovenantMD has achieved much success since that inauspicious office-less beginning 3 years ago, having grown to employ 4 providers serving 1800 patients at two locations in Lancaster and York.  We are well on our way to living the dream of Direct Primary Care, and we are realizing its tremendous benefits both in physicians’ and nurses’ work lives and in the quality of the care we can deliver to our patients.  There are now close to 1000 DPC practices around the country.  I do believe that the healthcare revolution we so desperately need has begun.  

Nurse Hannah and Dr. Rohal, with Carole, October 2016

Nurse Hannah and Dr. Rohal, with Carole, October 2016

As I began my talk, so I will also end it…with a story about a housecall.  I told you about our $1 price point for patients over the age of 100.  In the 3-year life of CovenantMD, we’ve only ever had one patient take us up on that offer.  And that was Carole (SHOW PICTURE), whose daughter was also our patient.  She lived with her daughter in Lititz.  She had already been a widow for 38 years, after being married to her late husband for 45 years.  My nurse Hannah and I did a few housecalls for Carole over the course of about a year.  At one of these we took the picture that you’re seeing (I thank her daughter for graciously letting me use this picture in my presentation today).  I did my best to diagnosis an itchy rash here, a nagging cough there.  Her diabetes remained well controlled despite her stubborn insistence that she would not take her diabetes medicine.  But now it is 5:15am on a September morning, and I get a call from Carole’s daughter.  Her mother had suddenly cried out for assistance and was having some labored breathing.  Would I come and see her?  Of course I would.  So I began making preparations to visit her home that morning.  But just a few minutes later, I got another call from the daughter, this time to let me know that her mother had just passed away.  My nurse and I still proceeded to her home, where we pronounced her death at 5:50am.  Then I, and Hannah, and Carole’s daughter, sat for several minutes together in her living room, reflecting on a long life well-lived.  

The two housecall stories I shared with you this morning have both to do with death and dying.  I think that there is no better context for a physician housecall, as it pays such dividends for patients, their families, and for their doctors and nurses.  But there are many other stories I can share about my experience with housecalls.  The most common indication I get for a housecall these days is to welcome a newborn into the world, just after they’ve been discharged from the nursery.  New mothers especially appreciate that they can remain in the comfort of their own homes, and that their newborns don’t have to venture out to a doctor’s office during flu season.     And just later this afternoon I have a housecall scheduled for a 93yo gentleman to follow-up on his long-standing COPD.  

I want to once again thank the PA HomeCare Association for having me this morning.  I also want to thank each and every one of you for what you do every day in bringing very needed healthcare services to your patients in their homes.  With professionals such as you, and with innovative practice models like Direct Primary Care that again make the patient the focal point of healthcare, there is hope for our ailing healthcare system.  Thank you, and enjoy your lunch!