Subscribe
Share
Share
Embed
The Clinical Excellent Podcast, sponsored by the Bucksbaum Institute for Clinical Excellence is a biweekly podcast hosted by Drs. Adam Cifu and Matthew Sorrentino. The podcast has three formats: discussions between doctors and patients, discussions with authors of research pertinent to improving clinical care and the doctor-patient relationship and discussions with physicians about challenges in the doctor-patient relationship or in the life of a physician.
[00:00:00] Dr. Cifu: On today's episode of The Clinical Excellence Podcast, we have Dr. Alex Lickerman talking about the direct primary care model.
[00:00:11] Dr. Lickerman: People behave according to their incentives, and that's what's largely wrong with our healthcare system at a certain level, I think. I want primary care to be influenced by the right incentives. And so I think the model's taking on, the model's taking off, if I were to look at my crystal ball, I think eventually it will be the dominant model, that may be 20 or 30 years from now, but fee-for-service medicine insurance is a dumpster fire. I mean, it's not sustainable.
[00:00:36] Dr. Cifu: We're back with another episode of The Clinical Excellence Podcast sponsored by the Bucksbaum Institute.
During this podcast, we discuss, dissect, and promote clinical excellence. We review research pertinent to clinical excellence. We invite experts to discuss topics that often challenge the physician-patient relationship, and we host conversations between patients and doctors. I'm Adam Cifu, and today I'm joined by Dr. Alex Lickerman. Alex Lickerman is a primary care physician. He's spent years at the University of Chicago as an assistant professor of medicine, director of primary care and assistant vice president for student health and counseling services. He currently leads a direct primary care practice in Chicago called ImagineMD.
I've known Alex Lickerman for 25 years and remain indebted to him for taking me out to lunch one of my first days after arriving at the University of Chicago. Thanks so much for taking the time to join me, Alex.
[00:01:27] Dr. Lickerman: Great to be here.
[00:01:29] Dr. Cifu: So knowing you, I could have asked you on to talk about a thousand different things, but I invited you today to talk about the direct primary care model. Can you just describe that for me, kind of what it means to you?
[00:01:41] Dr. Lickerman: Sure. So the literature actually is evolving and what the term means has been changing over time but basically, direct primary care is simply a change in payment model, about how primary care is paid for. So at its most simplest level, uh, in the fee-for-service world, typically you get paid a fee when you perform a service. So for primary care, that would be an office visit, would be the service. In the direct primary care model that, um, is completely changed. It's literally like a gym membership. You pay some, uh, standard fee, usually a per member per month fee that gives you unlimited access to your physician. And the reason that that's so revolutionary is because one, the cost of doing business, of having coders and billers and chasing after insurance companies for payment all goes away. Uh, you can reduce your support staff, therefore, dramatically, and you can limit the number of patients each physician has to care for to a much more reasonable number from the number it has ballooned to in the last 20 years or so. That's, in my view, created most of the problems we have with access and quality in primary care.
[00:02:48] Dr. Cifu: Sure. So I'm already going to go a little bit off script with a question because an economist who I won't name, who I follow closely, um, talks a lot about how, you know, we have house insurance for disasters, right? And we don't call on our insurer when we need to replace a light bulb, right? So for most of these patients who you are providing, you know, the majority of their care to, do a lot of these people have kind of catastrophic insurance if they, I don't know, get pancreatic cancer out of the blue?
[00:03:19] Dr. Lickerman: Yeah. They have to have some insurance because even though the statistics will tell you that when you get the type of access to and time spent with primary care doctors in a direct primary care model, you can handle about 80% of all a patient's lifetime medical needs, there's that 20% where they have to be referred out. Right? Primary care doctors diagnos cancer, but we don't treat it.
[00:03:39] Dr. Cifu: Right.
[00:03:39] Dr. Lickerman: So you have to have some type of insurance. I find your use of the term catastrophic, slightly ironic only because it seems like most insurance these days is basically catastrophic, meaning that the deductibles are so high, you're basically a cash pay patient until you have some catastrophic thing, but yes, you typically have to wrap, uh, their primary care, a direct primary care fee structure with some supplemental insurance for those reasons.
[00:04:01] Dr. Cifu: But so your vision, the way you talk about it, actually sounds like economically, you know, maybe over the course of somebody's life, you know, that this saves money because you're actually spending less because of the kind of direct care, knowing patients, spending more time with patients on a regular basis, though maybe at the end of life, you know, I don't know if things go bad, you know, there'll be more money spent at that time, but probably no more than you would've spent without this model.
[00:04:29] Dr. Lickerman: Right. We actually now have data to suggest that that theory that people have touted about direct primary care really does work. We get patients from two broad categories. We get individuals who probably have signed up with us because they've had a lot of negative interactions with the fee-for-service healthcare system, they're paying out of pocket, our fees like a gym membership, literally.
[00:04:51] Dr. Cifu: Right.
[00:04:51] Dr. Lickerman: But then we also are getting scale from companies that self-fund their health plans, who actually sign up their employees to become our patients and they will pay our fees on behalf of their employees.
[00:05:02] Dr. Cifu: Mm-hmm.
[00:05:03] Dr. Lickerman: And we've done some case studies where we show, as you might think, the hypothesis is, if you have that kind of upfront access to primary care, you can avoid all those unnecessary ER visits, conditions can be caught early enough that they don't turn into big complicated things that require surgery, you can take care of it with physical therapy, you prevent a lot of specialty referrals simply because we have so much more time we can actually practice to the top of our training, which we do.
[00:05:24] Dr. Cifu: Right.
[00:05:25] Dr. Lickerman: We do a lot of mental health stuff because we have time, and so you can avoid a lot of negative consequences of unaddressed mental health issues. So in one of our plans, we actually saved them 34% from their spend, what it would be compared to a group that had a plan designed just like us without us. That was the only difference, we were the only variable difference. And I'll tell you interestingly, the greatest bulk of that saving was in pharmacy.
[00:05:48] Dr. Cifu: Huh!
[00:05:49] Dr. Lickerman: Which was not something I expected, but now I understand why, and if you want to talk about that, we can.
[00:05:53] Dr. Cifu: Right, interesting. And it must be, as a recruitment tool for these businesses, I would imagine this is something that's attractive.
[00:06:01] Dr. Lickerman: It's becoming so, I mean, especially with the pandemic, the increases in premiums from the fully insured, you know, have just unbelievable numbers, 30%, 40%, 50% increases, right? They're not getting a single improved level of service for these increases. They're just going up and up and up. So more and more companies are saying, we have to find some alternative. And here we are showing our study and our data that's been independently verified actually. And then they're saying, "Hey, the other issue we're struggling with is winning the talent war, right? And retaining employees in this economy." I mean, people are switching jobs, like they're switching houses, and...
[00:06:36] Dr. Cifu: Well, they used to switch houses.
[00:06:37] Dr. Lickerman: Used to switch houses, I guess I should say. That's right. And so, it is huge because, um, and it's very interesting, every year we've done this when we actually go to open enrollments and we stand up in front of these employees and explain our offering. And we're met with unbelievable skepticism, which just tells you how bad the traditional healthcare system has become. They don't believe they could actually get 24/7 access to their own doctor.
[00:06:58] Dr. Cifu: Right.
[00:06:59] Dr. Lickerman: And then about six months into the plan, suddenly everyone's singing our praises, and then this next year, then about 50% more of the employees come over to the plan and choose us because it's such a difference in experience for them.
[00:07:09] Dr. Cifu: Interesting. Um, so you've done quite a variety of things in your career. You know, I mentioned some of them. Uh, you were in primary care, had an academic medical practice, my colleague, you did hospital medicine almost before hospital medicine existed as a thing, you did student health for a while, you've done hospital administration. What was the thing that kind of led you to direct patient care? Like why did you change your career path?
[00:07:31] Dr. Lickerman: So the real story is...
[00:07:34] Dr. Cifu: We can edit this out.
[00:07:35] Dr. Lickerman: We can edit this out if we need to. No, we won't. In 2015, I had been several years running student health at the University of Chicago, and I had taken that job because student health was perceived as it is on many, if not most campuses across the country to be a disaster. And I thought, this is a fixable problem and I wanted to fix it and I wanted to try to build it into something that I had a vision for. And I was hired by somebody who hired me to do that. That person then left and her second in command took over, and her second in command actually was not on board with that, in fact was stimying a lot of the innovative things I wanted to do. And I was just getting frustrated. And then I was thinking, well, what are my options? I could go into full-time clinical care, but you know, 20 years into my career at that point, to do full-time medicine at the U of C especially just seemed utterly overwhelming and I realized all the things I had done, you know, the first 10 years I was at U of C I basically was teaching, loved that. Then I got, you know, accidentally pulled into administration, discovered, oh, I really like doing this. I like reinventing myself and I finally thought, you know, I really just want to be a doctor again. I just want to, as we talked about earlier, the core thing for me, the thing I really enjoy the most is taking care of patients. And, um, I was searching for a model that enabled me to do that in a way that was sustainable because I just don't think the way primary care is practiced in the fee-for-service world is sustainable now, and certainly not for the doctors, and the patients, I think intuitively understand how bad the system is for them and they experience that in terms of the frustration about things they can see, their inability to reach their doctors. I don't think they necessarily think to themselves, "Maybe the quality of care I'm getting is being compromised by this terrible system." Maybe they do. That's what I wanted. And so I had thought about this model actually with Scott, Scott Stern, 10 years earlier, and this is when we were hospitalists and incredibly frustrated with the way the inpatient floors were working and the danger we thought patients were being put in, and we flirted with the idea, but neither of us thought at that time the world was ready for it.
[00:09:30] Dr. Cifu: Yeah.
[00:09:30] Dr. Lickerman: And we weren't ready for it, but then I suddenly thought, you know what? There has been a straw here that's broken this camel's back, and I'm going to just do it.
[00:09:36] Dr. Cifu: It's so interesting to hear you talk about that from the sort of patient realization side, because until you said it, I've never really thought about this, but it is striking how much empathy a lot of my patients have for me in my doctoring, you know, who will, who will sort of say, "God, I'm so sorry to bother you with this, but you know, this must be really difficult for you..." And it's interesting, it's turning the tables in a way that really should not be turned.
[00:10:06] Dr. Lickerman: In fact, it's fascinating you would bring that up because one of the greatest shocks to me when I started this practice was I had a patient who on a Monday morning called me and said, "So listen, I went to an urgent care clinic over Saturday because I had this cough and runny nose, and they gave me antibiotics, it's not helping. What do I do?" And I said, "Well, first of all, why did you go to urgent care? Why didn't you call me?" And there was this pregnant pause at the end of the line and he finally said, "You know what? I never even thought about it." It never occurred to him. And then he started to tell me how often he would be in my office when he was at U of C, because he was a patient of mine who followed me and said, "Yeah, I knew you were always in such a hurry. I felt so bad for you. I would only tell you the most important things, I was withholding issues." And I'm thinking, how much does this go on? That patients are actually empathetic toward our plight...
[00:10:49] Dr. Cifu: Right.
[00:10:49] Dr. Lickerman: ...and don't talk about things, they think, "Oh, I just... That's not important." But of course, it is. They don't know it's not important.
[00:10:55] Dr. Cifu: Right. They might be holding back something critical.
[00:10:57] Dr. Lickerman: Yeah.
[00:10:58] Dr. Cifu: So I guess an easy question, you know, how has it been? What's good? What are the challenges?
[00:11:03] Dr. Lickerman: It's been awesome. Honestly, best decision I've ever made. I really have fallen back in love with the art and practice of medicine. I feel like I'm practicing the best medicine of my career because I have time. I mean, time is the secret sauce.
[00:11:17] Dr. Cifu: Yeah.
[00:11:18] Dr. Lickerman: I'm never feeling rushed, I'm never putting my hand on the doorknob, having to go to the next patient. I have time to think. I don't have to just, you know, nail myself to the initial diagnosis I think and just stick to that and not consider other issues. I have time to read, to reconsider, to examine people, to talk with them and explain with them, to them in detail what I think might be going on and how we're going to think about it to make my thought process transparent, educate them. To me, this is what being a doctor at its best looks like, and it's been absolutely wonderful. I don't feel overwhelmed. I get my notes done. I'm not a slave to billing and charting in a billing situation. So it's really been absolutely wonderful. I miss my colleagues at the U of C. I miss some of that intellectual discourse. Uh, I miss teaching a little bit but I teach my patients.
[00:12:06] Dr. Cifu: Sure, sure.
[00:12:06] Dr. Lickerman: But I feel also the reason I started this, the practice and the company has evolved, it's not just about my own practice anymore.
[00:12:14] Dr. Cifu: Yeah.
[00:12:15] Dr. Lickerman: I really feel very strongly that this model is the best model for American society and the way primary care should be delivered. So I'm wanting to grow the business because I think it's very difficult for physicians to make this leap, to make this change. Now, did you also ask me what I don't like about it or the challenges?
[00:12:32] Dr. Cifu: I did, I did want to hear about that.
[00:12:33] Dr. Lickerman: Yeah. The challenges actually are not in the medicine at all.
[00:12:37] Dr. Cifu: Okay.
[00:12:37] Dr. Lickerman: That actually, we figured it out. We make this work really well, being available for call 24/7 is actually easy when you have a small, or I should say right size patient panel. The challenge is the business aspect and selling this and convincing to get scale these self-funded companies or companies, I should say, who self-fund their health plans, but the wave is here. It's been seven years and we've been spending the last six literally travelling around the country, educating the marketplace, telling them we exist, how this works. It's not easy to understand this in one sentence very quickly. That's been really challenging, but that hard work is finally paying off and now it's just the headaches that come with running a business.
[00:13:17] Dr. Cifu: Sure. When you were talking about, you know, how much you love medicine in this setting, it sounds exciting because I often think, you know, you and I are about the same age and you know, I feel like I'm at a place in my career where, you know, not to pat myself on the back, but I feel like I'm doing a good job, right? Like, I know a lot of medicine, I understand how to talk to people, to a real range of people given my own health struggles over the years, you know, I've gained my own empathy, which is important. And it's neat to hear you talk about how, um, you know, as you reach that place in your medical career, that this has sort of allowed you to perform at your best.
[00:13:58] Dr. Lickerman: It really has. I mean, like you, I, I mean, we spend decades achieving mastery and I feel like I have, like you achieved a level of mastery. Uh, I'm very confident about what I know, but I'm also very honest with myself where my limitations are and what I don't know. And, uh, there's a great joy in feeling your mastery and practicing it, which also I think must include a certain level of humility with medicine, obviously always, because you can always be wrong and you can always make mistakes and you do. But yeah, I am professionally more fulfilled in this model than I ever was in fee-for-service.
[00:14:34] Dr. Cifu: Right.
[00:14:34] Dr. Lickerman: And I think, I'm very sad for so many doctors. Let me just tell you this. I announced at U of C six months before I left and every time I would be stopped in the hallway, because word gets around, right?
[00:14:45] Dr. Cifu: Yeah, yeah.
[00:14:45] Dr. Lickerman: And everybody knows and they'd say, "I heard you're leaving." And then half joking, half serious, almost every physician to a t said, "Can you take me with you?" And I'm thinking, you know, this is not good when 50% of physicians are, you know, we know, burning out, and you know, the issue is not, we need more resilience training...
[00:15:01] Dr. Cifu: Yeah, yeah.
[00:15:02] Dr. Lickerman: The issue is we need to reform the system, which we're practicing. So yeah, I feel like I've kind of escaped that fate a little bit, and I'm happy for it.
[00:15:09] Dr. Cifu: So how does this, and I don't know if this is a fair question, but you know, how do you see this as sort of fitting into the whole like, landscape of American medicine? You know, you are not czar Alex Lickerman, can't sort of change the whole country to this. So in the near term, I don't know, 10-20 years, you know, next generation, um, like where do you see this fitting in?
[00:15:31] Dr. Lickerman: Yeah, I kind of think of us like Tesla in the sense that Elon Musk's idea was, he was never going to be the only electric car producer. He wanted to lead the way and inspire, and show that this could be done and scaled and convince other people with resources to join him so that the market changed. And I feel sort of the same way. We want to grow as far, as wide as we can, but we can never of course, take, you know, there's not going to be a monopoly of any, you know, healthcare provider, but I think we need to recenter primary care at the core of medical care. There's, you know, the data as well as I do, there's tons of data about the benefit to society when the ratio of primary care to specialists is correctly balanced, as it is not in the United States. I want to restore primary care to its primacy. I want primary care to be influenced by the right incentives. I think the incentives have become so perverse in so many ways, um, and people behave according to their incentives, and that's what's largely wrong with our healthcare system at a certain level, I think. And so I think the model's taking on, the model's taking off and it's going to take off, if I were to look at my crystal ball, I think eventually it will be the dominant model, that may be 20 or 30 years from now...
[00:16:34] Dr. Cifu: Yeah.
[00:16:34] Dr. Lickerman: I think it'll be very slow, but, um, fee-for-service medicine insurance is a dumpster fire.
[00:16:40] Dr. Cifu: Yeah.
[00:16:40] Dr. Lickerman: I mean, it's not sustainable.
[00:16:42] Dr. Cifu: And as you talk about it, I mean, I can easily see that happen among, you know, sort of employed people, right? That instead of the current model of healthcare insurance coming with your job, um, that either support for or payment for, you know, direct primary care comes together. Could you ever see a place where like, look, this is just the right way to provide care, um, that for people who are not employed, that they fit into a system?
[00:17:13] Dr. Lickerman: Absolutely. In fact, my idea is, and there's pilots being done now in the Medicaid systems in different states around this. I mean, we know how much the Medicaid population consumes and overconsumes healthcare.
[00:17:25] Dr. Cifu: Right. Right.
[00:17:26] Dr. Lickerman: How, uh, how high a degree of morbidity that group has, uh, perfect population...
[00:17:32] Dr. Cifu: And that's probably just the same, I mean, that's probably because of undercare at the beginning...
[00:17:37] Dr. Lickerman: Right, absolutely.
[00:17:38] Dr. Cifu: And therefore end up, we spend a lot of money because we're intervening too late.
[00:17:42] Dr. Lickerman: Too late, catching up, poor access to care, uh, bias in care, all the things that have been studied really well at the U of C. Right? So that's a group, you know, a high utilization, high medical complexity group that has the most to benefit from this model. And so the idea is prove out the model, I mean, I'm not the one who's going to set the policy, but it occurs to me, right? Prove out the model. These pilots are... Have the Medicaid pay a direct primary care services fee, it's... I mean, primary care costs are the smallest cost of your healthcare span, right? It's 3-5%, should be, you could argue maybe 15% but what you get in exchange for that investment is dramatic reduction in downstream care, which is the most expensive part, and more importantly, you like, really revolutionize the health of this really underserved population.
So I think over time as the model proves itself out, it will eke into the minds of government, you know, programs and planning and policies, and I think that proposal, I really think as a society we can take, we can bring everyone into this model in different ways, right? Because not everybody has the same access to healthcare, uh, and employment, but I think we could do it.
[00:18:44] Dr. Cifu: It's a great way to think about it because I often joke that, you know, nobody pays attention to like how I'm spending money because in the grand scheme of things, the money I spend in medicine is poultry compared to like how much everybody else spends.
[00:18:55] Dr. Lickerman: That's right. Yeah.
[00:18:56] Dr. Cifu: And so in a way, I mean it is a... It is, I don't want to call it a cheap solution because everybody cheapens what we do, and I don't need to be behind them cheapening it too, but it is a great way to think about that.
[00:19:07] Dr. Lickerman: There are a lot of disincentives though, right? I mean, hospital systems like the U of C actually benefit from primary care doctors ordering a lot of tests. And a lot of times if you give primary care doctors enough time, they don't have to order a lot of tests, right? If you right-size it, there really is a lot of greed in the system and it's, you know, it's because of the way the incentives are set up. So, this would be, um, a cure for that. I'll go... I will say that word, a cure, doesn't fix everything, obviously in the healthcare system, but it fixes a lot of it.
[00:19:37] Dr. Cifu: Yeah, I often think sometimes, you know, reviewing records of people who were either, you know, referred to me in primary care, end up in the hospital when I'm on service, you know, occasionally even, you know, reviewing malpractice cases that I see ridiculous things being done. And when I think about like, what's behind this and you know, sometimes you think just because people didn't know. Sometimes it's that like, you know, people were lazy and weren't thinking and so just kind of did everything, right? And sometimes, you know, hopefully the smallest amount, it's just graft and it's like, "Okay, look, we need to order more carotid ultrasounds."
[00:20:14] Dr. Lickerman: Yeah, I mean, I know we get, doctors get accused of that all the time. I really think that's the smallest percentage of it.
[00:20:19] Dr. Cifu: Right, right, but when you talk about your practice, you are sort of making up for most of those things, right? All of a sudden you have time so you can actually really read and think about things and not do things just because you don't know. Right?
[00:20:31] Dr. Lickerman: Right.
[00:20:32] Dr. Cifu: And you're not rushed, so you're able to really consider.
[00:20:36] Dr. Lickerman: I mean, there's a huge variation in practice style, as you know, and what I say is, you take any physician who is on the hamster wheel in fee-for-service medicine, you pluck them up and you put them into the direct primary care model, they will flourish into their best doctor selves.
[00:20:50] Dr. Cifu: Right.
[00:20:51] Dr. Lickerman: Whatever that may mean. Not all doctors are created equal, right? But I do think, uh, in terms of increasing the likelihood that medicine will be practiced well, uh, you have to put doctors in a context in which they have that opportunity, which really means they have to have the time to think, which is what we've lost.
[00:21:08] Dr. Cifu: Alex, thank you so much for taking the time out of your day so that I could interview you. Anything else you want to say before I wrap things up?
[00:21:16] Dr. Lickerman: You know, I think that...
[00:21:19] Dr. Cifu: Don't be trying to recruit all of my listeners.
[00:21:21] Dr. Lickerman: No, right, I wish I could. I think, um, I guess what I would say is since I left the University of Chicago, I have learned just how broken our healthcare system is in great detail. Before I left, I knew it was not working so well, the trends have continued, so it's worse than it was when I left but I really well understand what is wrong with our system, and I don't think the solution is coming from Washington DC, it's disappointing to say that, I don't think a lot of the proposed solutions that, you know, universal healthcare, are, you know, people don't really understand the ramifications of that. There's good ideas or good effects to that, there's some really bad effects to that, as one solution, but, um, we have to fix this. And it has to, it seems like it's going to have to be done at a grassroots level, and it is being done at a grassroots level. There's a lot of really innovative people out there who are trying things like direct primary care solutions that we are using, uh, that actually are working.
The truth is actually the solutions to the fracture of the healthcare system already exist, they just need to be scaled. So I never imagined myself as someone who would be part of a revolutionary movement. That's not really been my intention, but I find myself sort of aligning, uh, my personal interests with the interests of sort of what I think the society needs. And so, I really hope people in the future are more open to these types of models and recognize... Or are willing to invest the time and energy to educate themselves about things so they really can understand when they're offered solutions, will this really work? Will it really not work? Because the biggest barrier we find to adoption of this is that if you own a company, the amount of energy required to, and time required to understand the healthcare landscape and make a good decision for yourself, it's kind of overwhelming. Anyway, it's coming, I think change is on the way, it's just slow, and I'm overall surprised to find myself saying, I'm optimistic.
[00:23:15] Dr. Cifu: Well, I'm thrilled to finally have a revolutionary on the podcast. Thanks for joining us for this episode of The Clinical Excellence Podcast. We are sponsored by the Bucksbaum Institute for Clinical Excellence at the University of Chicago.
Please feel free to reach out to us with your thoughts and ideas on the Bucksbaum Institute Twitter page. The music for The Clinical Excellence Podcast is courtesy of Dr. Maylyn Martinez.