The Death of a Preventive Healthcare Clinic
Imagine if your healthcare provider was truly focused on preventing disease rather than treating it. Imagine if your physician was focused on maximizing lifestyle changes in order to avoid medications and surgery. Imagine if your physician supported your fitness and wellness goals as vigorously as he or she supported your disease management care. Finally, imagine if patients had access to a gym with fitness and yoga instructors, mental health professionals, and primary care physicians -- acting as a team under one roof. Their goal is to maximize your health and happniess.
Well all of that was part of MDPrevent, which shut its doors last December. The story of MDPrevent is equal parts a glimpse into the future and cautionary tale about the present.
Dr. Steven Charlap, the MDPrevent founder, composed the company's post mortem in a post at The Atlantic. Charlap identifies three key causes of the venture's failure: providers, payers, and patients.
First, few primary care and internal medicine doctors would refer to us. When I first met with a few dozen of them to introduce myself and the model, they raved about the concept and assured me they would make referrals. They said there was nothing like us, and they were right. Yet, other than for a small handful, they did not refer. When I asked several of these doctors why they had not referred, the most common explanation was that they simply forgot, or that they had made a referral, but their patients chose to not come. Some local specialists told us they would not refer to us because of fears of offending their primary care and internal medicine referral sources.
The hospitals were no better. One local hospital initially asked us to open a Certified Diabetes Education Center because the hospital was shutting down its own program for financial reasons. As opening the center was consistent with our educational focus, we exerted much time and money to get certified so we would be open by the time the hospital shut down its program. The hospital initially told us they would refer diabetics to us, but then someone reversed the decision and the hospital decided to refer to its sister hospital instead. We also met with another local hospital and asked them to allow us to incorporate our prevention model into their primary care practice, and they also turned us down.
Then there were the payer problems. Most of the third-party insurance companies in the area did not cover our services at all. Medicare was the exception, but reimbursement was insufficient to cover our costs. Although the Affordable Care Act included provisions to reimburse for services such as an Annual Wellness Visit (AWV) and Intensive Behavioral Therapy for Obesity (IBTO), Medicare still paid less for such visits than other appointments of a similar length. As a result, many doctors told me that they had simply started lumping the AWV with a scheduled medical visit, often spending less than 15 minutes on a service that, when done right, could easily exceed an hour.
We also approached the larger Medicare managed care companies, thinking that they would embrace our model as a way to save money on hospitalizations, prescriptions, emergency care, and specialist doctor visits. One small insurance company did contract with us in 2013, and not a single one of their patients needed a hospital visit after seeing us all year. We attribute that to the fact that each patient was offered, and most took advantage of, no-cost nutritional and psychological counseling. The other companies rejected us, and we were told by their representatives that they did not want to threaten or dilute their existing doctor relationships.
The final contributors to our demise were the patients themselves. Primary prevention requires work: making better food choices, adding more physical activity, engaging in meaningful activities, and developing tools to better manage stress.
Based on our review of the credible research, our model mostly excluded dietary supplements and multivitamins because the science mostly did not support their use. When it came to pharmaceuticals, we didn’t rush to prescribe if there were a non-drug alternative. This approach was a turn-off to many patients who expected a prescription or emphatically clung to beliefs in supplements. And the no-cost, no-deductible, no co-payment provisions in Medicare’s preventive benefits may have had an adverse effect on people’s sense of its value. How much would you appreciate something that has no cost to you? For many patients, it seemed easier to take supplements than to be more attentive to food labels and exercise habits.
MDPrevent was rejected by a healthcare industry that is operating rationally under its current incentive systems. Why would specialists refer patients to a niche provider with a prevention orientation? Specialists rely on referrals for services that the niche player is trying to prevent. Why would middle managers at insurance companies change reimbursement policies for an organization that contains a vanishingly small panel of patients? Why would patients change behavior when inaction carries weak economic penalties?
The good news is that the healthcare industry is slowly, steadily changes its orientation towards keeping preventing disease. The rise of ACOs is a reason for optimism:
Another reason for optimism is the growing percentage of health systems that are introducing health pans, which is expected to reach 50% by 2018. Timing is everything. The adage among entrepreneurs is that being too early to the market is the same as being wrong about the market. As a taxpayer and a patient, I hope that MDPrevent was simply too early and that a next generation of prevention-oriented providers will crop up in force later this decade. Here's to Dr. Charlap rising again to lead that charge.