Innovative Practice Interview with Dr. Chad Krisel of Integrative Family Medicine of Asheville

November 19, 2019

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Q: Please describe a brief history of Integrative Family Medicine

A: My business partner, Brian Lewis, and I had a goal to create an accessible clinic that took an integrative approach to primary care. We quickly realized that such clinics did not exist. The integrative clinics that did exist were often out of reach financially for many patients. We also saw many independently owned primary care practices struggling to remain solvent and being taken over by big hospital systems. We wanted to create something that could serve patients financially and offer a better overall healthcare experience for them as well as provide a model for physicians of something alternative to the fee-for-service insurance based system. 

   We originally wanted to open a low overhead fee-for-service clinic without insurance. We were researching all kinds of alternative practice models and ended up in the right place at the right time as direct primary care was just starting to unfold. We loved the idea of patients paying a low monthly fee and in doing so having better access to their physician while allowing the physician to take on much lower patient volume and therefore able to provide a higher quality of care. An article from the Journal of Health Affairs in 2012 noted that for a private practice to accept insurance, it can cost up to $83,000 per provider per year so it’s no surprise that practices were going out of business or hospital systems would buy them. Larger hospital systems are able to see these businesses as “loss leaders” to feed their “specialist machine”. Studies consistently show that when physicians have higher volume, they have much higher referral rates to specialists, while primary care physicians are well equipped to deal with 80-90% of patients medical complaints. Brian and I were fortunate in that we were able to take a gamble on something that wasn’t proven yet. We were the 2nd practice of this kind in NC when we opened in 2011 and possibly one of the first 10 in the country. Now, there are thousands of practices using this model, with at least 6 here is Asheville. We were fortunate because we went to state schools for medical school, we didn’t have kids yet, and thus we didn’t have much debt. We both worked at Mercy Urgent Care for a few years, saving money with this idea in mind and found a space in the River Arts District in the middle of the Great Recession which allowed us to open our doors debt free in 2011. 

Q: What were the reasons you decided to implement this model? 

A: We wanted to provide an integrative primary care approach. At the same time, we wanted to make it financially accessible in a way that offered super high quality and affordable care. This only seemed possible with the direct primary care model, which I believe to be the future of primary care. Patients want to get better and doctors are in alignment with this goal, but the fee-for-service medical payment model unfortunately does NOT align with the goals of the patients and physicians. The fee-for service medical model profits off of seeing more patients and an increase in RVUs (relative value units) which promotes more testing, procedures, etc. The fee-for-service business thrives off of seeing more sick patients and can contribute to worse patient outcomes. There is very little incentive for the administrators in a fee-for-service system to promote patients becoming sustainably healthy. This has led to the unnerving fact that the 3rd leading cause of death in the U.S. is via iatrogenic causes. (caused by the medical system). In the United States, you are statistically safer flying in an airplane (even jumping out of an airplane) than you are entering a hospital system. 

Q: Have you learned any Key Lessons in this process?

A: Don’t reinvent the wheel, learn from others who have already made mistakes. Have an idea of what differentiates you. With the 3rd leading cause of death being iatrogenic and medical debt being the #1 cause of bankruptcy, something needs to change. While Medicare for all will fix the bankruptcy issue, it does not address the 3rd leading cause of death being iatrogenic issue. Before we fully start entertaining Medicare for all, I would love to see the politicians talking about ways to promote primary care, such that physicians are seeing no more than 12 patients per day. We are showing that this can be done in a direct primary care model. Thus far, this has been the most effective, actionable model at creating this.  

Q: Tell me more about the integrative primary care approach:

A: Integrative primary care seeks to start care while a patient is healthy and develop a long-term relationship with them to educate, prevent disease, and increase their odds of living a long, high quality life (life span and health span). If patients are sick, we want to catch the illness and treat it early. Our team consists of a health coach, nutritionist, and medical providers and we offer monthly classes taught by community experts. We focus on 5 major areas of health: nutrition (food as fuel and medicine), meaningful physical activity (realistic goals based on patients particular physical limitations), stress management (stress is pervasive in modern culture), and building community (fostering and encouraging healthy relationships) within their own lives and amongst our patients in Asheville. The 5th area of health we focus on is the belief in something bigger than ourselves whether that’s the power of people coming together, a particular religious figure, spirituality, etc. Optimizing those 5 broad categories  are some of what has been shown to promote a long, healthy life. 85% of medical dollars in the United States are spent on preventable, life-style related illnesses. If that’s the case, why aren’t we paying more attention to the preventative, education end? Another level of care we of course offer is that of being available when serious events happen and guiding patients through the expensive medical system while using best practices that are evidence based. We utilize both evidence-based Western medicine and natural options. We aim to provide the most effective, well studied, and affordable approach to any given problem. Thankfully, this approach is becoming more mainstream and hopefully, in the future we can drop the term “integrative” (as Andrew Weil suggests) and simply call this approach “good medicine”. 

Q: What challenges have you experienced if any?

A: We didn’t have a precedent so we had to learn as we went along and every few years we’d upgrade software and internal operations to support our primary goal of providing impeccable care to our patients. 

Q: How would you describe the impacts and outcomes of these changes? 

A: I wouldn’t look back. Our number one mission is to provide financially accessible and high quality care. This is exemplified by many of our patients coming to us initially because we are a more affordable option and the quality of care is a welcomed finding after the fact. At the same time, many of our patients are on the other end of the spectrum, being quite affluent and coming to us for the quality of care, with the relatively low price being a welcomed finding. Thus, we are able to provide high quality care that is being used by folks on both the lower and upper end of the socioeconomic scale. We see 11-12 patients per day, no more than 2 patients per hour. We are consistently seeing patients minimize or eliminate their medications and reversing illnesses such as hypertension and diabetes. It’s hard to imagine ever practicing medicine in another way. 

Q: Did you have influencers or mentors who helped make the decision to make these changes?

A: Our main mentor starting out was Brian Forrest. He practices out of Apex, NC and he was one of the founders of the direct primary care model. Garrison and Erika Bliss, also early innovators in Direct Primary Care, influenced us early on as well.  Andrew Weil is arguably the founder of the integrative medicine model and very early on was advocating for this comprehensive approach utilizing evidence based modalities from a broad range of ideologies with the priority being what’s best for the patient (situationally). Wayne Jonas, David Rakel,  Reid Blackwelder and Jon Kabit-zinn have also influenced us. 

Q: Is there anything else you think would be important for other providers and leaders in the WNC medical community to know? 

A: If folks are feeling like what they’re doing is ineffective to their primary goal of getting their patients well and staying well- have the courage to explore alternative models. There are many alternatives to the industrial fee-for service system beyond direct primary care that can be effective. I like direct primary care the best because it retains the financial attainability for patients. 

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