Here is an approach that vastly improves patient care, reduces patient and doctor frustration, all while reducing total medical costs. I believe it is the logical future of primary care medicine.
The fundamental problem in health care delivery today is a highly dysfunctional payment system that leads to higher costs, lesser quality, and reduced satisfaction. It also means less time between doctor and patient with the loss of “relationship medicine.” The core problem? Price controls by government and commercial insurers and regulations, also by insurers, that reduce the trust and core interactions between doctor and patient. The doctor, not by choice, is the insurer’s client. The patient is no one’s customer and visit times are all too short. I have argued in the Washington Times as an Op-Ed that paying the doctor directly is better for all concerned.
Some of the best attempts to improve this dysfunctional delivery system have been accomplished by primary care physicians themselves. They have essentially said, “I won’t take it any longer; this is not good for my patients or for me.” They have also said it is time to “stop tinkering” and make a fundamental change. They have opted for a new, better system — direct primary care — rather than wait for others to fix it for them.
The concept of direct primary care is to reduce the number of patients in a PCPs practice so that each patient gets added time as needed. Often this means removing the insurance system as the payer from primary care, and it always means a payment model that compensates the PCP directly by the patient. Direct primary care takes many forms. There are two principal payment systems.
One is for the patient to pay the doctor directly for each visit, usually at a rate far below what would have been charged in the insurance model since the overheads of billing and coding have been eliminated. Many such PCPs post a defined price list — transparency. This is sometimes called direct pay or “pay at the door,” unlike how it was until a few decades ago before insurance morphed from being only for major medical or catastrophic issues to being essentially prepaid medical care.
The second model is for the patient to purchase a package of care for the year paid by the month or annually. This basic model comes with many variations and may be called direct primary care (DPC), membership, retainer, or concierge. Despite the various names, they all have certain characteristics in common, but there are many variations in how the practice functions.
All of these models offer a reduced patient-to-doctor ratio; instead of the typical 2500–3000+ patient panels, the PCP may adjust the number of patients to a low of 300 when the panel is very ill or a high of about 800 for a panel with mostly low-risk patients. Some accept insurance and also charge a lesser retainer; most just charge the monthly or annual fee.
With a reduced patient panel size, the PCP commits to offering same or next-day appointments lasting as long as necessary, a comprehensive annual examination, email and text communications, and an invitation to contact the PCP on their personal cell phone 24/7. Some make house calls and nursing home visits for no extra charge; others add a modest fee. Some see their patients in the ER, and some follow their patients in the hospital.
There may be an arrangement to obtain laboratory testing, imaging, and procedures at highly discounted rates from selected vendors. Some practices offer a limited number of laboratory tests at no charge. Some PCPs are supplying medications at no or wholesale costs. For the patient on multiple prescription medications, the savings on drugs can more than offset the monthly/annual subscription cost of direct primary care.
Many PCPs in these models only work with specialists who are willing to discount their fees for those of their patients who pay cash, have high deductible plans, or have no insurance at all.
Often regarded as highly expensive and only for the “elite,” the rich, or the “one percent,” in fact, DPC/membership/retainer/concierge practices can be of a quite reasonable cost and very appropriate for those with no or limited insurance and for those with modest incomes — “blue collar” concierge medicine.
Fees range from about $500 to $2000 or more per person per year. [I will ignore those doctors who charge a very high fee for “exclusive” services.] By some degree of common usage, those on the lower price end often refer to their practices as direct primary care or membership, whereas those at the higher end often refer to their practices as retainer or concierge. To the extent that there is any real difference, it is probably in the number of patients in the panel or number seen per day, the extent of the annual evaluation, and added values such as following one’s patients in the hospital and in the ER.
For those with high deductible insurance policies from work or the exchanges, connecting with a direct primary care physician can offer significant savings. The individual and the physician now have a direct professional business relationship. The person begins to take a much more active role in the entire care process. And the doctor can allot meaningful time for patient interaction — a return to “relationship medicine.”
With little to hope that government or insurers will improve the lot of primary care physicians, direct primary care is a rational manner for PCPs to change the paradigm and return to relationship medicine. It means better medical care, less frustration, more satisfaction for doctors and patients alike, and an encouragement to medical students to consider primary care as a career option. It also means that total medical care costs go down, way down. A triple win.
