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.

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I introduced Henry in an earlier article; here is his story in more detail. Henry is a 69-year-old widower living alone in a small town about 60 miles from the nearest metropolitan area. He has a small pension and healthcare coverage via Medicare, a Medigap policy, and a Medicare Part D drug policy. He was recently hospitalized in the ICU with a serious urinary tract infection that spread to his kidneys [pyelonephritis] and to his bloodstream [septicemia], and then his lungs [acute respiratory distress syndrome.] This was a recipe for rapid demise, but the needed intensive acute care is where American medicine excels. It was the full court press to save his life, and it was successful.

A week later, he called me and asked for some advice. He was discharged from the hospital to take his former medications plus a few more. He was now to take twenty-three — yes, 23 — different prescription drugs, some once, some twice, and some three times per day, along with one by shot monthly. He was not sure why many of them had been prescribed and asked if I thought he needed them all.

I responded that, at 400 miles distant, I could not be his doctor, but I would review the list and offer some questions he might ask his physician. He sent me the list, and I reordered it by category: two for heart failure (he did not know that he had heart failure!,) two for diabetes, three for high blood pressure, one to lower his cholesterol, a monthly shot of testosterone for impotence, one to shrink his prostate (it was felt in the hospital that an enlarged prostate had been a predisposition to his urinary tract infection), one for depression, an antibiotic to finish up the treatment of his kidney infection and a few others.

I asked him who his primary care physician was and learned he did not have one but went to four different doctors, each of whom treated different issues, and none of whom shared all of his information with each other. Whenever one of them checked his blood pressure, it would be elevated, so that doctor would either add a drug or increase the dosage of one or more.

He told me that it was always normal when he went to the local drug store and checked his blood pressure. I told him it might well be that he had “white coat hypertension,” meaning it was only high in the doctor’s office. Perhaps if he took these regular readings to his doctor, the physician would get him off one or more of the blood pressure meds. Besides, two of the three had a known side effect of impotence. Finally, I noted that he was on one drug to shrink his prostate, yet the testosterone might well be causing some of his prostate enlargement.

Henry’s story represents much of what is not working in the delivery of medical care today. He has four complex, chronic illnesses – heart failure, diabetes, hypertension, and depression. These all require careful attention and care coordination, preferably by a single primary care physician who knows the patient’s home and social setting as well as his direct medical issues.

The blood pressure medication story is representative. He was getting many too many drugs that he did not need and had become impotent as a result. Rather than looking for the cause, he was given another drug [testosterone] that probably had no value but was likely enlarging his prostate. As a result, he developed an infection that almost killed him. The hospital doctors had added a drug to shrink his prostate but left the testosterone in place. And all these drugs were expensive for him and his Medicare Part D insurance plan.

Heart failure and diabetes together consume more than 50% of our healthcare dollars. Here is a person whose care is not being adequately monitored; instead, he is getting one drug after another without attention to what else is happening. This lack of care coordination is a prime reason why the costs are so high yet the quality so low. The problem is less that drug companies charge too much for many drugs (they do) but rather that too many drugs are prescribed unnecessarily or inappropriately.

It is also instructive that Medicare pays without question for intensive hospital care – tens of thousands of dollars in Henry’s case, yet pays primary care physicians minimally – even though with time to listen, think and consider, a PCP could have, with limited costs, prevented the hospitalization.

My first suggestion was that Henry needed a primary care physician, one to call his own. He learned that a young doctor he had met at a nearby hospital would be setting up private practice near his town, so he became one of the first patients. Since the PCP did not have many patients yet, he gave Henry the time needed. A few months later, he called and told me that he was now taking just seven medicines, felt better, and was saving a lot of money.

But during our initial discussion, I also asked him what he weighed. I have known him for over forty years but had not seen him for more than twenty. I recalled a stocky, muscular man with perhaps a bit of a beer belly, so I was surprised when he said he weighed 285 pounds. His wife of more than 50 years had died a few years before and he found himself lonely and isolated. He rarely went out and told me he did not exercise; it was just too difficult. He fixed his own meals, mainly from prepared foods.

I asked him what he planned for lunch and was told soup and a sandwich. The soup was a canned one, so I asked him to read the sodium content to me. It was 320mg, or 35% of the daily recommended amount. The can had “two servings,” but he planned to eat the whole thing or 70% of his daily salt requirement (assuming he was not on a restricted salt intake because of his high blood pressure and heart failure) in the soup alone! The sandwich was salami on white bread with some lettuce and mayonnaise.

That sounded great for his high cholesterol problem. Together we figured out that he ate about 2000 calories per day, which he thought was about right based on the soup can label. I suggested that 2000 calories was about right when he was 22 and in the Army, but now, since he did not exercise and needed to lose weight, this was way too much.

My next suggestion was that he needed to get out, interact with people again, carefully consider his diet and begin a modest exercise program, perhaps just a short walk each day. When he called later, he told me that a friend had gotten him to start going with him to the local senior center, where he had made some new friends. Eventually, he agreed to go to evening dances, where he met a widow whose company he enjoyed. His depression seemed to have lifted; he was exercising and enjoying dancing again. I could hear the smile in his voice.

Henry still has four serious chronic conditions. But with a single physician serving as his primary care physician who was aware of all of his medical, emotional, family, and financial issues, his care became much more effective. And when he did need a specialist, which was now rare, the primary care physician became the orchestrator, not just the referrer. As a result, Henry now has better quality medical care, he has a much higher quality of life, he is spending less of his money and much less of Medicare, Medigap, and Medicare Part D’s money. In short, it is a win-win for all concerned.

The key to improving Henry’s care was to find a PCP who would and could spend the time with Henry necessary to offer such comprehensive care. Today, because of high overhead costs and low insurance payments per visit, most PCPs need to see about three patients per hour. They just do not have the amount of time a person like Henry requires. But those that do provide such time offer much better care. Yes, more time per patient means fewer patient visits per day, so someone has to pay for the difference. Insurance rarely does, which is unfortunate. The patient will have to pay the PCP directly, “Direct Primary Care” or DPC. But as we will see in later articles, the total cost of care comes way down, quality goes up, and patient and doctor become less frustrated. Henry is a great example of how totally dysfunctional care can, quite simply and a very low cost, be converted to excellent, cost-effective care.

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