The primary care doc fix is in 

Matthew Mintz, MD recently shared how primary care doctors are set to lose more than half of their salary. It’s well documented how primary care has faced a number of challenges with half of primary care physicians saying they’d leave medicine if they could as was mentioned in an earlier piece. There’s talk of a “doc fix” as physicians believe the debt ceiling deal is going to lead to a horrific outcome. Fortunately, it’s not all doom and gloom. Many primary care docs have found their own “doc fix.”

At the same time as traditional fee-for-service primary care docs are getting squeezed, there’s an exploding trend around the Direct Primary Care (DPC) model. Having written extensively on Direct Primary Care (click here for DPC-related articles on KevinMD, Reuters, Forbes, Huffington Post, etc.), I’ve hear about an extraordinary number of DPC practices or enablers (e.g., providing software or back office capabilities) popping up all over the country. Like anti-lock breaks and airbags that were once only available to the well-heeled but now are available to everyone, the same is happening with retainer-based primary care. Generally speaking, these low cost (freed from insurance bureaucracy, typical monthly fees are $50-80) DPC models have one-third of their patients who are uninsured. MedLion’s next clinic to open is in Salinas, CA. They are catering to the immigrant, farm worker population. Josh Umbehr, MD of AtlasMD shared how one of his patients lives in a storage unit and his fees are less than the co-pays at the local public health center.

MedLion, AtlasMD and many others bust the myth that retainer-based medicine is exclusionary. A little reported on facet of the health reform was the inclusion of Direct Primary Care Medical Homes in the insurance exchanges that will serve to rapidly grow this new segment. Showing this isn’t something solely popular with Democrats, one of the most vocal opponents of the PPACA (Rep Bill Cassidy (R) Louisiana – also an MD) has proposed a bill to pay for Medicare primary care this way.

Rather than dealing with the risk of the aforementioned halving of primary care salaries, DPC MDs are consistently taking home 50-100% more than their insurance-dependent brethren. They are doing this while reducing malpractice premiums 50%, enjoying 30 minute appointments and some running with no administrative burden at all. Not long ago, DPC pioneers had to custom develop their own solutions spending hundreds of thousands of dollars. Today, there are software companies providing solutions at a tiny fraction of that investment, there’s service bureau companies setting up to enable these practices and there’s an industry association establishing certification to help scale these models.

I predict in under two years that the primary care physician who doesn’t have at least 10% of their patients paying this way will be the exception to the rule. The economics and results are simply too compelling to ignore. Consider that the byproduct has been the following:

  • Combining a DPC model with a high deductible wrap-around policy saves 20-50% off of a typical health premium for a higher level service
  • DPC physicians are taking home 50-100% more income (or scaling back hours)
  • Patient satisfaction rates exceed Google and Apple
  • Downstream costs for the most expensive facets of healthcare (surgical, specialist & ED visits) are reduced 40-80%

Gradually, more and more employers are understanding what IBM found when they studied the results around the globe on their $2B of healthcare spent. The formula is remarkably simple: more primary care access led to healthier populations which led to less money spent. Not sure where to start? An earlier piece addressed overcoming barriers to building a direct primary care practice.

Dave Chase is CEO of, a Patient Relationship Management software company, previously founded Microsoft’s Health business and was a consultant with Accenture’s Healthcare Practice.  He can be found on Twitter @chasedave.

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  • Craig Joseph Casey

    Direct Primary Care is a great alternative to overpriced insurance and unsustainable government programs. And with Doctors making more, there will be more of them, easing rationing worries:  Concerns of ACOs dominating the market place, achieving monopoly status and raising prices. Also employing gatekeepers to deny expensive treatments, ie HMOs back in the early days.

  • Anonymous

    My PCP has been doing primary care for 30 years. He tells me that in all his years as a PCP, he will admit that 85 percent of what he does on a regular basis is routine medical care that a trained nurse practitioner (NP) or a trained physicians assistant (PA) could easily do. He says that the other 15 percent of the more serious cases get referred to specialists. Other than check my BP and listen to my heart and lungs, the only other tests my PCP does is routine blood work and I’m even referred out to a lab to get that done. It’s time we stopped the insanity and started to realize that you don’t need a doctor for a flu shot or to remove a splinter. Imagine if 85 percent of primary care was done routinely by NPs and PAs. Imagine the cost savings and imagine the number of jobs that would be created for the middle-class. Also, if seniors were given the choice to see an NP or a PA, we wouldn’t be constantly hearing doctors crying about how little Medicare pays for senior citizens. Seniors need to be encouraged to experience lower costs by having the “choice” to opt to receive their care at a neighborhood clinic instead of at the expensive doctor’s office. If there’s anything the makes me angry, it’s a whining doctor threatening to not accept Medicare patients just because they don’t get paid enough. I say, take all that Medicare work away from them!show less

    • Venk Adigopula

      what you say may be true about internists and some FPs. it may not be true about pediatricians and ob/gyns, who are also part of primary care. parents want to know their children are growing healthy, mentally, physically and emotionally. women want to know that the stresses on their bodies and minds from an increasingly insane modern work and home load, are manageable. these can often be communicated not from clinical routines, but from the knowledge base of licensed MDs. granted, there are those office visits that a NP or PA could easily do, but an MDs role in pediatrics and gynecology is just the reverse of your numbers, 85% MDs versus 15% for mid-level practitioners.

      • Anonymous

        Was a talking about specialists? Obviously, you didn’t fully read my post. Most health care dollars are spent on routine medical care. Care that can be done by NPs and RNs and PAs. We simply don’t need MDs for most of our care. Stop lying! Besides, what did we do back in the 40s and 50s without pediatricians and ob/gyns? Your words “growing healthy, mentally, physically and emotionally” just go to show that parents want to turn their role of common sense parenting over to some moron with an MD or a PhD. That’s just bull!  Pure bull! We aren’t drinking that kool-aid! 

        • Anonymous

          “Most health care dollars are spent on routine medical care.”

          Absolutely not true.

          “Stop lying!”

    • Anonymous

      ” Imagine if 85 percent of primary care was done routinely by NPs and PAs. Imagine the cost savings”

      Primary care docs’ income is a miniscule part of health care spending, so there would be almost no savings there. NPs and PAs tend to order expensive tests and specialist consults at much higher rates than docs, so this would be a big increase in costs.

  • Anonymous

    Thank you for this post.  I generally think of “concierge” medicine when I think of direct primary care, but truth be told we should return to that health care structure.  Essentially we do the same in paying an insurance company as a middle man to cover our medical expenses – a model of business that is not focused on improved health outcomes or quality care but statistics and profit.  In ensuring that health care is affordable for all by charging a reasonable monthly fee for care, we recognize that health is a human right and not one only available to those who can afford it. 

    This proposition not only helps the health care provider, who frankly are being screwed by insurance companies and the government, but the patients.  Health care providers should not be held to the whimsy of political games and infighting.  The fact that the public is unaware of the constant battles to fight for reasonable pay to doctors who are fundamental in our health care system (sorry davemills555, but you are emphatically wrong and quite ignorant of the facts to a point where I will not even deign to enter a conversation with you) but at the same time have the populist idea that health care spending is out of control because of physicians (when we should be looking to insurance companies, pharmaceutical companies, hospitals, and device manufacturers, to name a few) is a travesty in my opinion.  Primary care doctors do make really good salaries compared to the general public – so perhaps there is less public sympathy for their situation.  However, in not recognizing the issue, we threaten the health care situation as a whole.  If doctors cannot be fairly compensated, if doctors cannot meet administrative costs, if doctors start to turn their focus to administrative and bureaucratic burdens, then why would a doctor want to become a doctor.  I assure you that most primary care physicians do not go to medical school, or finish medical school, in the hopes of becoming millionaires.  Rather they probably told their admissions board that they wanted to help people.  There is no way they can do so if we continue to force them away from focusing on care.  There are doctors out there who deserve more than we give them, who are genuinely care for patients in a way that Nurse Practitioners and Physicians Assistants (though not to belittle them, as they are a great tool in providing primary care) can’t.  There are doctors who were once great but burned out as a result of our health care “system.”

    As I said above, the idea not only assists doctors, but assists the public.  Insurance out of pocket can cost upwards of $400 a month at the least.  (I won’t get into the insurance mandate here at it other than to say that it won’t work.)  This forces many to go without or put themselves under heavy financial stress (sometimes leading to bankruptcy or worse).  A $50 fee would save so many.  Not just the patient, but society in general.  If patients are healthy – their cares carefully listened to in a meaningful office visit not hurried by the need to see more patients in a day to attempt to keep their practices afloat fighting insurance companies and the government for payment – it benefits society.  Lower health care costs will ONLY come from focusing on the patient.  It will not come in cutting costs or financial incentives.  It will not come through measuring specific metrics.  It will come from a doctor who can spend time with a patient (which may result in a referral to a specialist in coordination with the care hey receive from heir PCP) and it will come from a patient who has the opportunity to see a doctor at all because the cost is not prohibitive.

    This model should be the next step in medical care.  It’s simple.  It makes sense.  It takes out the middle man.  It won’t be perfect and can’t be implemented over night.  But has the potential to change health care in this country in a way that no other model thus far proposed will.

    Thank you again for this post.

  • Anonymous

    I have a doc fix for you…

    If docs don’t like the money they get from Medicare, let’s explore the idea of having a WalMart big box style of health care to take over the Medicare market that current docs are always threatening to refuse.

  • Patrick Fitzgerald

    There is hardly anything in the world that some man cannot make a little worse and sell a little cheaper, and davemills555 is this man’s lawful prey. -Adapted from John Ruskin

    • Anonymous

      Uh, I’d rather have “a little worse and sell a little cheaper” and get everyone covered than a system that is so expensive it excludes over 50 million Americans and leaves another estimated 25 million more underinsured. Designer Health Care for the wealthy isn’t health care. It’s just another country club for the rich! Oh waiter! I’ll have another martini!

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