Why patients should pay doctors directly

There are distinct advantages for the patient who pays the primary care physician (PCP) directly: higher quality, lower cost and greater satisfaction.

The fundamental problem in health care delivery today is a payment system that is highly dysfunctional leading to higher costs, lesser quality and reduced satisfaction. The core problem? The patient is no one’s customer. With employer-based insurance, the physician’s customer is the insurance company that sets the rates, defines the rules and accepts or denies the bill. And the insurer’s customer is the employer. This is much different in concept and function than the professional-client relationship with your lawyer or tax accountant. Those relationships are direct; you establish your requirements, negotiate the fee or choose a different provider. In medical care, the patient has no standing in the financial arrangement whether employer-based insurance or Medicare or Medicaid.

Add to this the non-sustainable business model PCPs find themselves in today. Insurers have kept reimbursements flat for a decade or more. Meanwhile office costs have risen. With more expenses and static revenue, the PCP tries to “make it up in volume” by seeing more patients for shorter visits. Twelve to 15 minutes may be fine for a quick blood pressure medication check or a sore throat but it is not enough for good preventive care. Nor is it adequate for the patient who has a complex chronic illness (e.g., diabetes, heart failure or cancer), which consumes 70-85% of insurance claims paid. This patient will need a multi-disciplinary team of providers to render all the care needed. But the team needs a quarterback and if care is not well coordinated by the PCP, the number of specialist visits will skyrocket, as will tests, procedures and expensive prescriptions.

How will primary care be paid for if not by the insurer? By the patient paying directly.

When it is his money, he commands more physician time, the time needed to do careful assessments, to call a needed specialist and describe the rationale for the referral and to request a prompt appointment. When it is the patient’s money, he will begin to challenge the doctor – “Do I really need to take that test, visit that specialist or take that prescription?”  “Will the result of that test alter my care or is it just to ‘be complete’”? Questions like these lead to better care and lower costs.

With a direct payment arrangement with the physician, patients can buy a high deductible policy with its lower premiums for the unexpected expensive needs. The patient and physician now have a direct professional business relationship. And the patient begins to take a much more active role in the entire care process.

Direct payment saves the doctor time and money (estimated to be about $58 per visit) by not having to do the billing functions. This savings alone could allow for more time with the patient at the same level of reimbursement as what insurance pays today.

Some employers make high deductible options available; this should be the standard, with savings going to a health savings account (HSA) to use toward paying for primary care. Medicare does not have a high deductible option, although it should. The Affordable Care Act allows for high deductibles in the insurance exchanges but not for Medicare where there are also no HSA options. High deductibles would be a useful accommodation and help bring down – today – the spiraling costs of Medicare.

The ACA also mandates that approved preventive care, including screenings, be offered with no deductibles or co-pays by both commercial and government sponsored insurance. Why not let the individual choose to either pay for preventive care directly or have free preventive care with correspondingly higher premiums.

Absent change in the insurance model, PCPs are taking steps on their own to change their business parameters. Large numbers are simply closing their practice and being employed by the local hospital. Others refuse insurance, expecting only direct payment. Other PCPs are switching to a retainer-based practice where they charge $1,500-$2,000 per year. They agree to reduce the number of patients followed from 1,500-2,000+ down to about 500. This allows for the time PCPs need to give comprehensive preventive care plus orchestrate the multi-disciplinary team care for patients with complex chronic illnesses.

There is a strong need now to change the professional relationship so that the patient has reason (dollars) to take control of their doctor-patient relationship. Direct payment for primary care services creates the appropriate professional-client relationship that leads the PCP to deliver quality and service while investing the patient in the responsibility of taking ownership of his own health and wellness. These are changes in the delivery system that need to occur and the sooner the better.

This post appeared as an Op Ed in the Washington Times, October 17, 2012.

Why patients should pay doctors directlyStephen C. Schimpff is an internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center and is chair of the advisory committee for Sanovas, Inc. and the author of The Future of Medicine – Megatrends in Healthcare and The Future of Health Care Delivery- Why It Must Change and How It Will Affect You.

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  • http://twitter.com/DarrellWhite Darrell White

    And how shall we pay the specialist? How will we incentivise her to be better?How can we avoid having the specialist simply do more work in less time?

  • John Bennett

    Sounds nice but most people with chronic illnesses could not afford to pay you doctor

    • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

      Mr. Bennet, DPC practices actually care for many patients with chronic conditions with great results. Some practices have rates as low as $19 per month, and they have been designed that way for easier access.

      • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

        People who have very limited finances would not be able to afford $19 a month to get healthcare from their Primary Care Physician.

        • medstudent4

          Nearly everyone in the US can afford $19 per month to get good healthcare. It’s called stop smoking, buying drugs, buying expensive phones, etc. I’d say that the vast majority of Medicaid and uninsured patients I see on a regular basis have far better clothing, phones, etc, than I do. If I can afford to pay for insurance on top of being over $100k in debt, the avg American absolutely can.

          • Homeless

            DPC practice in my area costs $150 a month. I can dress better than you by going to my local Goodwill…I don’t want to see a doctor who thinks I am a drug addict.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            All very excellent points. I have heard that before about those that are on Medicaid or uninsured and the things that they buy. However, I am talking about those that are in extreme poverty when I say about those with limited finances would not be able to afford $19 a month to get healthcare from their Primary Care Physician.

          • John Jones

            Those patients who can’t (or don’t want to) pay $19 a month belong with Medicaid -problem solved.

          • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

            And I agree with you 100% on that John. Especially for those that can’t afford $19 a month.

          • Samantha

            You don’t qualify for medicaid because you’re poor. At least in my state, you can’t have public assistance beyond food stamps unless you have children. To be eligible for medicare/medicaid you have to be on disability or past the designated age. I wish things were that simple, but it just isn’t.

      • Samantha

        Please tell me where I can find medical insurance for $19 per month, because I will be happy to pay it. This $19 magic number is something I haven’t been able to locate. My guess is that price, if it exists, would only apply to people in good health without pre-existing conditions who won’t need as many doctor visits as people with chronic conditions. And tell me how I’m going to pay for my prescriptions? Many people don’t pay attention to what things really cost, and that’s an education issue. I do know what my care and prescriptions cost because I’ve had to pay for them out of pocket. Those prescriptions, and I take only two, would cost me more than $300 per month. Add that onto that $19. And the prescription “insurance” plans out there are little help. I can get a whopping 20% off of the meds I take.

        People want to make it sound so simple and it’s just not. Catastrophic plans, which are cheap, can have deductibles of more than $10,000. The average person cannot afford to pay that. People talk about how it’s not right that it’s so easy to declare bankruptcy these days. Talk to a few of my friends who have had to do it strictly because of medical bills. It wasn’t their fault they got cancer or were in a horrible car accident. Maybe insurance wasn’t meant to pay for routine care. But the reality is that for people with chronic conditions “routine” care doesn’t mean a quick trip to the doctor every once in awhile. It means specialists, tests and medications. So a DCP system doesn’t account for those people.

        There are major holes in the system and it seems that depending on what side of the argument you’re on some of them are ignored. Am I in support of the ACA? Kind of. I haven’t been able to get enough details about coverage and pricing to really know.

        And yes, I’m willing to pay the taxes. My health is important to me. If it were really THAT simple to get comprehensive care for $19 a month, we would all do it. The issue is that the people who need medical care the most, the people with health conditions, won’t be able to get care for that amount. That is what the ACA is trying to address.

        • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

          Dear Ms. Samantha, the $19 a month mentioned is not health insurance, merely a fee to access basic health services in primary care, such as physician visits, affordable medications, labs, etc. It does exist at MedLion, at $19 a month for dependents under 21 years of age. Even better, is that $19 a month is for one or more children collectively. Adult pay a higher rate, but still lower than some of the cheapest insurance plans. Because this is not insurance, there is no exclusion for pre-existing conditions, nor is sub-standard care practiced. In fact, the facilities at the corporate-owned clinics are beautiful. The reason why everyone is not doing it is because the industry is still new and getting noticed, hence, the article we are discussing.
          I agree with you that DPC doesn’t account for patients who need constant specialist care, hence the “primary” in Direct Primary Care. Perhaps someone else will create a good system for specialists down the road. The reality is that most people seek primary care first, comprising almost 70% of medical visits. If DPC can lower costs in these category, decrease via complication rates via better access, then in my humble opinion, a lot is accomplished. DPC is by no means the silver bullet that will fix our current system, but it is a step in the right direction.
          Your point about insurance plans with extremely high deductibles is well-taken, and yes, many patients can afford the lower premiums. But when they have to pay out-of-pocket at regular rates for all the chronic care, on top of their monthly insurance bill, it is very expensive. DPC tries to minimize the out-of-pocket costs in routine care under that deductible. I humbly believe a $10K deductible plan is better than no plan at all. One night in the ICU can cost over $10K, and I have seen patient hospital bills in excess of $1 million. I am sure many of those patients wish they had a $10K deductible plan, and I have many of them in my practices.
          I don’t believe there can ever be a health care system that will make everyone happy, but we shouldn’t give up trying to find solutions, even partial solutions. Perhaps a combination of several partial solutions will lead to the better system we are all looking for in our great country.

          • Samantha

            Some insurance is better than no insurance, I agree. That is why despite the fact that a HDP does not really meet my needs, I have it anyway. Yet a $10,000 hospital stay would likely bankrupt me the same as a $1 million hospital stay. And yes, some generic medications can be obtained at very low costs. I looked into several programs because the HDP I’m on has no prescription coverage. I take two medications that have been generic for years, neither of them are available at a reasonable cost. If you need a name brand prescription, God help you. But the issues with the prescription drug business is separate, so I digress.

            I’m not saying that DPC wouldn’t be a step in the right direction for some people, it just seems that people are arguing it’s the answer when it covers only a small portion of what the major issues with health care are. The people who need health care the most, the people with pre-existing conditions who need specialist care and prescription coverage, are not going to be helped by something like DPC. While it’s important that primary care is available for all, I consider that to be almost a side issue of the real problem. The purpose of something like the ACA is to help the people who can’t get insurance coverage or can’t afford it.

            I still don’t know if the ACA will help resolve the healthcare crisis. I’m hopeful but not naive. My disagreements with this article is the assertion that something like a HDP will help reduce costs for physicians, which it doesn’t, and the implication that something like a DCP solves a lot of the problems with our system when it only solves one of the many. Patients should be asking “do I really need that test” regardless of whether or not they have insurance that covers it. But why aren’t the doctors asking that question of themselves before they tell a patient they need a test? If doctors are apparently pushing tests and things that aren’t necessary, how is that an issue with our current insurance system? My doctor doesn’t make money by ordering tests for me. I pay the lab for the test, I pay my doctor for the visit.

            I guess being someone with health conditions does make me somewhat biased. I’m not saying that DCP is a bad idea or shouldn’t be available. But to me insurance is supposed to be something that helps me when I need it most. If I can’t even have access to insurance which provides decent coverage for prescriptions and specialists under the current system (and I am willing to pay a reasonable premium for that) because I already have health issues, that’s a big problem. Unfortunately a DCP won’t help with that, but (theoretically) the ACA will. We’ll see.

          • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

            I agree with many of your points, less with others. If you were in one of our practice areas, I would offer you a chance to experience our care without cost to experience the service. Your frustrations with the health system are dear to me as a physician wanting to care for the community. I truly wish you all the very best with your health, and hope more solutions can arise to help us all.

          • Samantha

            It’s obvious to me that you care greatly for your patients and community, and I wish there were more out there like you to help us solve some of these problems. If we had more people actively involved I believe we would be able to find solutions that address the different issues and perhaps we could jigsaw together a better system. If I had a DC practice in my area it is definitely something I would look into, because despite the HDP I have that doesn’t really meet my needs, the combination of the two would probably make things somewhat better, even if it didn’t solve all the problems.

          • Ana

            Speaking as a med student with chronic health issues, and speaking as someone who has been hospitalized and needed surgery in the past, I agree with many of your points.

            My daily meds cost:

            Med #1 – $150/month
            Med #2 – $550/month
            Med #3 -$190/month
            Med #4 -$100/month
            Med #5 – $75/month

            And no, generics aren’t available and I can’t take cheaper alternatives (I’ve tried them — poor efficacy and/or intolerable side effects).

            Someone who has chronic health problems is typically already cash-strapped because of:

            1. Medication costs
            2. Missing work due to their health problems/hospital stays/doctor’s visits

            Such a person typically cannot afford an extra $59/month + $10 per visit to go to MedLion. There was a time I used to get Urinary Tract Infections on a monthly basis. Each infection would require TWO visits to the doctor — the first to get antibiotics, the second after I was finished the course of antibiotics to re-test my urine. At that rate, I would need to pay $10 x 24 = $240 + $708 = $948/yr + the cost of antibiotics and phenazo just to treat my recurrent UTIs, nevermind the rest of my health issues!

            People who say that health insurance is only meant for ‘catastrophic events’ have no understanding of what it means to be chronically ill. I didn’t ask to be chronically ill — and no, I don’t smoke, drink alcohol, do drugs, and I’m not overweight, so it’s not ‘my fault’ either (whatever that’s supposed to mean). Being diagnosed with a chronic illness IS a catastrophic event, in terms of the long-standing impact it has on your finances. Health insurance SHOULD cover routine care. In my experience, the people who think it shouldn’t cover routine care have never been seriously ill and their ‘routine care’ consists of sporadic visits for minor things like strep throat and immunizations every couple years. Yeah, you don’t need health insurance for routine care if you’re HEALTHY.

            As for my surgery and week-long hospital/ICU stay in 2008 at the age of 19 — I’m thankful I didn’t have that worthless high-deductible ‘catastrophic’ health insurance. That surgery, hospital stay, and multiple visits to the ER would have completely bankrupted me while I was still a teen.

          • Samantha

            You just said something brilliant that summarized so much of what I have tried to say. Being diagnosed with a chronic illness really IS a catastrophic event. Over the years the cost of treating a chronic illness will likely meet or exceed that of what a perceived “catastrophic event” would cost. The only difference is you won’t pay it all at once.

            I too highly suspect that the people who argue that we only need traditional catastrophic coverage are people who are healthy, though there’s no way to know for sure. I’m lucky in that my illness is currently well managed and I’ve been able to skip seeing a specialist since I had to change my insurance to a HDP, though I should actually be seeing one somewhat regularly I just can’t afford it, so I’m taking a bit of a risk. But what other choice do I have?

            I think many people who are healthy take it so much for granted. I truly hope they stay healthy so they don’t go through some of the things I have had to. They don’t seem to realize that the ACA is really to fill the gap for the people who can’t get insurance and/or can’t afford it, and they assume that everyone just wants everything for free. I am perfectly happy to pay out of my pocket for decent insurance. The problem is that I have a preexisting condition and insurance companies won’t take me, plain and simple, and the state plan available for “high risk” patients is astronomically expensive. All I want is to have insurance available.

          • Homeless

            So you were deceptive when you touted primary care for $19 a month? It’s really not affordable unless you are a 10 year old.

          • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

            There was no “deception.” Our fees are clear. We have 20 year old diabetics who pay $19 a month. You must be older, so felt deceived. Understandable.

          • John Jones

            Geez, what a whiner! One day a doctor will save your life. And his or her name won’t be Dr. Google! Ha! I guess to some, their life is worth less than $19!!!!!

          • Homeless

            Dr. Google already saved my life…

          • John Jones

            Then why are you complaining so much? You’ve already found your golden Dr. Google system! Stick to that, pal. You just like freebies, that’s what’s really got you hot and bothered, cause you’re forced to pay for it! Welcome to the real world!!

  • Homeless

    I have a high deductible health insurance. When I have a medical visit, my provider has to bill my insurance so the visit goes against my deductible and I pay contracted rates. Why is it proponents of direct pay tout the high deductible insurance as saving the system money by eliminating billing?

    According to your theory, I should get better care because I pay “directly” to my PCP. I don’t. I find my PCP unable to provide prompt care and I usually will seek care at an urgent care center staffed by nurse practitioners. Of course, this is my money and it is a heck of a lot cheaper to see these NP’s. I self refer to a physical therapist for a chronic injury…no need to spend that extra money to tell my PCP that I need PT. As for specialty care, a trip to a PCP to get “permission” or to “check in” is just waste of money. Ultimately, I rely on Dr. Google for much of my decision making, saving a great deal of money.

    • kjindal

      judging from this and your other posts, sounds like you will be unhappy with any model that involves doctors. So for you, keep using Dr.Google. Then if and when whatever chronic condition you are treating requires experience & judgment, remember the adage “you get what you pay for”.
      good luck.

      • Homeless

        I already didn’t get my money’s worth and you think if I pay more, it will change?

        • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

          But, what if you paid less? And also got better access from a good PCP?

          • Homeless

            There is no offer on the table for paying less. The endless diatribe of how we patiens just stop using our insurance, everything would be cheaper and everyone would get great care. At times with my high deductible healthcare insurance, I have been unable to afford care. But that’s ok, because I saved all that money.

  • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

    Excellent insight into why fields like Direct Primary Care (DPC) are emerging with force. DPC practices (not to be confused with concierge practices) disrupt the status quo by making the need for insurance in primary care unnecessary. By making primary care affordable in a way whereby patients and employers can easily pay into it, insurance is reserved for catastrophes and major medical events. Insurance, as a business, was never meant for common, routine events such as encountered in primary care – it was meant for rare, expensive events. DPC models don’t necessitate patients to be price-gouged and underserved, create savings for employers, and tremendously enhance professional satisfaction for providers (by reducing patient load and increasing physician revenue). I predict Direct Primary Care will become the standard primary care private practice structure in the very near future.

  • http://www.facebook.com/profile.php?id=881580563 Kristy Sokoloski

    Dr. Steve, very excellent article as Mr. Qamar has stated. And while I understand why some people would think that direct payment would help the situation it would be a huge problem for those whose financial situation would not allow them to access care as was brought out by Mr. Bennett. This is the way dentists have gone, but by doing this many people who need dental care are not able to get it because they don’t have the money to pay for the services like cleanings, etc. Many people’s financial situation is such that they can’t afford to pay $19 a month or higher for medical care such as from their Primary Care Physician as I mentioned to Mr. Qamar. So with that said what are these people supposed to do other than to not access healthcare at all for their problems which is also not a wise thing for someone with chronic health problems? How are they supposed to get to their Primary Care Physician for help and care if it went to having the patients pay them directly since they can’t pay a monthly fee?

  • Samantha

    In speaking of high deductible plans you are overlooking a few key issues. Having a HDP does not mean that overhead costs for the physician are lower. They still have to bill your insurance company so that the charges go against your deductible, just as “homeless” mentioned below. Another factor is that even with an HDP your physician still only charges the contracted rates with your insurance company. I learned this recently as I was forced into an HDP and when I received a bill from my doctor I saw that they had applied the “provider write-off” to my bill and I did not pay their full rates as I would if I had no insurance and paid directly. HDPs will not reduce overhead or increase fees paid to the physician.

    In order for a direct pay system to work everyone would have to do it. If I am one of a few patients who does, why would my physician be any more willing to spend more time with me in an appointment? And I successfully have conversations with my doctor about whether or not certain tests are necessary and so on. If you have a doctor who does not have your best interests at heart, what you need to do is find another doctor. I have done so when a I had doctors who were like that.

    I agree with Kristy that this would result in a situation similar to dentists. Even with insurance I couldn’t afford proper dental care for years, and then because I had so many problems resulting from no dental care it cost a small fortune to get all the necessary work done. And while it might sound like a good idea for someone with chronic conditions to have an HDP to cover the big stuff, I can tell you that as a person with a pre-existing condition even an HDP is expensive and insurance companies won’t even sell one to me. If I couldn’t go through my employer my only option is to go through our state’s health insurance pool, which would cost a whopping $700 per month. Not affordable for the average person at all.

    I have concerns about the ACA. I don’t know what pricing will look like. I don’t know if it will provide me with better options as a person with a pre-existing condition. But the current system is not working for me.

    • southerndoc1

      We’ve explained high deductible policies to the OP many times before, but he seems to intentionally not want to understand them.

    • John Jones

      “Qamar” preaches that all doctors are going to turn to this model. Maybe he’s right. Maybe some insurance company will create a plan that is non-primary care and there might not be any deductibles for you to worry about!

  • http://www.facebook.com/dayna.gallagher.9 Dayna Gallagher

    Dr. Schimpff “hits this one out of the -ball -park” …The patient is NO longer a consumer of healthcare. They no longer know nor perhaps care what an office visit cost is. Most do not know what the price of their prescriptions.

    Expelling insurance in primary care could renew Patients’ knowledge of what costs actually are.

    Sir, your final paragraph could end government interference in the patient/physician relationship by establishing a new beginning.

  • John Jones

    This article has nothing to do with “equal access for all.” It’s about helping to fix a broken system. Equal access may be a right, sure, but who then pays the doctors? The government? Good luck with that! Doctors are opting out of Medicare and Medicaid faster than jackrabbits! What I don’t understand is how all people who preach “free” health care for all don’t understand it’s NOT free! If you want a European system (which mind you has its fair share of flaws), then are you prepared to pay what they pay on taxes? Like a 17% VAT in the UK? Americans are so spoiled. They feel entitled to health care, but don’t want to pay directly, or indirectly via taxes. As “Qamar” and “medstudent4″ point out, $19 a month is not too much to ask! Gimme a break! If you can’t afford $19 a month for private primary care, then you have the mentality where you wouldn’t even pay a dollar for health care! Employers have spoiled employees by paying into their benefits for too long – now everybody feels “entitled” to continued free care. Sorry, but in a free market/capitalistic/free enterprise like America there will likely never be a one-payer system. And once the new ACA kicks in, good luck finding a doctor folks!! LOL!! At least I’ll have the sense to pay $19 a month to see a doctor. Y’all can wait months to see a Medicare-accepting doc if you want, ha! Gimme a break!

    • Homeless

      25% of our income goes to healthcare. It sure is free.

      • John Jones

        No, Homeless genius, 25% of our income goes to wars, the deficit, and running our country. It is the price you have to pay for living in America. Want health care, too? Then pay for it. Either to doctors, or via more taxes. By the way, the VAT in the UK is a 17% sales tax on everything in the country from paper clips to automobiles. Income tax is ADDITIONAL.

        • Homeless

          No… Insurance premiums, Medicare, Medicaid accounts for 25% of our household income. We pay income tax, sales tax, property tax on top of that.

  • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

    The ACA, though an honorable gesture, does little to account for the shortage of primary care physicians that plagues us at this time. The problem is expected to worsen just as millions of patients will be looking for promised care. Mr. Jones is correct – Medicare is seeing its highest rate of physician opt-outs in US history. We as physicians need to take charge and have the courage to change the current health care system. Is Direct Primary Care a perfect health care solution? No. But what else is being done at a time when patients aren’t able to access basic care, employers are forced to pay (or drop) high premiums, and doctors are getting burned out and ceasing to practice? True, Direct Primary Care may very well be a reflection of a broken system, but at least it is an attempt to better the status quo. I was a physician accepting all insurance, but didn’t feel it was safe having to see 35 patients a day for an average of 8 minutes each. I had to see 25 patients a day just to pay my office lease, staff, billers, EMR systems, and basic practice overhead. With the remainder of the patients seen, it was barely enough to pay student loans, let alone enjoy a satisfactory life. Hours were 7 to 7, and my health, along with my patients’, were in danger. So I created the first Direct Primary Care practice in California. Patients spend up to 30 minutes during visits, I have hefty-but-not-crazy patient loads, more sane hours, and I feel like I have the time to make a difference in my patients’ lives. Better access to basic primary care that is affordable has helped my patients stay out of hospitals, see fewer specialists, and require fewer tests. Many patients who can’t afford our least expensive monthly fee ($19), I treat for free. In my Las Vegas office, being launched soon, we just sent out coupons to 10,000 patients for free visits. We give discounts to students, and give a percentage of our revenues to charity clinics. We may be a reflection of the current health care system’s faults, but we consider it to be an honest effort towards what may lead to a fix. Our Direct Primary Care model is successful, and doctors have adopted our model several states. Patients are happier, doctors are happier, employers are happier. Sometimes, in the case of a severed artery, a tourniquet can buy the time needed to save a victim’s life. For without the tourniquet, there is no hope at all.

  • futuredoc

    I am delighted that this post garnered so many comments. I certainly do not claim to have all the answers and the comments that this is just a patch to a dysfunctional system rather than a true fix are on point. But I am certain that one thing that needs to be fixed now is the doctor-patient “contractual” relationship, making the patient the customer. Direct payment does just that. BTW I do realize that with high deductibles the physician still has to send in the claim forms so that the patient’s insurer can recognize them. And the insurer in most cases has a contract with the physician that prevents him or her from charging other than the “negotiated” rate with the insurer. Of course all of these issues go away if the physician no longer accepts any insurance – Medicare, Medicaid or commercial – and goes to the direct primary care or the retainer-based models. The former can be quite inexpensive and in both cases the patient can then request more time as needed.
    Stephen Schimpff, MD

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