Medical students should get excited about direct primary care

You’ve heard the story before: a young man or woman with idyllic dreams of practicing primary care goes off to medical school, only to have their dreams crushed by the realities of 7-minute visits, “production goals,” and unstable reimbursement — you’ve heard of the Medicare sustainable growth rate, or SGR, right?   Every time you turn around, there is someone talking about primary care physician burnout or complaining about practicing on a hamster wheel.

I left a career I loved as a US Marine to pursue medicine, and I didn’t do it naïvely.  I knew full well the realities of modern practice, but I took a leap of faith that I would find a way to practice medicine that would be fulfilling and allow me to be there for my family.  Although I loved the idea of building meaningful relationships with patients and families, the downsides of primary care just seemed too daunting, so I thought I would go into emergency medicine.

That all changed when I read about Access Healthcare, the practice founded by Dr. Brian Forrest in Apex, NC.  A friend had sent me a magazine article that featured Dr. Forrest’s practice, and I was blown away.  Forrest had figured out a way to provide care to the uninsured and underserved, spend enough time with his patients to build meaningful relationships, excel in quality outcomes, maintain a good quality of life, and make a decent living to boot.  It all sounded too good to be true but after getting to know him and eventually doing my Family Medicine clerkship in his practice, I can say that this is truly a transformative model of care.

Direct primary care (DPC) is a model of delivery that hearkens back to the glory days of the family doctor.   In DPC, the physician’s sole focus is on the patient.  Patients have easy access to their physician through open scheduling and often, email, cell phone, or Skype — methods discouraged by current reimbursement mechanisms.  Visits are unrushed, and patients get the time they need, whether it’s 10 minutes or an hour.  The physician-patient relationship is the foundation, and instead of one-way communication, patient and doctor develop plans of care together that are targeted towards the patient’s own values.

DPC works by extracting the third-party payer from the equation.  Third-party involvement in primary care adds an enormous burden of cost and time — a burden that doesn’t add to, but actually detracts from, the quality of care.  When that burden is removed, the savings are dramatic, and the whole physician paradigm shifts from chasing reimbursement to providing the best care possible.  In DPC, the patients pay the physician directly for service through an affordable subscription or transparent a-la-carte pricing.  Just imagine if your car insurance was responsible for changing your oil.  We’d go from a service that practically anyone can afford, to one that hardly anyone could afford, with the result being fewer people getting necessary maintenance, leading to engine damage, breakdowns, and exorbitant repair bills.  Sound familiar?

The Affordable Care Act (ACA) includes a provision that allows for direct primary care services to be coupled with a wrap-around insurance policy and sold on the health care exchanges.  Such a product has already been developed in Washington state and is available on their exchange.  There are efforts to provide care to Medicaid patients in this model as well.  DPC addresses the triple aim of improved quality, lower cost, and improved patient experience in an incredible way and can be delivered to any patient population.  If you care about finding a way to deliver care to the underserved, then you have to be excited about DPC.

The ACA, with its expansion of access to care, heightens already existing concerns about the dwindling primary care workforce, but many of the proposed solutions out there don’t address the reasons that students shun primary care, including rushed visits, production goals, constricted scope of practice, and shrinking reimbursements.  DPC addresses all of these issues in spades, and once students realize there is a viable option out there, they will be turning to primary care and family medicine in droves.

Direct primary care makes me incredibly optimistic about the future.  I will avoid the hamster wheel and provide the kind of care I envisioned, while building deep, rich connections with my patients.  I will be offering a level of care previously only available to the rich that almost anyone can afford.  I will be taking meaningful steps towards true, primary-care driven and patient-centered health reform, and I won’t have to wait for the “system” to figure it out.  I will be able to provide the majority of care my patients require instead of having time only for refills and referrals.  In short, I will be part of the solution, both for my patients and for the system as a whole.

Brian Lanier is a medical student who blogs at Primary Care Progress. He can be reached on Twitter @lanierbrian.

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  • PamelaWibleMD

    Hi Brian ~ The same excitement exists for “ideal clinics” and many ideal clinics embrace the DPC model. It’s all about putting the patient first. When I left assembly-line medicine, I decided to hold a town meeting and allow patients to design their own clinic – a real win-win situation for the patient and physician. http://www.youtube.com/watch?v=4YJz5wvt2bk

    • NPPCP

      Exactly!!!!

  • Thomas D Guastavino

    Question. How does a patient who is non or underinsured (i.e. medicaid. ACA) afford the subscription fee or for that matter qualify for medicaid in the first place? Anyway, I digress…. Thanks for sending another clear cut message to the supporters of health reform who have assumed that providers will blindly accept whatever ridiculous rules and crumbs are thrown at them.

    • Brian Lanier

      That’s a great question, and there is some ambiguity regarding whether HSA funds can be used to pay a monthly subscription. I believe that prudent practices are advising patients monthly fees are not currently considered qualified medical expenses for HSA purposes. Some DPCs offer a-la-carte menus of services and these can be paid for with HSA funds. Also, services provided by a retainer practice not covered by the monthly fee and charged separately would qualify. There are lobbying efforts for legislation that would clarify this: http://dpcare.org/expandQME

    • fatherhash

      this question brings up an ironic point. from my understanding, HSA funds are supposed to be used for “qualified medical expenses” implying medical services that would be covered by, let’s say, Medicare.

      from my understanding, Medicare also does not allow (participating providers) to charge patients extra for services they already cover.

      so for those that are still Medicare-participating, i’m not sure if they can have their cake and eat it too.

  • William Rusnak

    Brian, glad to see another student in the same situation. Many people were baffled when I switched last minute to apply to family medicine instead of radiology, despite having competitive board scores. Discovering direct care was a big part in that decision. Like many of us, I love the job of a PCP but hate the fact that most had lost control of their practices. Not taking insurance eliminates so much overhead that the prices are affordable for most people and the quality of care is improved so much because physicians have a lighter patient load. Insurance needs to return to what it was meant to be: something we never want to use except in emergencies.

    • NPPCP

      This is a great article!! I agree!! I am moving toward a DPC hybrid model in my private NP clinic. It really does work and is very affordable for the customer. The autonomy and financial rewards are a great blessing! Thanks again for the great post!

      • NPPCP

        Owning my own private NP practice and having no one between the insurance company but me and my CPA has shown me just how much is wasted on middle managers, “executives”, managers, etc. As employed healthcare providers we singlehandedly support an entire industry of suits, “motivational speakers”, experts, “supervisors” of all types, etc. They are all literally making unearned wasted money on our backs. This model has the potential to change the provision of healthcare for all MDs, DOs, and NPs. It’s kind of like coming up out of a big river and slowly picking off the 15 leeches that have attached themselves to you. Very excited about it!

    • Kristy Sokoloski

      Not taking insurance may eliminate the overhead which is a good thing but then you are going to run in to a situation where people that need to see you won’t be able to see you can’t because they can’t afford it. If I didn’t have insurance I would not be able to afford to see my doctor like I need to, and the same with my relative as I just mentioned to the person above.

      • William Rusnak

        Kristy, most people currently pay well over what they would pay if they had direct care coupled with a “catastrophic” plan. Some of these cash-only practices charge less than $50 per month. Some are fee-for-service, costing maybe $60 per appt. There are so many options available for people and negotiating is possible because no third-party is involved! I just think many forget to look at their paycheck to realize that their healthcare costs them hundreds of dollars a month. With some adjustment in their current plan, almost everyone could afford to pay for direct care.

        • NPPCP

          Great comments and great discussion!! Thanks again for the article. The replies are great and it’s good to see this catching on!

        • rbthe4th2

          Unfortunately not sir. I have retired people who can’t afford it, all but one of my siblings couldn’t afford it. An extra $50 a month is a payment on a credit card. They already skimp on medical care because they have trouble with the copays. Working 2 part time jobs also may not allow you the time during the day to take off, meaning disjointed care if you can afford it at the night shift.

      • Brian Lanier

        Kristy,

        Collectively, we have been paying roughly twice what we should for our health care. People that get insurance through their employer are paying for this through increasing employee portion of premiums, increased co-pays/deductibles, and stagnant wages. People that buy insurance on the market pay the entire premium (at least prior to the ACA and exchanges) but these two individuals are not that different—the employee gets a tax break—but both of these individuals are bearing this burden (remember, stagnant wages!). When a covered employee goes to the cardiologist and gets a $1200 echocardiogram (that should probably cost $250), that employee is bearing that cost in a way that makes them think they aren’t. These are the people that will personally benefit the most from DPC, the employee (and employer) and the person buying insurance for themselves. As for Medicaid, I think that we can one day help this population buy this kind of high-quality, low-cost care, but that’s another topic.

        I will say that the kind of low-deductible coverage you describe is becoming a rarity and that more and more people are going to be directly exposed to the exorbitant prices we have been paying for health care services. These folks will be seeking value, and there’s no better value proposition than DPC.

  • Dave

    One common thread among these successful DPC practices is this: they are started by established physicians with a large patient rosters. Granted, many patients won’t make the switch, but enough do so that the practice has some baseline of income and can eventually turn a profit. I wonder how feasible it would be for someone straight out of training to start one?

    • William Rusnak

      Look up Josh Umbehr, another big name in direct care. He told me that he started right out of residency.

      • Dave

        Wow! Hadn’t heard of him but looks like he’s managed to do it! They’ve already expanded to 3 physicians too, so things must be going pretty well. Thanks for the info!

    • Brian Lanier

      Here are some more examples: http://www.integrativeasheville.org/
      http://neucare.net/about/
      http://www.acchealth.com/ (mentioned in article)

      I think it is absolutely possible to do this straight out of training, at least I plan to! As far as I’m concerned, this is the true growth potential for DPC and that’s why I wrote this article. I think that most folks work locum tenens for a year or so while saving up cash/paying down debt. Debt burden would certainly be a factor.

    • http://www.physiciantools.com/ Jim Ingham

      It is more difficult starting out of the box building a DPC practice, but doable. There is one advantage of no legacy costs associated with moving from a traditional model, like extra office space, staff you do not want to let go, etc. But with a strong referral program growth can really take off once a low level of critical mass is achieved…..

  • Kristy Sokoloski

    On the fee that you charge a year what is that fee per month? And then the fee for an office visit is like what someone pays as a copay is what I pay as a copay through my insurance. And a hospital fee, interesting. The reason I ask about the fee a year on a monthly basis is because of curiosity. And the reason for the curiosity is because it confirms what I told someone else. That if more doctors go to direct pay then someone like my relative and I won’t be able to afford to see our doctor as we do now. We don’t have luxury expenses.

  • Brian Lanier

    Dr. Qamar,

    Thanks for your kind words. I have been keenly following MedLion’s progress for a while, and look forward to your continued success.

  • Brian Lanier

    All, thanks for the great comments and discussion. I truly think that DPC has the potential to dramatically impact our health care system for the greater good. One of the perhaps unintended consequences of the Affordable Care Act is that many more Americans are going to be directly exposed to the high costs of care in ways that they haven’t before. Much has been written about high out-of-pocket exposure of Bronze and even Silver plans in the exchanges. And employers are increasingly shifting costs directly to employees. As this trend progresses, people are going to start to seek value, and there’s no better value proposition than DPC.

  • rbthe4th2

    I couldn’t afford $55 a month on top of insurance. I have to have insurance else I can’t pay for my medical care. Thousands of dollars for one treatment alone, I would be paying for months for that and then another $55 on top of it with a mortgage and car payment? Many of us simply can’t afford it.

    • fatherhash

      you likely could afford it if your regular insurance was cheaper….which is how it should be if you pulled PCP coverage out of it.

      • rbthe4th2

        The problem is that with my insurance, I’m having to pay for those who can’t. Hospitals are going to charge me more because they can, to pay for those who can’t. I’m not allowed to “opt out” for my workplace.

        • Brian Lanier

          DPC as a movement is relatively young, and there are certainly many that can’t take advantage of it, largely because there aren’t enough physicians practicing in this model yet. My goal for writing this article is to get the attention of medical students and residents to raise awareness of the possibilities of the model. Many DPC pioneers have providing services to business as their primary business model. A business owner that offers a low deductible plan to employees could potentially pay the $400-$600 DPC subscription for the employee, help fund an HSA, and shift employee to a high-deductible plan. This arrangement could result in a substantial net savings to the employer, the same or less out of pocket to the employee, and most importantly, substantially better primary care for the employee. This means better chronic disease management, less ER trips, less missed work, increased financial security for the employer leading to increased job security for the employee.

  • NPPCP

    Yes Sam, this is going to be great for all of us! Have already seen significant revenues and increased autonomy/freedom from insurance companies. This is a wide open field for all of us!

  • Thomas Luedeke

    Although I think DPC is a wonderful and obvious development, we’ll see how long it is before the politicians and insurance companies see doctors fleeing the coop, and force them back in with legislation banning or curtailing the model. Analogous to the occasional political rumbling I hear of forcing doctors to accept Medicaid/Medicare patients as a condition of licensure.

  • Thomas Luedeke

    Yup, except that it is *voluntary* indentured servitude. If people think we have a doctor shortage now, just wait until they try something like that…

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