Affordable direct care doctors are the long-term health care solution

In 2010, I started practicing direct care in Wichita, KS. I steadily built a full roster of subscribers who pay between $10 and $100 per month to see me whenever they need to, for as long as they need to, however they want to (at their home, in my office, or via the Internet), all with zero co-pay.

Recently, a patient of mine developed ongoing shoulder pain. He’s middle-aged, insured, in good health overall, and as expected, refused to get an MRI.

As a direct care practitioner, I act as my patients’ family doctor (routine checkups, consultation, etc.) and as their personal urgent care physician (lacerations, broken bones, earaches, and stomach flus) I can handle all of this at no extra cost.

I write and fill their prescriptions, some as low as pennies per pill. Patients do pay for their labs and panels, but our wholesale rates come out lower than the copay of most insurance plans.

I even have someone who helps them find super affordable wraparound insurance plans in case of major trauma.

Just last week this same patient called me up first thing in the morning: He was in severe pain.

“Dr. Josh, I’m ready for that MRI.”

So I immediately made the call to a local lab technician, because I wasn’t fifteen minutes behind my third appointment scheduled for the first hour of my day like most doctors working within the traditional fee-for-service model.

Because of the relationship I’ve built with the lab, my patient owed only $400 for the MRI, instead of the out-of-pocket cost of $1,500 that’s billed standard.

Within 45 minutes, my ailing patient was leaving the lab. Within a few hours, I was reviewing the results.

But critics are probably shaking their head, wondering why this man would want direct care when he’s currently insured.

Well, the thing about insurance is that in almost all cases, patients need to meet their deductible in order for insurance to cover things like MRIs. An Obamacare silver plan comes with a $3,000 deductible – twice the amount due! If they went to the same lab and used their insurance, they would owe $1,100 more out-of-pocket.

And they would still owe that monthly insurance premium that’s really only there in case of major trauma.

And they would risk having to go to an overpriced ER if they had any trouble late at night or on the weekend.

It’s worth remembering that insurance is a business and they sell their benefits like every other company. Major medical plans will typically offer “free preventative care” in effect saying, “as long as you see an overworked doctor of our choosing, you pay nothing.”

Except you do pay. You pay by waiting 18 days to get an appointment. You pay when doctors talk to you for 7 minutes and have to look down at your chart to remember your name. You pay when these doctors refer you to the same lab for the same MRI and you’re indebted $1,500 because you haven’t met your deductible yet.

That’s why it baffles me when people have knee-jerk reactions to paying cash for medical services.

“Oh, cash-only medicine, that’s only for the rich,” said an associate of mine while we were in Los Angeles years ago. She went on to manage patient experience for a prestigious medical center, a place even the insured might only dream of receiving care.

Then there are critics who say things like, “You doctors seeing fewer patients will reduce access to primary care.”

Or our favorite gripe, “You’re going to create two-tiered health care.”

As a direct care practitioner I take offense to these attacks because they lack perspective. Do critics of an affordable option that delivers real value want health care without any tiers? And what would this tier look like? Millions losing existing coveragerising premiums for small businesses, cheap Obamacare plans sneaking in absurd drug costs …

To me, this sounds like a universal health care system that equally fails all people of all socioeconomic backgrounds.

Why would someone criticize me when I tell people, I’m happy doing what I’m doing, I’m happy to consult other doctors in doing similar work, and I’m happy to motivate students to choose family medicine instead of a specialty?

Critics see affordable cash-only doctors as the root of our doctor shortage. I see us as a viable long-term solution. When students begin to perceive the financial and emotional benefits of practicing family medicine — two things I can personally vouch for their attainability — then this doctor shortage might actually be addressed.

And when critics want to examine the chip on their shoulder, I’ll be glad to negotiate for them.

Josh Umbehr is founder, Atlas.md.

Comments are moderated before they are published. Please read the comment policy.

  • Close Call

    Thanks for highlighting your practice. Direct primary care really sits in that sweet spot for many patients and physicians who want a simpler and more personal type of medicine. Whenever I talk to med students and residents about DPC practices, their eyes just light up.

    • Dr. Josh, AtlasMD

      Thanks for the support and congrats on sharing DPC with students and residents! And you’re right that they light up to the concept of medicine “the way they promised us it would be.” Meaning that we can focus on patients, not paper work; families, not insurance forms.

      This is better, more affordable care for the masses. I don’t see how this won’t become the predominate PCP model in a few years.

  • SarahJ89

    I’m insured, but would be happy to pay instead IF it was affordable. Most of the direct pay practices I’ve seen are simply out of my league.

    There’s also the problem, in my area, of our local “non-profit” hospital which has gobbled up every practice in a 30-mile radius. They pay their CEO nearly a million a year, spend a lot of money on PR, a new fancy atrium (that looks exactly like the one in the actual regional medical center that is this suburban hospital’s direct competitor), etc.

    This hospital is not likely to stand for any doctor breaking ranks by setting up a direct-pay practice. We had one here a few years back who tried but had to close his practice because he couldn’t make ends meet. My guess is this money-grubbing hospital will stop at nothing to prevent their docs from breaking loose. I watched my own doctor fight for years to maintain his independence. The cost of EHR finally caused him to capitulate and get bought by the hospital.

    • Dr. Josh, AtlasMD

      You’re probably right that hospitals won’t play nice…except for your first line…you’d be interested for the right price.

      Sam Walton said the customer has all of the power and can fire anyone from the CEO down just by shopping somewhere else.

      As patients learn that DPC can be affordable and puts the patients first, i think they’ll demand a better product.

      • SarahJ89

        Oh, if it was the right price I definitely would prefer it. Most I’ve seen require a huge annual fee, plus per visit. I only go to the doctor once a year, to get my one prescription renewed. This year I had two visits, thanks to a nasty tick bite. I’m pretty much of a cheap date and would be happy to swap my outpatient insurance for direct pay.

        We do avoid our local hospital at all costs. We have identified which outside our immediate area are best for particular conditions. Nonetheless, when I broke my arm my brains immediately vacated my cranium and we ended up in the local ER. Which led to a referral to their orthopod. What came after that was an unhappy experience so we’re now practicing driving a bit further no matter how bad the pain so we can avoid the place.

        • SarahJ89

          PS: Pamela Wibble, who writes here on occasion, seems to charge reasonable fees. Unfortunately, the 3000-mile trip to her office kind of leaves me out of her pool of prospects.

          • Dr. Josh, AtlasMD

            you might watch http://www.iwantdirectcare.com to look for doctors and other patients in your area that are interested in DPC models.

          • SarahJ89

            Why, thank you for this.

          • Dr. Josh, AtlasMD

            happy to help

        • Dr. Josh, AtlasMD

          Our price for wholesale medicines and lab testing is upwards of 95% off. If its on a big box $4 list, then we typically get it for a penny or two per pill.

          Not to mention you can now access your doctor by phone, sms, email etc 24/7 and have same day appointments that last 30-45 minutes each.

          Now we don’t recommend you dump the insurance completely, just that you scale it back to save where you can but still have coverage for heart attacks and cancer.

          • SarahJ89

            Your last paragraph describes my ideas perfectly.

          • Dr. Josh, AtlasMD

            good to hear

  • Dr. Josh, AtlasMD

    Little companies eat big companies all of the time. Instagram had 13 employees and was bought for a $1 billion by google….

    Thats b/c little guys are able to move faster and innovate easier than the large companies.

    But as employers realize they can save 30-60% on their insurance premiums while getting better, cheaper care, they’ll find a way to embrace/adopt DPC.

  • Dr. Josh, AtlasMD

    Fair point HJ.

    1) The goal is to help save you as much on copays, medicines, labs, imaging and insurance premiums so we can lower the effective cost per year. So a few hundred saved on an MRI, a few hundred saved on premiums, on medicines and its pretty close to a wash.
    2) But for many patients, they save MORE than it costs per MONTH, making this a cost benefit to them.
    3) Most states, a physical therapist would require a physicians note first.
    4) I’m glad you had a healthy year, but can you predict when your car will break down? Probably not, hence the business model for AAA. Most can predict which years will be healthy and which won’t, so this is still a way to control your health care costs to a degree.

  • Patient Kit

    A couple of questions: (1) How do you determine how much your patients pay for membership per month? Is it a sliding fee based on income? Or is the $10 – $100 per month reflecting something else? I assume that fee is per person. (2). Just for an example, let’s say I’m paying you $75 per mo for membership. How much would it cost me to come see you with a fractured arm?

    I’ve actually never had to pay $400 for an MRI under any insurance I’ve been covered by. Neither my past private Blue Cross plan or the Medicaid plan I’ve been covered by for the last year (HealthFirst in NYC) charged me any copay for an MRI or CT. So, $400 doesn’t sound like a great deal to me.

    I am one of the doubters about DPC. But I’m still actively trying to grasp how it might work for me.

    • Dr. Josh, AtlasMD

      always happy to answer questions.

      1) price is based on age only, not on medical conditions. Yes the fee is per month.

      Children 0-19 years olds, $10/month with at least one parent membership
      Adults 20-44 years old, $50/month
      Adults 45-64 years old, $75/month
      Adults 65+ years old, $100/month

      2) Membership covers unlimited home, work, office and technology visits, no copays, all procedures that we can do in the office are free of charge, and access to our wholesale prices on medications and labs for up to 95% savings.

      3) A bone fracture just depends on the severity. No extra charge from us. Xrays $20-40. If only splinting is required by us, then its free. If casting is required, $50 at the ortho’s office (negotiated discount).

      If you have insurance that doesn’t have a copay for MRIs then you very rich (likely expensive) insurance. The goal would be to carve your insurance back to a reasonable level to save you $500 per month. The fact that it may not cover most MRIs is fine then b/c you likely don’t get an MRI each month so you’re saving money that way.

      I’d love to answer any questions that might be helpful. Think of it as better care for less money.

      • Patient Kit

        Thank you. I think specific details like this will help me understand DPC better. I didn’t realize that the monthly membership fee is determined by age. So, I learned something already. I’m in my fifties, so I guessed right on $75. Given the difference in rent costs (and everything else) in KS versus NYC, I wonder whether docs here in NYC would be able to do it for that little.

        Before I was laid off, I had an employer-provided Blue Cross plan for 18 years. I worked for a nonprofit org and our salaries were relatively low so my employer paid 100% of the premium. When I COBRA’s it, I paid $700 a month. It was a very good plan. As I said, no copay for any imaging tests. No copay for labs. No copay for physical therapy, which I had 3x a week after a fractured femur and again after a ruptured Achilles tendon. For the last year, since I was diagnosed with ovarian cancer while uninsured, I’ve been covered by Medicaid, which also has no copays. Good luck to me, I know, finding this in my next insurance plan, hopefully via a new employer.

        I just had my third CT in a little over a year. None of them cost me anything. So, $400 doesn’t seem like a bargain. I’m being monitored by my GYN oncologist for recurring ovarian cancer. Likewise, several MRIs that I had before three orthopedic surgeries didn’t cost me anything.

        I don’t think insurance that only covers catastrophic illness would work for me. I really need access to my specialists and, as is much lamented here by primary care docs, those specialists are expensive. Insurance has to cover all specialists, as far as I’m concerned. I don’t think a primary care doc could have handled any of my orthopedic injuries. All three were complex and required major surgery.

        I’m having a hard time imagining being able to get by with an inexpensive insurance plan. So, I don’t foresee that expense getting significantly lower. Which is why I’m having a hard time understanding how all primary care costs not counting toward my deductible would be a good thing. I expect a deductible in my future but I haven’t had a deductible for the last 20 years so that will be a new and brutal concept to adjust to.

        Another question: Where would OB/GYN care fit into a DPC/catastrophic insurance plan for most women?

        Do you think DPC is better for healthier patients or those with major health issues?

        • Lisa

          I have very simular thoughts about DPC. Right now I have employer provided insurance. If I stay in network, my out of pocket costs are minimal. But I can go out of network if I want to and pay somewhat more. I like this feature because I have access to more specialists I may need in the future.

          I am sure if DPC models become more prevalent my employer would start offering an insurance plan that includes some combination of direct care, a high deductible insurance plan, and a health savings account. But a lot of PCPs would have to change their practice models. And the thing is that running a DPC practice is really running a small business. I suspect many doctors won’t want to do that. It sounds simple on paper but what happends when something comes alongs and increases the doctor’s cost. They will have to raise the monthly fee, deal with unhappy patients, etc.

          Someone compared having direct care to having AAA coverage. The thing is that one year I used my AAA coverage too much. I got a nasty letter from them saying they would drop me if I used their services again within a certain period.

          • Dr. Josh, AtlasMD

            Hi Lisa, you make a great point and many people are in a similar situation where employers are paying for insurance. That insurance is often structured to encourage people to stay in the system. The problem is the system is broken. You’re paying for red tape and paperwork, not patient care.

            We often are able to help employers readjust their insurance to lower the cost and improve the quality of coverage. In fact, just in March we lowered the cost of insurance so much for a company, that the employees all got a raise.

            That is the power of a DPC model.

            You’re absolutely correct that doctors don’t like running a business. Thankfully, a DPC model is infinitely easier to run that the complex insurance based model. This eases the burden significantly on the work of running the business.

            Thanks

          • Lisa

            I don’t think I am paying for red tape and paperwork with my insurance. In the last 6 years, I have had six surgeries (breast cancer, two hip replacements, cataract surgeries. extensive physical therapy including treatment for lymphedema and one hospitilization for cellulitis). I haven’t had any problems getting the care and I needed and have had minimal out of pocket costs. I don’t have trouble getting same day appointments with my PCP or another doctor in is practice. If I need an appointment with a specialist, I am seen quickly.

            My point is not all insurance models are broken. I think a direct care model will work as an option for some; I just don’t think it will work for all patient populations.

          • Dr. Josh, AtlasMD

            You’re most definitely paying for red tape as part of your insurance. Just look at the studies that show on avg 22% of a doctor’s time is spent/wasted doing non clinical insurance paperwork. That increases the cost significantly. Or that the average doctor has 7 support staff (each) to play the insurance game. Vs a DPC model like ours that has 1.5 FTE staff for 3 physicians.

            But as a physician we’re always going to see the extra hidden costs in the healthcare system where as patients have a limited view of that waste.

          • Lisa

            My PCP is in a group practice; the staffing level is no where near what you mention above and I never had a problem with my insurance paying a claim. In addition, none of my doctors have ever mentioned a problem. Approvals for the services I have needed seem to be easy to obtain. Perhaps that is because my doctors don’t order unnecessary tests.

            The DPC model still involves paperwork and from what I know of running a small business, I suspect that the support staff needed would be more like 2 people. Someone has to keep the books, handle your accounts receivables (the monthly dues), pay your vendors, answer the phones, prepare exams rooms for the next patient and so on. I’ve seen small dental practices and medical practices that have one support person per doctor. And I don’t see how they can get much more efficient.

            What the insurance company does for me is negotiate prices, especially with specialists and hospitals. You mention a $200 MRI at some point. In my area, the cheapest a cash patient can get an MRI is about $2,000 which is more than most insurance companies will pay. How the heck can you get a $200 MRI for you patient?

          • Lisa

            I just realized you didn’t respond to my crack about AAA above, but you are the one who brought up the model of the AAA as being comparable to DPC. mmm…..

          • Dr. Josh, AtlasMD

            I did not reply to the AAA comment b/c thats not how doctors operate. We have never fired a patient for “over use” or “misuse” of our model. That would be against our oath to get rid of a patient b/c they had a lot of medical needs. It demonstrates a lack of understanding about how physicians operate.

          • Lisa

            While I believe you wouldn’t fire a patient for solely for overuse, I think there are circumstances where a DPC would dismiss a patient. Because what a direct care practice really is offering is a form of insurance. If too many people make ‘claims,’ ie need to many services, the practice can’t make money.

          • Patient Kit

            Hi Lisa. I share your experience of getting excellent, complex medical care with lots of choice and little out of pocket costs with the insurance I’ve had. I’m skeptical that DPC would really decrease cost or increase access and choice for many patients. That said, the kind of low/no deductible, low/no copay insurance that we’ve had is getting harder to find.

            I also share your concern about how doctors will run their cash small business, not being noted for their business skills. On the other hand, private practice has always been a small business, so maybe that concern is misplaced.

            In a thread under the article on primary care access just below this post, one of our “guest” docs commented that she has a DPC doc herself and feels like their doc-patient relationship is so superficial that she might as well go to a stranger doc at an urgent care center. I think that says a lot about whether DPC is the answer to all of our problems. It is not. It might be good for some docs and some patients, but it is not the big fix some docs are trying to sell it as.

        • Dr. Josh, AtlasMD

          I’m sorry to hear about your numerous health issues. And i’m glad to know that you had good coverage through your employer and then medicaid.

          Unfortunately, insurance like medicaid is bankrupting many states and our country for some of the benefits you enjoyed. Insurance that doesn’t require a copay means that its more expensive to the employer/employee/tax payer. So medicaid probably paid $600-$1200 for the same CT that we can get from $200. Even if you don’t pay directly for the service, you can see that the system is paying more than it should (largely b/c of complications from red tape.)

          So if private or public insurance embraces DPC, then it means the same or more care for a lower price b/c we remove the red tape of care.

          So i’d like for your medicaid to continue to be able to care for you, but at the rate the system is going, it will be bankrupt in a few years. then no one gets the care you’re enjoying now.

          I understand that when patients are given access to the true cost of care (hidden in an insurance system), its difficult to see the full value of a DPC model.

          But I believe most can conceptualize the savings of wholesale labs and medicines for 95% off. The value of doctors doing less paperwork and more patient care.

          I believe that DPC is better for patients who are sicker and have more needs b/c that means more opportunities for care without copays, more access, more medicines and labs for more savings etc.

          Thanks,
          Dr Josh

          • Patient Kit

            Thank you. I’ve bounced back 100% from my orthopedic injuries and I’m doing well post-OVCA surgery and dx. I’ve had excellent medical care with very little out-of-pocket cost to me and lots of choices as long as I had insurance. I came to expect that with Blue Cross but the quality of care I’ve had under Medicaid has been a revelation compared to the horror stories we here. I’m sure that is easier to find here in NYC, which is chock full of doctors and major academic teaching hospitals, than it is to find on Medicaid in small town middle America. I hope to be off Medicaid soon and back to work, hopefully for a new employer with a decent health insurance benefit.

            The idea of not having insurance is terrifying to me, as it is to anyone who has been through any serious medical crisis. I hope you are not advocating for the end of Medicaid (or Medicare). I’m very grateful that my government was there for me, albeit in it’s Kafkaesque way, as a safety net in my time of crisis.
            I’ve worked and paid heavy taxes for 40 years so, I contributed to that Medicaid safety net.

            I’m not unaware of the escalating cost of healthcare and would love to devote a good part of my time to working on reforming our system so it is better for both patients and doctors and is sustainable. In my opinion, the root cause of the ever-rising costs is that profit-driven corporations (Big Pharma

  • Dr. Josh, AtlasMD

    thanks ;-)

  • Lisa

    Your comment about buying a pig in the poke when you buy insurance is only true if you don’t pay attention. When I chose my employer provided insurance, I was able to determine exactly what was covered. I read the plan hand book, which explains exactly what is covered and at what rate.

  • Dr. Josh, AtlasMD

    Hi JB, thanks for the comment. I want to address the point you make b/c it’s a very common and understandable concern.

    What has caused the physician shortage is the current model. The current model is what is burning physicians out (early and often) and is requiring more and more administrative effort which results in less time to see patients.

    I do NOT think that DPC will worsen the physicians shortage for the following reasons:

    1) improve job satisfaction to keep doctors from burying out, retiring, leaving the profession, retiring early etc.
    2) encourage medical students and residents to chose primary care settings like peds, family, IM, etc
    3) improved efficiency – a study showed that 22% of a doctors time is spent on non-clinical paperwork. Getting that time back would be like adding 165,000 physicians to the work force. And the projected shortage is only 50-100k.

    Also, how much cheaper would your insurance be if you were able to save money by not insurance primary care (ie not insurance gasoline). B/c primary care is very affordable to administer when you remove the red tape.

    • Arby

      I think savings are higher also for the reason that whatever your employer pays for your coverage they are not paying you. If I could opt out of my employer coverage and use that money to pay for concierge coverage, i would be far ahead of where I am now.

      I think people get used to “invisible money” and have no idea how people paying less into the system than what they are extracting is anything but an illusion of good coverage.

  • Lisa

    My plan hand book does say that maternity care is covered (from your example) and how many days of rehab care is allowable each year (again from you example). And it does warn me that it only covers medically necessary procedures, etc. Very specifically. It also lays out the appeals process. So I do know that it is necessary to get pre-authorization for non emergency procedures if I want to be certain they are covered. But I have not had problems getting them & I did not buy a pig in the poke.