Say no to bureaucrats and yes to direct care

Yes, it really is time to revoke the health care mandates issued by bureaucrats who are not in the profession of actual healing.

Daniel F. Craviotto Jr. writes in the Wall Street Journal, “In my 23 years as a practicing physician, I’ve learned that the only thing that matters is the doctor-patient relationship.”

Craviotto, Jr. is a doctor who embodies the fight of direct care. How we interact and treat our patients truly is the practice of medicine. There’s a problem with the rising cost of health care. (For starters, Oregon spent over $1,000 per subscriber on just a website to sign up for coverage that might not even provide a doctor.)

And there’s a larger problem when the individual physician in the trenches doesn’t have a voice in the debate. Bureaucrats are telling doctors what they can and can’t do.

And that needs to stop.

As a group, the nearly 880,000 licensed physicians in the U.S. are, for the most part, well-intentioned. Does anyone endure the gauntlet that is a residency program — 10+ years of training — to do anything except their best work?

Yes, the demands on physicians are great, and many of our families pay a huge price for our unwavering commitment. But shouldn’t our nation take great shame in knowing fee-for-service docs tack on 2+ hours of transcription every working day just to get paid, maybe, for the work they’ve already done?

How can bureaucracy, split between so many non-practitioners, own up to the cleavage of time that it brings upon the very people working to keep our nation healthy?

When do we say damn the mandates and requirements from bureaucrats who are not in the healing profession?

How do we stand up and say we aren’t going to take it any more?

For starters, we say yes to direct care.

We say, stop, every time a doctor joins the movement, every time a doctor pledges to make that transition (and makes a plan to help their patients through it).

We say it every time a patient says, “Give me affordable primary care.”

We say, stop, when we cut the red tape: Offer affordable services for cash, make insurance something that’s only used in real emergencies, and render EMR regulation and meaningful use incentives null and void.

The Centers for Medicare & Medicaid Services do say that fee-for-service docs have to use an EMR or they’ll be penalized with lower reimbursements in the future. Some meaningful use criteria from Medicare tell physicians what they need to include in the electronic health record or they won’t be subsidized the cost of converting to the electronic system and we will be penalized with lower reimbursements.

Meanwhile, keep in mind: EMR vendors are raking in the dough and saving us nothing.

Meanwhile, across the country, fee-for-service doctors waste precious time filling in unnecessary electronic record fields just to satisfy a regulatory measure.

Is that the best use of time for a highly-trained individual?

Physicians are tired — tired of the mandates, tired of outside interference, tired of anything that unnecessarily interferes with the way they practice medicine.

And as we know, physicians top the list of professions with the highest suicide rates.

Yes, we’re irrational humans. But we’re doctors, too. So let’s be scientific — saying that EMR machines are literally making doctors kill themselves is a stretch. But, if we have the data that says, “We work in a profession where suicide is common, and we promulgate activities that are totally meaningless, i.e. hours of transcription that could be spent with loved ones,” how is this ethical?

No other profession would put up with this kind of scrutiny and coercion from outside forces.

The legal profession wouldn’t.

Labor unions wouldn’t.

So why should we?

Josh Umbehr is founder,

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  • Kristy Sokoloski

    Dr. Jeff,

    How do you propose to go about helping the patients that won’t be able to afford to get to your practice because of it being direct care? There are going to be many, many patients that will never be able to afford to see you again because of the fact that it’s a direct care model.

    • Close Call

      Honestly, it’s really not the doctor’s job to do that. The task of making YOUR healthcare more affordable isn’t a burden a doctor should bear alone.

      If you want direct care to be affordable, you have to make your voice heard. Reach out your elected officials, talk to your insurance company, talk to your employer. If you have employer sponsored coverage, tell them how paying your direct care fee will save them money and save you from taking half a day off of work every time you get sick. Let your voice be heard, and fight for a system that’s better than what we currently have. A direct primary care’s fees are a maximum of $1200 a year…. why do you assume this has to be fully borne by the patient? Employers pay on average 5X that to an insurance company each year. You should demand that THEY figure out how to provide the direct primary care premium out of that amount.

      • Lisa

        There aren’t any direct care practices in my county (there are several concierge practices, another matter entirely). Even if there were, I don’t see getting my employer to paying a direct care fee on my behalf is going to save them money. Most of the cost of insurance is not for coverage of primary care, but for coverage for major medical expenses. I see what my employers pays for high deductible plans versus what they pay for a plan with lower deductibles like mine. The difference is less than the fees you mention.

        Some other things that I have heard about the doctors saying about direct care bug me. I can’t figure out the economics of it. How can they offer 95% off lab fees? I can’t figure how they can do that. My insurance pays the lab directly for any testing; my doctors office isn’t involved in the billing or collection of fees. I don’t see why the lab would give such a big discount to the patients of one doctor. There are a few labs around that offer testing directly to patients; they claim the prices are low, but to me they seem to offer a few standard metabolic panels and the prices seem high. I have similar thoughts about direct care practices dispensing drugs. State laws regarding the dispensing of drugs differ, but the laws do seem to have one thrust – that the doctor shouldn’t be profiting from the sale of the drug.

        • Dr. Josh, AtlasMD

          Lisa, i’m sorry that you don’t have any DPC doctors in your area so that you can see it working.

          How can we offer these discounts? Very simple – we don’t have the red tape. We do a ‘physician purchasing contract’ with the labs which is a standard practice. Now the lab gives us a discounted rate b/c they are paid for 100% of services w/o any additional paperwork. Unlike the coding, filing, refiling and lost reimbursement that is common when labs are billing insurance companies.

          So its ok for the pharmacy to profit off of the medicines but not the doctors? I’m not sure what kind of logic that is…Regardless, we don’t profit off of the medicines b/c we’d rather have our patients trust.

          • Lisa

            I think the proble, from the point of view of the lawmakers, doctors profiting off medication is that may lead them to prescribe unnecessary medication.

          • guest

            Lisa, I think you are perhaps unaware of the fact that insurance companies are routinely (and fraudulently) denying claims and that getting a claim paid these days can require several hours of work on the part of a dedicated staff person.

            Patients are unaware that this is going on, since the burden of dealing with their insurance company has been removed from them, the insurance company’s customer, and placed onto the doctor, who has no leverage at all with the insurer.

            If “paperwork is part of doing business,” then perhaps patients would like to take back that part of the business? After all, that’s the way it used to work.

          • Lisa

            Everytime I see a doctor, for anything, I have to sign an agreement that I will pay the charges if my insurance company does not pay. In past six years where I have been a ‘frequent medical flier,’ I have been aware of one problem with the payment of a claim. This problem involved payment for a test that was 1) relatively new and 2) expensive. I knew before hand that my insurance might not cover this test. All other surgeries, procedures and physical therapy, durable medical equipment etc. were preauthorized. I don’t think the preauthorizations were that hard to obtain as I recieved notice of approval within several days.

            I sat with my doctor once while he requested pre-authorization for an MRI. I knew how much work was involved. Not hours for sure.

            I’d take back handling insurance claims for smaller, routine charges. But I couldn’t afford to pay cash for larger claims, such as surgery. No one I know could.

            One of my friends just had surgery. She reviewed her bill and found errors in the bill, for drugs and services she didn’t receive. Perhaps some of the problem with insurance billing is on the provider’s part and not on the part of the insurance company.

          • Dr. Josh, AtlasMD

            Lisa, i think that your experience as a patient is an N of 1. You’re not seeing that world that most physicians are living and working in where they are drowning in red tape and bureaucracy. If you good insurance, it may not be hard to schedule an MRI. If a doctor is working with a patient that doesn’t have good insurance, it could take hours and still not get approved.

          • Mike Henderson

            It has been my experience that insurance companies deny claims frequently and without just cause. What “guest” is saying is that staff spend many hours weekly dealing with all of the prior authorization, rejected claims and other miscellaneous busy work – this doesn’t cost the insurance companies anything and thus is of no concern to them. Its not just any one thing, its the multitude. Insurance companies have the coding and billing system balanced heavily in their favor.

            My experience with calling to get a preauthorization is maddening. You call the number, listen to the messages, hit the buttons, wait, hit more buttons, wait and then speak to someone with a high school degree – its just a bunch of hoops to discourage us from ordering what we think should be done. Therefore, when they wear us down, we just don’t offer patients those treatments.

          • Dr. Josh, AtlasMD

            Mike, i believe that your experience is more on par with that of most other physicians.

          • LeoHolmMD

            If people saw what was on the other side of the curtain, they would go DPC.

          • Dr. Josh, AtlasMD

            Amen. One of my favorite quotes is:

            “If it can be destroyed by the truth, it deserves to be destroyed by the truth.”
            ― Carl Sagan

            So its our duty as physicians to help patients understand and see what is wrong With the current system. True doctor patient advocacy means continually improving the system so that patients get better, more affordable care.

      • Patient Kit

        Many employees have little to no negotiating power with their employers and are in no position to “demand” anything of their employers. Also, if employees are lucky enough to receive any health insurance as a benefit from their employer, you can’t assume that switching to a purely catastrophic plan is the best thing for all employees, depending on their particular health status and needs. With some big employers, employees have a menu of healthcare insurance options to choose from. But with most medium and smaller employers, employees don’t have a choice about what insurance plan their employer offers. There is a tension between employees who need more inclusive coverage and those who feel like they don’t need that (until something unexpected happens, of course, and they suddenly do need more coverage than that bare bones catastrophic plan). I’m just saying that it’s not as easy as you make it sound for your patients to just “demand” that their employers pay their DPC membership fees.

        • Dr. Josh, AtlasMD

          Demand? I’m not sure who said that.

          Its a free market and we can’t demand any one pay us. But we can sell a product that we think is a better value at a lower price. We are free to present our ideas to employers and if they like it b/c it makes sense for them, then they are welcome to purchase it. Simple.

      • Dr. Josh, AtlasMD

        Well said Close Call! In fact we work with many employers who pay the full amount each month for their employees (our corporate rate is $50/all ages).

        We also help the employer by lowering their insurance by decreasing the amount of coverage that is required to get the same level of care.

        Wholesale meds and labs are a great example of this b/c we can often save up to 95% on these services and thus remove that from their insurance plans for great savings w/o sacrificing quality.

    • Bubba Punk

      Is it fair that some people grow bald faster, that some people grow up in single parent homes where the mother/father doesn’t read to him/her at an early age, that some people don’t make as much money as others, that some people don’t have the “right look” to be good at sales, that some people are shorter than average, that some people are overweight and have trouble losing it, that conniving manipulating people are more likely to get promoted? Of course not. But life isn’t fair. And we all just need to get used to it.

      • Patient Kit

        So, what then? We should just accept many Americans having little or no access to the medical care they need? We should just accept that not all Americans with cancer can be treated? In my experience, when people advocate for just accepting such blatant injustice, it’s usually coming from people who’ve got what they need themselves.

        • Dr. Josh, AtlasMD

          I think the point is to fix what we can and then move on to the next thing that we can fix. You don’t eat an elephant one bite at a time.

          Example: airbags as a life saving device were so expensive when first introduced, that they were only available in top end cars. Now they are Available/required/affordable on almost every car.

          If we can make health care affordable for 80% of the population, that will in turn help drive the cost of care down for the other 20%.

          • Patient Kit

            At this point, I’m having a hard time seeing how direct pay/cash only doctors will be better for 80% of the population. I guess I see it more as one more example of the widening division between the haves and have-nots in this country.

            Two populations that I don’t see this being good for are (1) those in lower socioeconomic classes like the working poor who are not quite poor enough to qualify for Medicaid and don’t have much cash left over after food and shelter and (2) those with serious medical histories who need to pay for more expensive low-deductible insurance anyway. Millions of people fall into one or both of those demographics.

            I’d love to be wrong about this and my mind is still open to it, which is why I am here talking about it. But my gut instinct tells me that a lot of people will not benefit if the majority of primary care ever switches to direct pay. I can see it working for some, more as a niche model. But, if you’re talking about 80% of the population, you’re talking about wanting most primary care to switch to direct pay.

          • Dr. Josh, AtlasMD

            Kit, cheaper, better, more accessible medical care that results in cheaper, better insurance is clearly better for 80% of the population.

            a) in your scneario the working poor that can’t afford food/shelter would qualify for medicaid and thus be covered.

            b) the other mistake is to assume that people with serious medical history would be better off with a low deductible plan. The plan they can afford is the best plan for them. And if a doc can help them get the care they need for a fraction of the price, then that means more $ to use elsewhere in their lives.

            And yes, i think that 80% of family doctors should be in a DPC model b/c i see how it benefits my patients.

          • Mike Henderson

            There is tremendous waste in the system and for many different reasons, many of which are due to insurance companies and the legal system. For example, a gore tex graft to fix an aortic aneurysm costs several thousand dollars. I observed a surgeon cut off less than 1/3, with sterile technique, and had to throw the rest away. Medications, labs, imaging and diagnostic tests are much higher than they need to be. Physicians have a behind the scenes view of this – which is why we are convinced getting control will reduce costs.

          • Dr. Josh, AtlasMD

            Its interesting to watch the effect of price transparency on the delivery and cost of care.

            With cost transparency you immediately give the patient/consumer the info they need to make better decisions.

        • Bubba Punk

          Well I don’t really have everything I need. I wish! I’m just saying that life is harsh. And we can’t just expect everyone else to fix all of our problems.

    • Dr. Josh, AtlasMD

      Kristy, Dr. Jeff makes a great point that many family docs will not be able to continue in their current practices b/c of increasing costs, burden, stress, red tape.

      Its better for each doc to stay in practice and focus on a smaller # than leave them all without a physician.

      But also, how many more people will be able to afford care when they are saving up to 95% on medications and labs with a DPC doctor?

      Also, many DPCs docs do a certain % of charity care or scholarship patients.

    • LeoHolmMD

      Perhaps negotiate with the doctor?

      • Dr. Josh, AtlasMD

        We try not to negotiate with each patient b/c its not fair to the other patients if someone is getting a unique rate. But also be/c we’ve worked to bring the price of meds, labs, procedures, imaging down as low as we can.

        That being said, we try to be aware of unique scenarios like scholarship patients who deserve assistance.

  • Lisa

    i beg to differ with you on that – uninsured patients are not well cared for.

    • p1doc

      I care for all pts the same. I don’t care one iota if they’re rich or poor. Therefore all the patients I care for receive good care.

      People who can’t afford 50 dollars a month are, once again, truly indigent. I treat such people all the time – so please don’t say they don’t get good care. They themselves pay nothing and their care is funded in one way or another by everyone.

      People who can afford 50 dollars a month but instead are forced to shell out hundreds of dollars a month for insurance and thousands of dollars for deductibles which they might not be able to afford – these are the self employed (like myself) who indeed have less access to medical care than the indigent.

      A direct pay model costing 50 dollars a month is accessible to anyone except the indigent. Most people spend much more on trivialities. To summarize: homeless – ER or dept. of health. Not homeless: pay 50 dollars a month for a doctor.

      • Lisa

        You may treat all patients the same, but getting medical treatment at the ER is not a good way to receive medical care for ongoing conditions and you are being not being truthful if you say that it is.

        Our county has a county run clinic and our state has expanded medciad, so someone who is indigent can get care. But what about the states that didn’t. I read the medicaid rules in Texas. Most adults, even dead broke adults, wouldn’t qualify.

        DPC does not do away with the need for insurance to cover major illnesses and injuries.

        • Dr. Josh, AtlasMD

          Lisa, DPC is not trying to say that we need to do away with insurance for major illnesses. Quite the opposite in fact. We’re saying that you should still have insurance for the big/expensive problems in life.

          However, insurance needs to function like insurance….ie insured risks. Look to car, home, life as examples of that.

          You don’t need car insurance for gasoline and you don’t need health insurance for 80% of the care that most people get.

          • Lisa

            I understand the reasons for insurance. My general attitute regarding insurance is that I insure items I cant afford to replace. I know, with my health history, I will probably a fair amount of medical care. To me therefore, it financial sense to purchase insurance that limits my out of pocket costs. I pay more on a monthly basis for this insurance but I have a good idea of what my expenses will be if I have major health issues. Belonging to a DPC and paying for a high deductible policy would wind up costing me more money.

            One other thing you all haven’t mentioned is how these policies coordinate with medicare. It seems like people would need medi-gap policies in addition to paying monthly fees for DPC.

    • Patient Kit

      Was there a comment here, now deleted, yesterday that said something like if patients can’t afford $50 for DPC they should go to a mental health clinic? What? Does not having money somehow equate with needing mental health care? And did the same commenter say that the uninsured are well cared for in our system? I swear, I read something like that last night but didn’t have time to comment.

      Actually, I had to step away from KMD for a few days and take a break from commenting. My phone was in danger of dying from getting wet because I found myself sobbing so much while posting here. If my phone dies a salty wet death, I want it to be from my beloved ocean, not from my tears. But like a bad penny, I’m back. ;-)

      • Lisa

        The comment was that along the lines if someone couldn’t afford $50 for DPC they must be homeless and/or indigent and could get good care at an ER or county medical clinic. Sigh.

        • Dr. Josh, AtlasMD

          Lisa, i didn’t see the comment. But DPC is not saying that it can fix 100% of healthcare. We are trying to fix what we can.

      • Dr. Josh, AtlasMD

        Welcome back Kit

    • Dr. Josh, AtlasMD

      Yes, b/c most doctors lose money on uninsured in the current broken system. But in this model they don’t lose money and instead are paid a fair amount to provide great care. Uninsured need DPC more than anyone else b/c of the savings.

  • Lisa

    Dr. Jeff is saying he will see patients for $50/month. Other doctors are quoting prices of $75/month of someone my age. Who says the costs will remain that low?

    I do not have direct care and I have never used an ER for the minor items you mentioned above, let alone an urgent care clinic. I’ve used my pcp for such minor items (except the kidney stone) who I can see on an same day basis if needed. I don’t take any medicaitons, but when I have they have been available as generic durgs and are cheap.

    My major objection to direct care is that it does not negate the need for catastrophic insurance. That is still expensive, has high deductibles and if the ACA is ever repealed would be unavailable to folks like me who have prior conditions. Most of my medical care for the past six years has been from specialists. But the total cost of that care is still less than the deductibles on a high deductible insurance plan.

    • Patient Kit

      I currently have Medicaid and I’ve never used the ER for anything minor either. In fact, during the 18 years before my year on Medicaid, I never used the ER while covered by Blue Cross except for once when I was admitted through the ER by my private practice orthopedic surgeon when my femur suddenly unexpectedly fractured while I was walking down the street (no trauma involved, there was an unknown tumor in my bone that caused the fracture). But I’ve never been to the ER for anything minor or for numerous things major even though I’ve never had DPC.

      • Dr. Josh, AtlasMD

        Hi Kit, yes and you’re like most patients who try to use the ER appropriately. However, a growing number of patients don’t have access unless they go through the ER.

        As an FP, i know when i work the ER, 80-90% of what i see is for basic issues that don’t require an ER visits. The ER is the most expensive way to get care and we want to help other patients avoid that.

        • Lisa

          The people who use ER for minor issues due to access issues will probably not be helped by direct care practices. ERs should be allowed to triage people and send people with minor issues to a clinic. Problem solved, imo.

          • Dr. Josh, AtlasMD

            EMTALA doesn’t let ERs triage patients away.

          • Lisa

            I know it EMTALA won’t let ER’s triage patients. I think the law should be changed and allow ERs to triage patients to a clinic, imo. But of course, you have politicians who say this country doesn’t need universal coverage because people can always go to emergency rooms and get any medical treatment so that won’t happen.

          • Dr. Josh, AtlasMD

            I think you just described medicaid.

          • Mike Henderson

            Minor issues are handled very well by direct care practices – they are clinics. DPC clinics aren’t overbooked. Therefore it is even easier to get a same day appointment for minor to urgent issues.

          • Dr. Josh, AtlasMD

            As are major issues b/c we have more time to spend with patients so we can take very complex patients and spend the time with them that they require. Not to mention cheaper meds, labs, procedures, pathology, imaging etc.

    • Dr. Josh, AtlasMD

      Lisa – The market will dictate the price and thats good for patients. I believe doctors will continually update their services to provide better care to patients to compete for business.

      A great example of how prices tend to go down, not up, is Dr. Mike with who we helped set up and his prices are actually lower than ours.

      Or even Dr. Jeff who’s talking about prices lower than ours.

      And again, I’d like to stress that DPC is NOT talking about stopping health insurance, but making it work better.

      If the majority of your care in the past 6 years has been from specialists, then you’re experience is different than the majority of patients.

      • Lisa

        I don’t go the doctor if I have a cold or other minor illness or minor injury. If I go the doctor, I am really ill or need a cast or stitches. Seriously, I was very healthy until I was diagnosed with non=agressive breast cancer that never caused any symptoms. Now I have ongoing health issues caused by surgery and drug side effects.

        I don’t believe a free market in relation to medical care is that good for patients.

  • Arby

    I can only hope to see more direct care offices in my area. If I knew of any now, I would join one in a NY minute.

    • Dr. Josh, AtlasMD

      Great to hear it! We’re getting a lot of interest from NY doctors. you can check out to look for a doctor in your area. Thanks for your support.

  • Lisa

    What my insurance company does for me is negotiate discounts with providers of medical services, including labs. regarding lab fees, I do not see how direct care practice can out negatiate an insurance compan. I just have hard time believing one doctor has more negotiating power than the insurance company. Same with radilogists. I can’t believe our local imaging center would agree to do an MRI for a cash patient for less than the price they would receive from an insurance company. They normally charge a cash patient more than what they charge people who have insurance.

    My copay for generic medications is $10 or less. It depends if on the drug. I’ve gotten scripts for antibiotics for $2. That said, I will agree a direct care practice might be able to offer patients cheap drugs if you stock a limited number of commonly used drugs. But based on my past experience, I’d have to be pretty sick to before that feature of a direct pay practice would be attractive to me.

    • Patient Kit

      Lisa, I too am having a hard time grasping how an individual primary care doctor has more power than a big insurance company in negotiating better fees for lab and imaging. Doesn’t everybody in healthcare being paid by insurance have the same chief complaint – that the insurance companies don’t pay them enough? I totally agree that insurance companies squeeze both ends, patients and healthcare providers, and the “savings” becomes bigger profits for the insurance co. But to frame it as an individual doctor having more negotiating power than insurance with labs and imaging is misleading.

      • Dr. Josh, AtlasMD

        Kit, i can help with that. It comes down to the ‘hassle factor’ and payment models.

        The insurance company requires significant man hours in staff to code, document, submit, claims that must then be handled by ins staff to read, evaluate, request re-submission (around and around this goes). All of this extra work and the ins may still decline payment.

        We order a test and guarantee payment 100% of the time for 100% of the charged amount.

        They are willing to take less profit if its easier profit.

    • Dr. Josh, AtlasMD

      Lisa, you may not be a customer for DPC. That doesn’t mean that others aren’t though. For example, my brother is bald…he has not use for a hairdresser…that doesn’t mean others don’t :)

    • Mike Henderson

      From a physicians point of view, the reason the supposed prices charged by providers is so high, is because they have to deal with insurance companies to begin with. The way this game is played is insurance drive up the cost of health care, then “negotiate” and take credit for supposed lower rates. Its smoke and mirrors. Insurance companies are the reason posted prices are so high. What patients need to understand is that cutting out the insurance companies is the only way to get to the true costs of providing care, which is lower than what the insurance companies negotiate.

      Insurance companies are acting like a true middle man – they have done a great job of convincing the public they are needed to protect patients from physicians, yet are the wolf in sheeps clothing. They absolutely increase your cost to see a physician and then manipulate your care, via that physician. That said, true insurance does have a role in the health care system, but not providing every little thing. As other physicians have pointed out, why does a patient “need” insurance to pay for pills that cost pennies?

      • Lisa

        Insurance spreads financial risk. The risk for conditions primary care doctors can treat is relatively minor, but the risk for conditions that can’t be treated by doctors is major. DPC is not going to touch the cost of cancer treatment or joint replacement (the two things I know about).

        • Dr. Josh, AtlasMD

          Lisa, again, no one is suggesting that DPC will directly change the cost of a joint replacement.

          It would be beneficial if you limited your comments to topics that your had a firm understanding of.

          Case and point, 75 percent of our health care costs are related to preventable conditions.

          Which means that PCPs are indeed more valuable than you’re insinuating.

        • Mike Henderson

          DPC isn’t supposed to spead the financial risk for cancer treatment or joint replacement. DPC, in my mind, is only about primary care physicians time and perhaps medications, labs and imaging prices at a cash price. You absolutely need insurance for the big ticked items. From my perspective, it doesn’t make any financial sense to pay your insurance company to pay me $60 for a visit – you have to pay the insurance companies 30% cut and what I get from the insurance company is reduced another 30% just getting paid. Pay me directly and you pay less and I get paid more with the additional benefit I don’t have to spend time making your insurance company happy.

          I’ll say it again – DPC isn’t intended to cover big ticket items as it is not insurance.

          • Dr. Josh, AtlasMD


            Cars: i pay for gas, tires, oil changes
            Car Insurance: hail damage, floods, accidents, injuries

            Homes: I pay for lawn care, paint, minor repairs
            Home Ins: hail damage, floods, accidents, fires

            Why would health care be any different?

          • Lisa

            I think DPC is a form of insurance. The difference is that the profit the insurance company made is now going to the doctor.

          • Dr. Josh, AtlasMD

            You’re wrong. You’re paying for a service; the doctors time, experience, skill etc.

            Insurance is defined as: a practice or arrangement by which a company or government agency provides a guarantee of compensation for specified loss, damage, illness, or death in return for payment of a premium.

            For DPC to be a form of insurance, than so would ever subscription/membership service like gyms, netflix, etc.

    • LeoHolmMD

      The government pays outrageous prices for absolutely everything. How is it possible they are being out-negotiated?

      • Dr. Josh, AtlasMD

        Lisa, you’re paying $10 for generic medications + the cost of your health insurance (divided into your portion and the employers portion).

        I get wholesale generics often for $0.01-2 a pill. Thats right, a penny a pill. So you should be paying 30 cents a month and instead you’re paying 3000% markup.

        • Lisa

          I get a lot more from my health insurance than generic medication and primary care. That is my point. Anytime I have received a medicine (other than a cheap antibiotic) I have also required a specialist’s care. The cost of the medication is minor compared to the cost of 6 biopsies (none of which could be done by a pcp), six surgeries, three MRIS, a bone scan, a CT scan, multiple x-rays, much physical therapy, treatment for lympedema (surgical side effect) and one hospitalization for cellulitis. So wholesale generic drugs are not enough to entice me.

          • Dr. Josh, AtlasMD

            The logical fallacy that you’re making is that your experience is representative of the average patient. You clearly are a high utilizer of care and as such are a great example of why health insurance (catastrophic or otherwise) is still valuable.

            You’re also confusing a solution for DPC as a solution for 100% of all care which is not what we explain it to be.

            We are championing DPC as a solution for a lot of care that a lot of people need. If you can’t see that others have different situations than yours, then we’ll probably just have to agree to disagree.

          • Patient Kit

            With all due respect, we were all “average” patients until that first bad diagnosis. In the system we live in now, it’s not just valuable to have good insurance. It’s necessary. I wouldn’t recommend that anyone just play the odds and hope they’ll just stay relatively “average”. I was very healthy for 20 years prior to a series of serious orthopedic injuries and then, out of the blue with no warning, cancer. People have to be covered for that possibility.

  • guest

    I’m lucky at my age I really don’t need to see a doc regularly (knocking on wood here). If I did, I’d sign up for direct care in a second. Same if I had a kid with a chronic illness. Real care takes time, something our current system is short on. I hope more and more people leave the traditional system and sign on to direct care.

    • Dr. Josh, AtlasMD

      Thank you for your support. This will be a grass roots movement led by patients who want better, more affordable care.

  • toolboxforwriters

    Excellent article. I am making the switch. Period. No choice. Heatlhcare is something sleazy, medical care is what I’ve been trained to give. Tangled web of agendas.

    • Dr. Josh, AtlasMD

      congratulations! let me know if i can help with anything. Best.

  • Patient Kit

    I think that’s a big assumption that most uninsured people who need an MRI (or same day surgery) will have all the cash at time of service. Many don’t have enough cash to pay the full fee before the service will be provided. Many of the uninsured are not uninsured by choice. They’ve been laid off from jobs that used to provide insurance. Or they work at jobs that don’t provide insurance and also don’t pay enough for employees to buy their own. What would you do with those patients who need an MRI but can’t pay the full fee in cash at time of service?

    Also, when you say the insurance co was charged $3,538 for tests that would have cost $400 with you, you don’t say how much the insurance co actually paid for those tests. We all know that everyone in medicine (doctors, hospitals, labs, imaging, etc) routinely submit severely inflated bills to insurance for far more than they know they will get from insurance. I’m not clear on exactly what you are comparing with the $3,538 fee for imaging and the $400 price they could get via you.

    • Dr. Josh, AtlasMD

      Which is why we don’t require the full payment from our patients for the MRI if we think they need it. We are here to work WITH our patients to help them get the care they will need.

      • Lisa

        And that will add to your overhead. Someone is going to have to handle your accounts recievable and make collection calls.

        • Dr. Josh, AtlasMD

          Actually it doesn’t. We’re able to do that with our current staff. Which is 1.5 FTE for 3 physicians which is about 90% fewer staff than most medical offices.

  • Patient Kit

    Dr Umbehr, first, I value my relationships with my doctors very much and I value doctors in general. I also hate the insurance companies as much as you do. The difference is: Unfortunately, in our current system, I and many other patients absolutely need that insurance. We can’t afford to just opt out of the insurance part of our system.

    I’m happy for you that direct pay is working out well for you and that you are happy with that model. But I think the enthusiastic, almost evangelical, tone with which some docs are presenting DPC as the answer to all of our healthcare system problems is misleading, both to patients and to docs considering making the change.

    I just read an interesting current (May 15, 2014) article on Medscape about the direct pay model in which three “experts” who have made the switch say it isn’t easy to do. They say many docs have unreasonable expectations and are shocked when many of their longterm patients don’t make the switch with them. So, they either lose most of their patients and must have a plan to attract many new patients or, commonly, they have hybrid practices in which 10% of their patients are DPC and 90% are traditional insurance patients. I can see how that hybrid model would bring in more revenue but it wouldn’t cut down much on the insurance hassle issues for doctors. And patients, who still need insurance for everything but primary care still have the costs and hassles of insurance too.

    I have no doubt that DPC is a good niche answer for some doctors and some patients. But probably not for most. You lose me when you start presenting DPC as a big sweeping answer to some very complex issues. There is a lot of loss involved — both docs losing their patients and patients losing their docs. I think that needs to be acknowledged.

    • Close Call

      I don’t think anyone is arguing that DPC and having insurance are mutually exclusive.

      DPC can be a great option if you are uninsured and you can’t afford the premiums on the exchange.

      DPC can be a great option if you are insured, but feel that you’re not getting the time nor the access to your physician. I’m sure you’re aware of this, but many physicians will compensate for the lack of time by ordering more imaging and labs.

      I disagree that DPC is not a good option for “most” people. >50% of the households in the U.S. have cable. >20% have satellite. Now what’s the percentage of those people who are insured? That’s a pretty big number. Are you saying that they can’t afford a DPC practice?

      Sure it may not work financially for you… but that’s okay. No one’s saying it’s going to work for 100% of population. But if you can afford cable TV or satellite…. you can afford DPC.

      • Patient Kit

        As long as we’re clear that DPC is an added expense on top of insurance for most patients. I have no problem seeing how it would get me more time with my primary doc, which I would love. I do have a hard time understanding how it would be less expensive for me, even in the “longrun”.

        I’ve only been in my current Medicaid/cancer position for a little over a year but I hope to get myself off of Medicaid asap. Previously, for most of my life, I had good healthcare coverage and access. When I move beyond this crisis point of my life, I am never going to forget the millions of people who are still stranded in horrible situations like I am right now.

        I’m always thinking about our healthcare system in two ways: (1) how to make it work for me right now so I don’t die a grizzly death relatively young unnecessarily and (2) how to reform our system to make it better for all patients and doctors going forward. I care about both passionately. But first, in real life triage, I have to find ways to survive this year.

        I think the value of DPC to individual patients also depends on whether it’s more important for them to see their specialists than the primary care doc.

        I agree that if people can afford cable or to smoke (@ $14/pack here in NYC), they can afford $50 a month for a DPC membership fee (although I question whether the fee would be that low here in NYC for a fiftysomething patient).

        For the record, personally, I don’t have cable (or any TV). I don’t smoke, own a car or a home. I don’t have a lot of extras to give up to redirect that money. I do have a smart phone and Internet access, which my sister is paying for for me because she knows it’s an indispensable tool since I am job hunting. A friend also bought me a YMCA gym membership because she knew that swimming is a lifeline for me physically and to help manage high stress. I wish I had been more of a materialist so I had tons of jewelry, etc to sell right now. But I don’t. The thing is — I don’t think I’m that unusual. There are many patients that don’t actually have the extra money for DPC.

        So, as long as we’re not talking about DPC as a simple answer or something that will work for everyone or even most people. As long as it’s just a niche option for those who can afford it, I’m okay with it. I would not be okay with all or most primary care going DPC. I don’t think we’re anywhere near that happening though, thankfully.

        • Mike Henderson

          “As long as we’re clear that DPC is an added expense on top of insurance for most patients.”

          RIght now, you are correct – DPC is an added expense to catastrophic insurance. This is where we are painted into a corner. From my perspective as a physician, primary care needs to get back the control we have abdicated to the insurance companies. A lot of what I learned in the last year of residency, was figuring out when not to do something – doing nothing can be a very difficult decision to make. When it comes to costs, primary care physicians do not have the time to thoroughly evaluate patients to determine what they really need and we provide “shotgun” medicine and over order tests, and referrals to specialists for things we really are capable of handling but need more time. I have referred patients to a specialist just so the specialist could explain more thoroughly what I didn’t have time to explain.

          My perception is that over time and with enough primary care physicians and patients in DPC, that overall insurance costs would come down. So it does make sense that those patients with more income start first. In the current system, we are not practicing to our full capability and are adding to the inefficiency and waste due to lack of time.

          • Dr. Josh, AtlasMD

            Indeed, DPC is and will continue to be a way to decrease the cost of insurance.

            Its great if i can save you $50/mo in prescription costs but its even better if i can save an employer $300-500/mo on premiums.

            So DPC isn’t actually an expense “on top of” but rather a path to better/cheaper health insurance.

  • Lisa

    Imaging centers will drop their fees for cash paying patients, but they will not negaotiate that much – at least not in my area. I sldo know that what insurance companies are charged for tests, imaging etc, bears no reality to what the insurance companies pay.

    • Dr. Josh, AtlasMD

      Yes, this goes back to the physician purchasing contract i mentioned previously. Doctors can get a better discount than most patients b/c of these contracts.

  • EmilyAnon

    I don’t find that cash pay always offers a significant discount. I was charged a $750 facility fee for having my colonoscopy in a hospital rather than a surgical center. I naively didn’t know I had a choice in the matter or that my insurance didn’t cover hospital outpatient stays. When I called the hospital billing office, I was offered a 20% discount if I paid in full that day. Maybe hospital cash pay policy is different from surgical centers, but it’s not as generous a discount as you describe.

    • Dr. Josh, AtlasMD

      We are able to get a colonoscopy for about $800 total cash price – but again, we’re able to get more aggressive discounts b/c of cash contracts.

      Thats one of the many values of a DPC model.

  • Margalit Gur-Arie

    When you say that “DPC does not answer to investors”, I assume you exclude corporate chains of cash primary care, such as MDVIP and Qliance, funded and owned by venture capital or private equity, from the definition of DCP. Is that correct?

    • Dr. Josh, AtlasMD

      I guess i reject the premise that investors is a bad idea. Investors are at the heart of countless great products and inventions.

      Qliance may have investors but their prices are similar to ours and we don’t have investors.

      As long as they are helping advance the cause of affordable, accessible care, i see it as a benefit. It costs a lot to get a practice off of the ground and many physicians don’t have that kind of capital.

      • Margalit Gur-Arie

        I make no judgement here about the badness or goodness of the idea. I just wanted to point out that some “direct” care does answer to investors and perhaps “direct” is an incorrect description for those practices, particularly when doctors are salaried employees, and even more so when the payment is provided by an employer to the corporate entity.
        It may very well be a great idea, but it is not “direct” pay, and it probably shouldn’t be advertised as such.

        • Dr. Josh, AtlasMD

          How does an investor change whether its direct pay or not?

          • Margalit Gur-Arie

            You are paying the corporation, not your doctor, and the corporation pays the doctor. How is this materially different than say paying Kaiser?

          • Dr. Josh, AtlasMD

            I think thats a misinterpretation. A grocery story, gas station, walmart are all “direct pay” b/c you’re paying directly for the product with out an artificial middle man like a 3rd party payer.

            The term direct signifies that there are only two parties involved: the patient and the provider (or the company hiring the provider) and no third party payer that requires consultation and can approve or deny.

          • Margalit Gur-Arie

            I don’t think the Kaiser model involves a third party payer, and there are other health systems that are offering to sell prepaid health services directly to people or directly to employers. Some are excellent (from what I hear).
            And, at least around here, there are prestigious health systems (academic) that offer cash only services, including ongoing primary care. So the lines are pretty blurred if you look at things this way.
            When I think of direct primary care, I think of a transaction occurring between two people, sort of like it used to be a long time ago. The mom & pop doc and the patient.
            All those other models are confusing the issue (for me).

          • Mike Henderson

            The payment may not be directly from the patients’ hand to the doctors’, but is certainly more direct than from the patient to the insurance company, to the corporation that pays the doctor. Using Kaiser as an example, Kaiser is not DPC. The difference between Kaiser and a DPC with investors, like Qliance, is the relationship between the physician and the investors. Years ago, I went to the Kent WA Qliance, just before it opened, and met Dr. Erica Bliss. This is a physician-centric clinic. We went through everything they did, and so far as I was concerned at the time, there were absolutely no barriers from the investors to getting the docs what they needed to practice at the top of their license. The building was smartly designed, appropriately equipped, and, while not remembering every question I asked at this point, it was clear they were doing everything possible to provide an environment I could only dream of working in. Based on what I saw, would argue that investors were helping their physicians do their best. While only knowing about Kaiser from physicians who have worked there, would say the differences between Kaiser and Qliance make them very different from each other. But I acknowledge your concern when it comes to investors – they should have no influence on the care patients receive, and Qliance seems to have found that balance.

          • Margalit Gur-Arie

            That’s good news. I am glad Qliance is doing well for the doctors it employs. Time will tell if those investors will stay out of patient care or not. Hopefully they will….

          • Mike Henderson


          • Dr. Josh, AtlasMD

            Thats the difference b/w a successful company and an unsuccessful company.

            If investors get involved in the wrong way (true for any business) then it will fail to help the consumer and fail financially.

            If investors get involved in the right way (ex apple) then it will continue to thrive and create value. It will make better products for a lower price each year. That is a business model that would help patients to thrive. Lets hope for that :)

          • Margalit Gur-Arie

            Sure, yes, let’s hope, and pray too….
            But :-)…… if I personally had to pick one, I’d pick the 100% independent, plain and unassuming community doc, any day, any time, with/without technology, with/without insurance, preferably without fancy alternative/wellness stuff, with/without labs/drugs…. and most definitely with admitting, and seeing his/her own patients in the hospital…. and I’d be happy to pay extra for that, and only for that.
            So let’s hope that we have some of those left standing too…. for skeptics like me :-)

      • Patient Kit

        “Invest” and “investors” should not be the dirty words that they have become. You, for example, invested a lot of time, effort, money and your youth in becoming a doctor. I have invested a huge chunk of my life working in the nonprofit sector working to help empower exploited people. I’m sure we’ve both invested plenty of our hearts and souls in our personal relationships. Someone has a good idea but little money, so they find investors who believe in that idea to help make it happen. Theoretically, investors should be a good thing.

        Unfortunately, corporate and private equity investors have corrupted the word so much by too often sacrificing everything else –employees, customers, safety, community, environment — for the sole aim of increasing their profits to the max, often as quickly and brutally as possible.

        So, yeah, “investor” is a funny word that could be a good thing or a bad thing, depending on the attitude with which it is done.

        • Dr. Josh, AtlasMD

          well said!

  • Lisa

    Leaving the administrative burden out of it. I think the cost of providing an MRI is more than $350. The last time I had an MRI it took over hour, so that meant one hour of a technicians time, the radiologist came in to inject some contrast material in addition to the time spent on the report. Add up the cost of the facility, the cost of the machine, front office staff to make my appointment and run through the procedure with me and I have trouble seeing how a business could make money if they sell an MRI for that amount.

    Many people I know do not have $350 in cash to fork over for an MRI, they do not have health savings account. Well, I geuss they can whip out their overburdened credit card and pay interest.

    As I have said before I think direct patient care will work for some segment oft he population, mostly those who are better off, but it will not work for many people. And I think many of the models being touted are not realistic. The numbers just do not add up to my accountants mind.

    • Patient Kit

      According to the recent Medscape article, “Cash-Only Practice: 8 Issues to Consider” (5/15/14), it has largely been more financially well-off patients who have been the early patient supporters of the DCP model. And it’s not hard to understand why. The article says it’s been hard to sell the concept to many patients, including many Medicare patients.. Again, not hard to see why.

      I think it’s telling that in this thread and in others about DPC here on KMD, the supporting commenters are
      mostly doctors and the doubtful commenters are mostly patients. I agree that DCP could be good for many primary care docs and some patients. But I do not see it as the model that is going to save us all in this dysfunctional system going forward.

    • Dr. Josh, AtlasMD

      You’re basing the cost of an MRI on what you “think it might cost”. Thats not the best metric.

      I can tell my patients the exact cost of their MRI before i order it for them and depending on the body part, $300-$450 is our average price.

      • Lisa

        I am an financial analyst, so of course I am going to try and figure out if your numbers make sense. I just don’t see how the imaging center is going to make money at the prices you are quoting.

        • Mark

          Lisa, the imaging center that we use did over 60 million in revenue last year, and they are salivating at offering cash prices. I do not know the overhead of there business, but can assure you that an MRI for $350 is what the patient pays. I guarantee that the imaging center is not doing us a favor by “giving” us a cash price. They understand the true cost of imaging, techs, overhead, and time in regards to cost.

          I would agree completely on your concept that DPC is not for everyone, but if you do not work for a large company that offers exceptional paid benefits then this is a viable option.

          In regard to cost for medicare patients, even at $100/ month, the fee usually pays for itself when you average the medication saving they receive in a DPC model, and now they have 24/7 care as a bonus.
          Considering that medicare patients are being squeezed out because doctors can no longer afford to take care of them due to re-reimbursement rates; whats your solution?

          It just seems that some people are going to complain about everything unless it’s free instead of actually taking responsibility for their health.

          Do you complain about paying for car insurance monthly and getting nothing in return unless your car gets wrecked?

          Do you get offended when you go out for dinner; they give you a bill and there is no negotiating the price?

          Do you feel that you should have skin in the game when it comes to healthcare?

          Do you think doctors should get paid for the services they provide?

          I Think that people are very quick to point fingers at the “greedy doctor” and the media has done a good job of feeding the frenzy.

          I mean $10-$100/ month, depending on age, is not a large price to pay for healthcare considering most people pay over $250/month for insurance and do not have a doctor!

          The wonderful thing about America is you have choices and can exercise those choices anytime you like.

          I choose DPC!

          • Lisa

            I would prefer tax financed single payer health care to DPC. As has been pointed out in these discussions, many people will not be able to afford DPC. To my mind, it is wrong to exclude whole classes of people from being able to get medical care.

            I do work for a large employer and do have good insurance. I pay for a portion of that insurance, but if I lost my job, I doubt I would be able to pay for DPC over and above the insurance I would need for major medical care.

          • Dr. Josh, AtlasMD

            DPC wouldn’t change that much in a single payer system b/c the gov’t simply can’t afford to pay for all of the care and all of the red tape, paperwork etc w/o raising taxes too high or limiting the care people receive.

            Even in a single payer / ACA Environment they’d still benefit from the $$ savings of a DPC practice.


          • Patient Kit

            Lisa, I agree. I’m in favor of a tax-funded single payer system too and so are many people/patients that I know. Admittedly, I tend to run with a liberal crowd. I’m convinced that we won’t be rid of the ever escalating problems of our Big Health system until corporate profit is no longer the main driver of healthcare in America.

          • Mike Henderson

            There are certainly strong advantages to tax funded, single payer system. Collecting via taxes is relatively inexpensive, everyone has coverage, and one payer means one set of rules. Kind of like schools – tax funded and everyone gets to go, and all of society benefits from an educated workforce.

            If Medicare is the example of a single payer system, as it basically covers everyone above 65, then what is concerning is that Medicare is even more abusive than the private insurance carriers. I work with vets, and avoid bringing up the VA clinics – they can have neutral to adequate experiences, but frequently get angry when reminded of the care they get. I do hear from physicians that the system isn’t too bad, but still not a shining example of single payer/single provider system. The idea of Medicare for all makes me even more nervous than insurance companies.

          • Dr. Josh, AtlasMD

            I think your example of schools doesn’t help strengthen your argument for the benefits of a gov’t monopoly.

            Schools are infinitely less complicated than healthcare and the gov’t is failing at schools….the post office..etc

            In most states, the K-Undergrad funding takes 50-60% of the total budget…more in some states.

            The state is demonstrating that they can’t run health care currently. I’d be afraid to see what would happen if that had all the cards.

          • Dr. Josh, AtlasMD

            Beautifully said!

            I don’t have car insurance to negotiate the price of gasoline b/c the market en masse ‘negotiates’ the price of gasoline to make it affordable.

            In the same way, we bring the cost of most lab tests down to $2 or $3 by cutting red tape.

            We function like a pharmacy to purchase medicines wholesale (ie pre retail mark up) and can out compete walmart’s list price for meds.

            Thats how the free market helps patients :)

          • EmilyAnon

            “We function like a pharmacy to purchase medicines wholesale …”

            How does this work if the patient needs chemotherapy drugs. One infusion session at my hospital is billed at $20,000. Insurance pays about $2,000. You can negotiate lower than that?

          • Dr. Josh, AtlasMD

            Well b/c we’re family docs and not oncologist, we’re not ordering or prescribing chemotherapy.

            We are trying to fix what we can but don’t pretend to fix everything like chemo, tramua, neurosurgery etc.

          • EmilyAnon

            Thank you for your reply. I’m very fortunate with my oncologist as he’s been like a PCP for a few issues that I thought might be cancer related but turned out to be something else. He caught my appendicitis and arranged a general surgeon to see me with instructions to inspect for possible hidden cancer recurrence (a laparotomy was peformed due to severe adhesions from previous open cancer surgeries) I know it was above and beyond the call of duty and I was so appreciative. He’s been in my care for almost 8 years and the thought of losing him…..well, I can’t even think about it.

          • Patient Kit

            I was just wondering the same thing. What if a direct pay patient needs some more expensive medication — like chemo or any other expensive med? Would catastrophic insurance pay for that? How would that work with DPC?

          • Dr. Josh, AtlasMD

            yes, that is why we encourage (not require) a major medical type insurance plan so they will have coverage for the car wrecks, cancers, heart attacks etc.

            That would work very well with DPC.

          • EmilyAnon

            I know I’m so fortunate to have insurance right now through my work, but who knows if that will change. I could lose it due to lay-off or the cancer advances that I can’t work anymore. But I do know I will need specialist care for the rest of my life, which means if I lose my insurance DPC would be a luxury and catastrophic insurance a necessity. I get a knot in my stomach thinking what night happen if my current insurance coverage changes.

          • Dr. Josh, AtlasMD

            Emily, what if the DPC doctor made your insurance cheaper so that you could afford both?

            What if your specialist was a direct care model and helped you get the same level of care for less money? Wouldn’t that be something worth exploring.

          • EmilyAnon

            Yes, of course that would be very tempting. But as I stated in another comment I currently have good insurance coverage through my work with small co- pays. If that status changes it’s good to know there are other avenues to pursue. I hope I don’t have to re-mortgage my house to maintain 2 insurances. Will somehow deal with it if/when I have to. Thanks.

          • Dr. Josh, AtlasMD

            Fair enough. But also we’d want to help your employer make your good insurance 1) better and 2) more affordable.

            An ERISA style plan for your employer, in combination with a DPC can see 30-60% savings w/o affecting the quality of the insurance.

            Thus, you’d have great care with a DPC practice, great insurance with an ERISA style plan AND more money in your pocket.

            It does sound too good to be true and i respect that. But its reality for a lot of our patients.

          • EmilyAnon

            In my sitution, it’s more than just an employer but
            an industry healthplan that covers us. I understand there are 60,000 current and retired members under my plan, The Industry Health Network is an umbrella covering many trades, all union members. We just received notice that UCLA has bought out the plan, and that there will be changes at the end of the year. We’re all suspicious and expect the changes will not be in our favor.

          • Dr. Josh, AtlasMD

            I can understand that concern. I know it sounds odd for a doctor to say this, but we need to make insurance profitable if we want to see improvements in insurance products.

            UCLA may cut benefits as a way to control costs which ultimately hurts the patients.

            We are working with ins carriers to see that DPC allows them to be sustainable and even profitable w/o cutting benefits. Maybe even increasing them!

          • Patient Kit

            You’re right — It is odd to hear a doctor, in our current healthcare system mess, express concern about making sure insurance is profitable for the insurance companies. I think the insurance companies have proven themselves more than capable of taking care of themselves and their interests.

          • Patient Kit

            Believe me, Emily, I feel your fear. I’m living that nightmare right now. Layoff followed by loss of insurance followed by OVCA dx followed by eviction notice. Talk about PTSD! Yesterday I actually blanked on my own home address, an apartment I moved into 13 years ago. I actually gave someone the wrong address and I see it everyday on my resume since I’m job hunting. I’ll never forget that move since it was during 9/11 with the ashes blowing through my previous apartment as I packed. Who knew things would get so much worse than that? I know that you’ve been through a lot, healthwise. I hope you never have to go through what I’ve been through, healthcare systemwise.

          • EmilyAnon

            Kit, knowing your story and other patients who post here makes me so aware of my blessings. But things change, and not always for the worse. One blessing in your hat is that your cancer is early stage. But even if you recur, it’s not the end. I’m still around 10 years with late stage cancer and a recurrence with good QOL. And I’m sure we’ll both still be here commenting on this blog on your 10 year anniversary, hopefully with insurance problems resolved.

          • Dr. Josh, AtlasMD

            I sure hope so!

          • Patient Kit

            Thanks, Emily. In spite of how difficult and scary this last year has been, I do know that I am truly blessed. Cancer found early stage, wonderful doctor, just got my latest CT scan and lab results back and still NED. it’s been hard enough adjusting to the cancer sword hanging over me all the time, but especially difficult during such unstable times, both personally and healthcare systemwise. You are a true inspiration to me. I, too, hope we’re both still alive and kicking in another ten years.

          • Dr. Josh, AtlasMD

            boy thats a lot to go through, well all wish you the best.

          • Lisa

            Catastrophic insurance usually means a high deductible policy.

          • Dr. Josh, AtlasMD

            Does it? Less look at an example.

            A full coverage plan for a family of 4 could cost 12k/yr with a $500 deductible ($12500) with after tax income.

            A catastrophic plan could cost $4k/yr with a 5k deductible. ($9k).

            The family has the opportunity to save 8k/yr but at worst would only be out 5k in deductible and still have 3k left off.

            If they used their HSA they could see a greater savings b/c an HSA uses pre tax income.

            So its a fallacy to say that a catastrophic plan is worse b/c it has a high deductible.

          • Lisa

            All I said, in reponse to Kit, is that catastrophic insurance usually means a high deductible policy.

            I actually think high deductible plans make sense in many/some circumstances, if the insured can afford the deductible. The plans probably don’t make sense for people like me, with high medical costs and employer provided insurance. My large employer offers three or four plans every year. One option is a high deductible plan tied with an HSA. But the employee has to contribute to the HSA; my employer does not make contributions. There are several options that involve flavors of HMOs and then there is the option I choose, which is a basically a PPO with no to low deductible and the option to pay more for out of network care. I like that feature a great deal. My contribution for this plan is about $100/month, while my for a contibution for a high deductible plan would be zero (pluis contributions to a HSA).

          • Patient Kit

            I can only hope that my next employer gives me similar choices. I’d pay for the good PPO plan in a heartbeat. The BC plan I lost right before my cancer dx was a PPO plan that sounds much like yours. My employer paid the full premium but I would gladly contribute to the premium cost. To that end, I’m concentrating my job hunt on big employers like big university systems and, god help me, the city of NY.

          • Patient Kit

            High deductible insurance would be a nightmare for me right now, as I attempt to start completely over financially from square one with zero money in the bank. It would basically mean that I would have to avoid going to the doctor unless it was a true emergency and absolutely necessary.

          • Patient Kit

            When I COBRA’d my Blue Cross plan after my layoff, I paid the full premium of $700/mo to continue it for as long as I could (and that was before my ovarian cancer dx, which inconveniently happened after I lost the BC.) It was expensive for an individual policy but it covered everything and there was no deductible. Access to good medical care is an important priority to me, so I paid it. I don’t have cable TV, btw. My health is a much higher priority than TV to me. Just wanted to say that, just because I’m not convinced about DPC, it doesn’t mean that I want doctors to work for free or that I don’t think I should have to pay anything for healthcare. Even this one year on safety net Medicaid (which truly did save my life), I paid for dearly in 35 years of paying heavy taxes. I would not like to have to pay extra on top of that $700/mo premium for primary care.

          • Dr. Josh, AtlasMD

            Oh ok i think i see the problem. The misconception is that this would be $700 per month for insurance plus $50 for the DPC.

            Actually, for most of our clients, it would be more like $500 for insurance plus $50 for the DPC. This is directly due to the savings that DPC can offer.

          • Patient Kit

            Hopefully, this is why we keep talking to each other, even when we passionately disagree about something — to try to understand each other’s POVs and correct any misperceptions.

            For me, I’m guessing that a DCP membership would be closer to $100/mo based on my age (fifties) and my location (NYC) where the cost of everything is higher (rent, labor, etc).

            But, yes, I’m assuming that would be in addition to a fairly high monthly insurance premium, be that $700 or $500/mo. What gets cut out of an insurance plan to cut $200 from the premium? If you get insurance from your employer, you often don’t have much input about what kind of plan you’ll have unless you work for a very big employer with a menu of insurance options to choose from. But hopefully your employer pays a big part of the premium.

            If we buy our own individual plans, we have control over what kind of plan we have. I’ve never had catastrophic insurance? What exactly do they usually cover and not cover? Obviously, a catastrophic plan would not cover primary care docs but would cover surgery. What about specialists? Do most catastrophic plans cover all specialists?

          • Dr. Josh, AtlasMD

            We are able to decreae the insurance premiums by several hundred dollars per month b/c of improvements in price and efficiency.


            Prilosec (for heartburn)
            Retail Pharmacy: ~ $225
            Atlas MD generic: $1.50

            Keppra (for seizures)
            Retail Pharmacy: ~ $400
            Atlas MD generic: $4.00

            Topamax (for migraines)
            Retail Pharmacy: ~ $130
            Atlas MD generic: $2.00

            Arava (for arthritis)
            Retail Pharmacy: ~ $1,000
            Atlas MD generic: $10.00

            Same is true for labs that we get for pennie on the dollar. Cholesterol panel $3, CBC, $2, TSH, $3 etc


            Also, our unlimited visits and no copays means patients don’t let conditions get worse and its easier to manage their conditions.

            All office procedures are included free of charge — benefiting patients and saving their employers and insurance companies.

            List: ekg, holter, spirometry, dexa, ultrasound, cyrotherapy, audiometry, medical laser treatments, lesion removal, biopsies, joint injections, laceration repair, minor surgical procedures, UTI testing, Rapid Strep throat Testing…

            Also key is that we don’t submit billing claims to the insurance for office visits, procedures, testing, labs, copays, imaging, pathology, etc b/c they are all made cheaper via the DPC model. That reduces administrative cost for the physicians, employers and insurance companies.

            i hope that helps explain how we can help lower insurance premiums.

          • Dr. Josh, AtlasMD

            oh and yes the major medical plans we help employers get do cover specialists with a copay and surgery, hospital, chemo etc. The works.

          • Patient Kit

            So, for example, if I fractured my femur or ruptured my Achilles tendon (both of which I unfortunately did), catastrophic insurance would cover orthopedic specialists and physical therapy as well as the surgery? My pathologic femur fracture (benign bone tumor, no trauma) took 2 years before it began to heal and while I was a mystery zebra, I saw 5 different orthopedic surgeons before I was solved.

            Also, where does gynecology fall in the DPC/catastrophic insurance model? Are GYNs covered specialists even when you aren’t in the middle of a GYN catastrophy? Or would they also be direct pay/cash only?

            I have lots of questions. Hopefully, my questions will help you get a good grip of the concerns about your preferred healthcare model from some patients’ POV.

          • Dr. Josh, AtlasMD

            Those exactly the kind of major (but thankfully) rare events that would and should be covered by insurance.

            Gynecologists are often the primary care physicians for a lot of women’s health so a DPC model would be ideal for Gyn. Also, there’s an OB model for DPC that works very well.

            As board certified Family Physicians, we do a significant amount of women’s health in our DPC model.

            We often help patients who’ve seen multiple docs and are able to help b/c we have the most value commodity available in medicine: time. Time to listen. Time to review old records. Time to consult each other. Time to work with the patient.

          • Patient Kit

            I could be understanding incorrectly, but it sounds like DPC docs envision doing quite a bit of what specialists do now. I’m not sure how I feel about that. I love some of my specialists and trust them with my life. I wouldn’t want to have to stop seeing them and see one primary care doc instead. Maybe this is because I’ve experienced better relationships with my specialists than with any primary care doc I’ve seen. Re GYN, my doc is a GYN oncologist and I wouldn’t want anyone else but him monitoring me.

            Re big events, I’m not convinced that they are that rare, although with 4 major surgeries in the last 12 years, I hope I’ve reached my quota and will have no more. But we live in a time in which many people are living long productive lives post-serious illness and injury. People are living post-cancer, heart attack, stroke, catastrophic injury and with serious chronic disease like diabetes and HIV. As the population ages, many of us are living with something serious. It’s not that rare. How much of that are you proposing that DCP docs should handle?

          • Lisa

            If imaging centers are salivating at the idea of offering MRIs for cash, I wonder why we don’t see cash only MRIs centers across the country. The only thing I ever see that is related to that are the ads for virtual colonoscopies that I get from time to time. Expensive and bad medicine…

          • Dr. Josh, AtlasMD

            Who says there aren’t cash imaging centers? Websites like are expanding daily to help consumers find affordable care. And imaging centers are among their most frequent utilizers, b/c imaging is (at its core) a commodity with a flexible price. An empty MRI machine makes no profit.

          • Lisa

            Thanks for the link. I’ve never heard of that site; I’l check it out.

          • Suzi Q 38

            An MRI for $350??? I would pay cash.
            Cut out the middleman.

          • Dr. Josh, AtlasMD

            exactly! same product but a better price. can’t beat that :)

        • fatherhash

          it appears you had some missing data in your financial analysis if the reality is that they really are getting MRI’s for ~$350.

          • Dr. Josh, AtlasMD


      • Suzi Q 38

        What about MRI’s of my brain, cervical, thoracic and lumbar spine? My insurance company was literally charged thousand of dollars. This does not include the radiologist’s report.
        When I needed a second opinion, the second teaching hospital took the MRI’s all over again as if the prior results were useless.
        Ditto for all the blood work.

        • Dr. Josh, AtlasMD

          Some of the more complex scans like brain or spine are still in the $400-500 range each.

          The blood work should be just a few dollars per test.

          • Suzi Q 38

            Those are good prices.
            I used to get all excited about using a $2.00 coupon off of a tube of Crest toothpaste.
            You are talking about saving some good money here.
            Where are you located?
            I am fairly persuasive, so I could give it a try and then talk to my friends and family if it all works out.

          • Dr. Josh, AtlasMD

            We’re in wichita kansas, but you can look at to try to find doctors in your area.

  • HJ

    If it’s OK to claim that hospitals are making money on the back of doctors then why can’t I say that doctors are making money off the back of patients.

  • Patient Kit

    I think most of us will likely agree that corporate executives (hospital, pharma, insurance) are all very overpaid relative to what doctors are paid. I, for one, certainly agree with that. I hope docs and patients can find a way to stay on the same side and fight our common enemy together, although lately I’m having my doubts about that.

  • SteveCaley

    The model we are racing towards is alive and well in Ghana, Lesotho, Nepal and Burma. Those who have the money, see the doctor. Those who do not, do not. That is DPC care.
    It was really an American experiment from the Roosevelt days to insist that all Americans could see a doctor, could get necessary medical care. There was a brief period of time in our country when we achieved it.
    Now, we are eagerly pursuing the ‘direct-to-patient’ market entirely familiar Bolivia and Pakistan. They never had doctors to begin with; here, let’s get rid of them and use iApps techno-magic. In the Third World, you want a medicine – go to the pharmacy and buy it! You want to see a doctor – you pay for it. Fly to Abu Dhabi or India or America to a Mayo Clinic and pay cash. Otherwise, well….
    We pretend we are working towards progress; in reality, we are racing towards oblivion.

    • Patient Kit

      It’s truly a very depressing and scary time to be sick in America. I guess I should be grateful for the Internet and the ability to do a lot of self-treating, at least for basic, minor stuff, if not for cancer. Real docs for some, Dr Google for others. I haven’t looked (yet), but there are probably detailed instructions online on how to perform surgery. A whole underground industry modeled on pre-1973 illegal abortion could mushroom. Why am I having so much trouble just accepting this reality?

  • Patient Kit

    Have I given any thought to this? Why, yes, as a matter of fact I have. Just because I don’t agree with you, it doesn’t mean I haven’t given it any real thought. By telling, I mean that maybe it means something that docs here like the idea of going DCP and patients here seem skeptical. A couple of possible meanings to that: (1). It might not be as easy as docs hope to get their patients to make the switch with them; and (2) maybe DCP will be better for some docs than it will be for many patients if it means they lose access to their doctors. Just saying that it’s not the simple solution some docs are trying to sell it as.

    • Close Call

      It’s not a simple solution, but it’s a solution that has the greatest chance of helping the greatest number of people.

      Here’s the alternative: People continue to see docs in a fee for service system, getting 10-15 minute appointments with 5-7 minutes of true face-time. No video-consults (think most states’ Medicaid will pay for that? no way), no weekend access, no discounts on meds/imaging/labs if you have a high deductible, more and more docs taking the easy way out and throwing pills, labs and imaging at a patient because they don’t have the time to actually listen to them (ever wonder why kids on medicaid get a ton of ADHD meds?). You’re private practice doc may take medicaid, but someday they’ll have to stop because they’re losing money on each visit. If you’re at a FQHC, those places cycle through docs and NPs every 3-5 years, so good luck having continuity with someone there. If you’re seeing a large vertically integrated medical center, have fun with the facility fees and markups on ancillaries if you have a high deductible.

      It’s exhausting to think how crappy our current system is.

      For the price of a cable bill, you can have continuity, access, better care, take less time off of work when you get ill or need to visit the doctor… AND you and your employer might save some money. It won’t work for your situation. And it won’t work for everyone. But it’s the best new viable option we have for most people…. and it’s growing.

      • Mike Henderson

        It seems like the information is being given regarding lower cost and better value.

        I can’t think of a better, more ethical way to do things. But have we painted ourselves into a corner in the past by trying to avoid valuing our services in order to avoid being viewed as greedy? Sure, no one wants to deny care to someone due to lack of a few dollars? However, because we have done this carelessly for so long and probably for those who weren’t really needy, the rest of the population doesn’t value what we do. So, how do we make the case for our value? Nurses in my state have done a great job of this. If they work nights, they get paid more. If they are called in, they get paid more. If they work weekends or holidays, they get paid more. If they don’t take their paid leave, they get a bonus check. If a physician does any of these things, they get underpaid anyway. Nurses who do it right, make more than many primary care physicians. No one tells them they aren’t worth it.

        • Dr. Josh, AtlasMD

          Because nurses work in a standard employee/employer relationship. When i used to work the ER as an independent contractor, i was able to negotiate for different rates at different times etc.

          But most physicians work in a broken billing/coding/reimbursement relationship.

          The business model for physicians is broken b/c we have such a high administrative cost relative to the amount we can charge/collect (in an typical insurance based model).

          Its amazing how much of that changes in a DPC model where the red tape disappears, the overhead drops by 90% and you’re free to focus on what the patient needs.

          • Mike Henderson

            I like the DPC model. But it is apparent that physicians need to figure out how to make the case, showing the strengths and weaknesses of the current system to the DPC model. In my experience, patients have been “mis-educated” by insurance companies, which has been tacitly approved by physicians.

            Do physicians need to form a union like nurses, or some kind of association, like “American DPC Association” to supplant the AMA? I think we need to work together to develop some kind of response to the current system. Instead of complaining as indivuals, we need to put some money into this and get something done. Would MDVIP or Qliance get involved as it seems like success would beget success?

            My main frustration is having the years of education in undergraduate, medical school, residency and post residency education taken advantage of by insurance companies and Medicare. They can only do so to the degree we allow them and since most physicians do allow this, I am stuck in the same boat they are.

          • Dr. Josh, AtlasMD

            Dr. Samir with medlion is working on a great group, the DPC Alliance. The AAPS is doing some wonderful work as well. Not to mention several other groups.

            Best of all though is the AAFP is working very very hard (as we speak) to build DPC training materials to help out docs.

          • Mike Henderson

            I will be checking the above out shortly.

          • Dr. Josh, AtlasMD

            feel free to email me directly from our website, or I’d be happy to help with anything.

      • Dr. Josh, AtlasMD

        Well done!

      • Patient Kit

        On one thing we do agree — it IS exhausting thinking about how crappy our current system is. But it’s even more depressing to me to just throw up my hands and accept the brutal human collateral damage of making our system worse for some in order to make it better for others. If the majority of primary care docs do convert to direct pay/cash only, who will treat all those who can’t afford them? Perhaps non-docs like me, with the help of Dr Google, could help treat the people that doctors will no longer see. I bet, with practice, I could saw off a cast without sawing off an arm.

    • Dr. Josh, AtlasMD

      Or maybe its that change is hard and the status quo, right or wrong, is comfortable b/c its what people know.

      What are the most expensive words in business? Answer: Because thats the way we’ve always done it.

      skeptical patients don’t mean that DPC doesn’t work, it just means they need to be informed about it like any new product they might consider purchasing.

      • Patient Kit

        To be clear, I hate our current dysfunctional, expensive, often cruel healthcare system as much as you and many doctors seem to. And I’m, in general, probably less resistant to change than the average bear. I agree that insurance companies are the devil but to survive my current crisis in our current system, I need that insurance for now.

        I’ve said many times here on KMD that I think the root of most of our healthcare system’s problems is that, in the US, healthcare is first and foremost driven by the profit motives of the big businesses at the center of it (insurance companies, pharma, hospital corporations). It’s gotten to the point where profits for them is, by far, more important than the health of the American people, including docs.

        To that end, I favor a single payer tax-funded system, medical education subsidized, docs on fair salaries. I know quite a few people who feel the same way. It’s not a matter of us having our heels dug in, resisting change. You and I both want change.

        • Dr. Josh, AtlasMD

          Yes we both want change.

          But I fundamentally disagree with your concept of a single payment system and the problems of a profit motive.

          I believe that only through the profit motive will be get to a rational, moral, accessible and affordable healthcare system.

          Name any product, service or industry and we can track how its better b/c of good business. Phones, cars, homes, food, clothes etc. And yes health care. You might say that health care is too important to leave to capitalism and I say that it is too important too leave to any other system but Capitalism.

          I’ve said my peace and i’m happy to let you comment last. thank you.

          • Patient Kit

            It’s been an interesting conversation and I appreciate your answering my questions about DCP, Dr Umbehr. I was starting to get the feeling that you thought I was merely resistant to change, which I am not, so I wanted to clarify my position.

            You have definitely identified a fundamental difference in our core beliefs. In this age of escalating corporate greed and exploitation in the name of maximizing profits for a few, I simply do not share your faith in capitalism as the savior of our healthcare system. The poor are getting poorer, the rich richer, the gap wider and the middle class squeezed. Not an environment that makes me think profit driven capitalism is the answer. To me, it is the opposite — profit driven capitalism is the heart of the problem.

            In general, I’m not anti-business, although I do believe strongly in corporate social responsibility. But what is good for phone and computers (like Apple) is not good for healthcare. I think healthcare is too important to be a big business. Everyone doesn’t need an iPhone but every American does deserve medical care. I see healthcare more as a human right than a business.

            I don’t think either a single payer system or widespread DPC will be easy to achieve, given our common powerful enemies with vested interest in stopping change. But that doesn’t mean we shouldn’t try to change the system.

  • Dave

    Great article! It’s exciting to see how the DPC movement is taking off and frustrating that so many people fail to understand how and why it’s a good thing. Maybe not right for EVERY patient, but right for many. There’s a DPC practice near my in-laws started by a couple of FP docs right out of residency. They both had to do a lot of moonlighting early on to make ends meet, but eventually word of mouth got out. They recently added another practice location in a neighboring city because so many patients were driving almost an hour to see them. If I lived there, I’d sign up too.
    No, DPC will not solve the problems of our healthcare system and will probably make the shortage of PCPs even worse in the near term as docs reduce from 3000 patients to 400. But if that’s what it takes to get “insurance” out of primary care entirely, then so be it.

    • Dr. Josh, AtlasMD

      Thanks Dave!

      I’d like to say that we believe DPC will actually help the physicians shortage for several reasons. The current model is what caused the shortage. The DPC models is our best hope for keeping docs from burning out, retiring, cutting back, changing professions etc. DPC will help revitalize medicine, attract students and residents to primary care, keep doctors in longer and make them more efficient.

      Also, most DPC docs will do 600+ pts and not just 400.

    • Mike Henderson

      In DPC, physicians can do more for each patient relative to a typical practice. This mitigates, to some degree, the decrease in patient numbers.

      Your last point is my hope. If we get the insurers out of the exam room, providing patient care will become what it is supposed to be – truly grateful patients, intrinsically rewarding, stimulating, and challenging. Then it will seem feasible for medical students to choose primary care in the numbers necessary to rebalance the system.

  • Dr. Josh, AtlasMD

    Thanks Doc and congrats. I’m excited for you and your patients. If there’s anything i can do to help, please don’t hesitate to reach out to us.

  • Dr. Josh, AtlasMD

    Well said Doc! We always hate to lose patients, but at least it helps you avoid burnout and leaving the profession.

    The “cost” may be $50/mo but the “price” may be well under that when you include all of the savings.

  • Dr. Josh, AtlasMD

    ummm….wow….I couldn’t have said it better.

    And for the record we’re able to help most employers decrease their insurance by 30-60% to more than offset the cost of the $600/yr/pt ($120/yr for kids) even before all of the other savings. Many employees get a raise afterwards.

  • Dr. Josh, AtlasMD

    exactly :)

  • Dr. Josh, AtlasMD

    Very true, but physicians are typically able to negotiate lower prices than the average patient. My experience.

  • Dr. Josh, AtlasMD

    Indeed, last i checked we stocked 180 different meds w/ variations on doses.

    Most people are happy if there generic med is $10 a month (typically 30-60 pills). I’m not happy if 1000 pills costs me more than $10 wholesale.

  • Dr. Josh, AtlasMD

    Dr. Mark, the HSA question is a little gray, but we think the IRS document 502 is very clear that any medical service provided by a physician is a qualified expense. We work with many accountants to help them understand this. But yes, we recommend everyone check with their accounting specialists.

    But you nailed it that they are paying a lot more with out the DPC savings. A great example is imitrex, cash price is about $100 for the generic at the pharmacy. That we get for $7 and sell for $7 to our patients. Add the $50/mo membership and they are still saving at least $43 every month. Not to mention they have unlimited access to their doctor for no extra charges.

    Thats how we help patients :)

  • Dr. Josh, AtlasMD

    It really just depends on the medicine. That is why we tell our patients that our price is their price. If thats better than what they can get somewhere else, they are welcome to get it from us.

  • Karen Ronk

    Well, this article has clearly provoked some good debate! I think that the model of direct care has a place in our health care system, but it will definitely not work for everyone. Because it seems to me that you would also need to have at least a catastrophic insurance policy for surgeries and/or hospital stays. And as many on this post have pointed out, a lot of people just cannot afford that.

    I think there is a big misconception out there about the financial “health” of much of America. And speaking as someone who was actually very healthy and fit before I went to a doctor for what should have been routine care, you really never know how your life can be turned upside down by a medical condition. Or how your resources can be drained and devastated. My insurance company was billed over $100,000 last year for my care. I am not sure how direct care pay would have worked for me.

    But if it works for others and they have the resources to be covered for any unexpected conditions or complications, then I would say by all means, go for it.

    • Dr. Josh, AtlasMD

      Hi Karen, thanks for the comment. The debate is definitely healthy and is a good tool for evaluating all sides of the issue.

      To clarify, we recommend but don’t require that our patients have catastrophic health insurance. About 1/3 of our patients are uninsured but they see the potential savings of a program like ours. Insurance is great for the major problems that can happen. But DPC offers an affordable option for the common care that 80% of people need access too.

  • Mike Henderson

    In my opinion, primary care physicians offer the best value in health care. Here is a question for the physician DPC supporters. Have we avoided valuing our services to the point that the public, insurance companies and government don’t see the value we provide? Is that their fault or ours? If something is given away for free, then its value is $0.

    • Dr. Josh, AtlasMD

      I agree but as an FP, i might be biased. But then again there’s plenty of research to support this.

      • Mike Henderson

        I am biased, which is why I pose the question. To me, we don’t cost that much, provide tremendous value, yet I perceive that many others balk at any price we may charge. I asked a Medicare patient to come back in a few weeks. He refused, stating I was just trying to make money off of Medicare. He absolutely had no idea I was losing money seeing him and he was about to take his large motorhome across the state, when gas was over $4 a gallon. He wouldn’t make it 1/4 the way to the next town before he burned enough fuel to pay his copay.

        • Dr. Josh, AtlasMD

          Yes, stories like that are understandable, especially after CMS released the payment data on physicians and how it was reported out of context for many providers.

          There’s a perception that doctors are making money when we’re not. Thats why its so important to educate patients on the true cost of care.

          Thankfully, a DPC model allows us to do that. We do the wholesale prices on meds and labs and no copays and free procedures to help rebuild the trust with our patients.

  • Dr. Josh, AtlasMD

    Sounds scary and depressing to be in that system. I’m happy to do anything we can to help.

    we have our blog and podcast that answer a lot of questions and you can contact us directly through our website.

  • Lisa

    I am not stuck in a bureaucratic nightmare. i get good medical care because I am involved with my care and do not accept what my doctors say at face value. And I don’t accept what is being said about DPC at face value either. It may well work well for a certain percentage of the population. But I don’t think it will work well for those with lower incomes and involved medical conditions, who need more care than a primary care can provide.

    • Dr. Josh, AtlasMD

      I think we’ll just have to agree to disagree. Its different when you’re a patient and not a physician. Become a physician and you’ll see first hand the bureaucratic mess that is the modern health care system.

      I do this everyday and i see first and the problem with the current broken model and the benefits of DPC.

  • Mike Henderson

    I am not aware of who is advocating for physicians in a way that makes sense from a PCP point of view. The AMA and AOA don’t seem to be, but maybe what they do is under the radar. The local state chapter seem to do some advocating around the edges, but nothing addressing the whole system. When it comes to the negotiating table, I can’t see a significant presence or influence.

    Patients are not represented either. They unfortunately can’t see behind the scenes to see how the system is designed to take advantage of them. As many on this site will attest, they are acutely aware something is wrong. From a cynical point of view, insurance companies view patients as revenue sources, and providers (hospitals, some physicians, medical equipment suppliers, pharma) as a means to bill the insurance companies.

    Your third paragraph is the crux of the matter. Why physicians as a group are not advocating for ourselves is difficult to understand. We see and know how the system dysfunctions better than anyone, yet seem relatively helpless. Patients have the true power, but can’t see the mechanisms in place that take advantage of them. That’s why I visit KMD. To see what it is I don’t understand and what patients don’t understand and try to bridge the gaps.

    The second paragraph nicely summarizes the negative aspects of real world practice. As much as the “non-clinical personnel” have infiltrated the system, physicians have let it happen. In physics, as you probably know, every action….

    The last paragraph/question is also very true. DPC’s are good, but we need more than that. Generally, primary care physicians need to decide to work together, define the problems honestly and also figure out how we contribute to the dysfunction. If it were totally up to me, PCP’s would form some kind of group to do the above, develop a strategy to educate/empower patients and together change the system. We have the knowledge, patients have the final authority. Our interests are much more closely aligned than any other combination of “stakeholders” in the industry.

    • Dr. Josh, AtlasMD

      DPC docs definitely need to work together. If you get into the DPC community you’ll see that they love sharing their experience to help other docs. Medicine has a grand tradition of helping each other like this.

      We offer all of our consulting for free and frequently have med students (the future), residents and docs visit the clinic to learn more.

      True doctor patient advocacy now means bucking a system that isn’t working to make our pts better :)

  • Dr. Josh, AtlasMD


    Well i think doctors all over the country are putting their foot down. When we stand up for ourselves, we stand up for our patients!

  • Dr. Josh, AtlasMD

    Barry, i’m truly touched. Thank you very much for your support and it means more than you may know.

    In my personal statement for residency, I said that i want to fight for the experience of my patients and i’m glad each day that i’m able to do that.

    Helping people is what I’m driven to do and sometimes that means being a physician, a friend or an entrepreneur.

    Often physician entrepreneurs are outcasted for being concerned with the business of medicine.

    But I’ve committed the last 6 years of my life and probably 2 million dollars of my own investment for the chance, just the chance, to try to help change medicine for the better.

    Thank you for taking the time to acknowledge and respect that.

    Bless you.

  • Dr. Josh, AtlasMD

    Well done Dr. Mark!

  • Dr. Josh, AtlasMD

    perfect example!

  • Dr. Josh, AtlasMD

    oh its growing by leaps and bounds! we started just to help patients and doctors show their support for the movement! :)

  • Dr. Josh, AtlasMD

    I think KMD reaches a very wide audience but i would suspect that the it has a greater % of medical viewer than most websites, so no big surprise that there’s a lot of docs in the comments.

  • Dr. Josh, AtlasMD

    The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore all progress depends on the unreasonable man.—George Bernard Shaw

  • Dr. Josh, AtlasMD

    Exactly. Profit itself isn’t a bad (in fact i’d argue that its very moral). But there’s a lot of Unnecessary expense/profit in a system with so many middle men.

    think about it, healthcare is the only 3rd party payment system in the world. Its clearly broken but we don’t acknowledge that it might be the payment system :)

  • Dr. Josh, AtlasMD

    Alicia, i think Lisa missed your point. Not that she’s experiencing the red tape in her care (i’d beg to differ). But you’re suggesting that she’s stuck in a bureaucratic mind set for problem solving. Correct?

    • alicia

      yes, it is not just Lisa, it is a huge segment of our population. It is not an insult, its just a hurdle we need to address.

  • HJ

    I disagree that hospitals add no value to medicine.

    If I had cancer, I suppose I would say that my insurance company adds value…otherwise I would not have access to the care I needed as I don’t see any direct care oncologists.

  • Suzi Q 38

    I am interested in the idea of direct care.

    I am 58, have had a hysterectomy due to cancerous cells, and an ovarian tumor. I have had spinal stenosis and lumbar back problems.

    They suspected MS in my c-spine, but the MS specialist has ruled that out for now. I limp and may need a total knee replacement, but was stubborn and requested the meniscus repair instead.
    My total cholesterol is 202. My A1c is 5.4 or 5.1, not sure. My fasting is 89. My BMI is 25.
    Presently I have PPO insurance. The insurance company collects $1K from my husband’s employer and $900.00 a month from us. I can see any specialist or doctor that I choose, at any time.They pay my PCP about $46.00 per visit. They pay my specialists about $150.00, I think….not sure.
    If I didn’t have insurance, I would have been charged about $100k for my c-spine surgery, which I believed saved my mobility.

    How can I utilize direct pay to assist my doctors, and yet have insurance for the hospital that does not put my husband and I at risk of losing our assets?

    In spite of my dedication to providing good insurance for the two of us (my husband agrees at my urging), mistakes have been made that almost rendered me a paraplegic. I am thinking that maybe Kaiser would not be much worse than I have already endured, and so why not pay less?

    As you can see, not all of us are easy case studies.

  • Dr. Josh, AtlasMD

    and thats why we need to put patients first again! :)

  • Dr. Josh, AtlasMD

    sorry to hear that but happy to help! we help doctors weekly to learn more about their direct care models. we have a blog and podcast as well to help.

  • Dr. Josh, AtlasMD

    Get angry, i love it. I’m from wichita and WSU’s basketball team is “play angry”

    i’ll check out the icd10watch link you referenced.

  • Margalit Gur-Arie

    The point is that CorpMed is CorpMed by any other name. If you read the exchange below, you can see that the “point” was addressed, and that everybody agrees that we should hope that these new corporate entities will turn out to be better for doctors and patients than the older corporate entities in health care, because they are starting out that way. So, I guess we will wait and see….. I can only hope that Dr. Mike & Dr. Josh are right, and that I suffer from chronic paranoia…. :-)

    • Patient Kit

      It’s not paranoia if there is really something to fear.

  • Patient Kit

    I think Dr Umbehr’s post sparked some excellent and respectful discussion, always the hope of any good piece of writing. What comments do you consider unrelated? Do you think that only people who are in gung-ho, enthusiastic agreement with Dr Umbehr’s DPC model should comment? Only those who want to applaud? As long as we remain respectful of each other, discussion is always more interesting and productive when everybody doesn’t agree on everything and we can learn something from each other. It’s in the best interest of any doc considering DCP to get a handle on what some of the key barriers/opposition/resistance is to it. I’m sure Dr Umbehr didn’t expect the comments thread to be one big pep rally. It’s always an exchange of ideas here.

  • Patient Kit

    I have a lot of respect for doctors. In fact, I’m in awe of what some of my own docs know and can do. I have no doubt that medical training and practicing medicine is very difficult. But navigating the realities of politics and business is a whole different thing than practicing medicine. And many docs don’t seem to be great at navigating that political/business world, given how much power docs have lost in a system in which they should have more power, given the importance of what they do.

    I don’t understand what you mean when you say that I shouldn’t be concerned with the level of difficulty involved in changing the system and that is something I should leave to doctors who are used to dealing with difficulty? Huh? (1) Docs and patients are in this together. If we don’t work together, nothing is going to change. It is something we should all concern ourselves with. (2) Non-docs have lots of experience dealing with difficulty too.

    What I think is driving the interest in the DPC model is docs’ desire to get their autonomy back and have more control over the money and be in a position that enables them to form better doc-patient relationships.. I think we are a long way from a massive conversion to DCP but, if that happens, yes, I think a big chunk of the population will be left out.

  • Patient Kit

    I definitely agree that our healthcare system is broken. And I do understand that health insurance does not guarantee healthcare. I’m just not convinced that DPC is the answer. What I want more than anything else is to stop living in constant fear of being cut off from access to doctors. Our healthcare system has been far more terrifying than cancer to me this year. I’m exhausted from living in constant fear of losing access to any healthcare, let alone good healthcare.

  • Kristy Sokoloski

    Dr. Jeff,

    I am glad that there will be some of your patients that will be able to afford to pay $50 a month for the care that you provide. And as a result I am happy for them. I had to ask this because for patients like my relative and I we could not afford $50 a month to see our Primary Care Physician. I bring up my relative and I as well as other patients like us on a regular basis when this topic of concierge practice or direct care practice as a solution to the payment for Primary Care Physicians to remind other the authors and readers of these various entries on this blog that there will be many of us that will not ever be able to get the medical care we need for our various conditions again. And if all doctors stop taking insurance like is regularly talked about then my relative and I and others like us are going to be in a lot of trouble. We may end up being a bigger part of the masses that have to depend on getting care either from the ERs or an academic medical center if one is close to us. And unfortunately, the academic medical center care is not always the best for a patient’s needs as we have seen from other regular posters that have shared their experiences with the Academic Medical care. The last time I paid a doctor $50 for an office visit was back in 2002 when that doctor (my gyn) was not on the health insurance I had at the time. However, with the problems I had going on at the time there would have been no way that I would have been able to pay $50 for every time I needed to see her for those problems.

    I know some people think that $50 a month is a reasonable amount to pay for being able to see their Primary Care Physician, and that’s great. But unfortunately for those that are on very fixed incomes and have to make the decision about what things have to be paid every month the mortgage, utilities/water, food, car payments and insurance for that car, and gas (if one has a car) are more important than getting medical care to stay on top of chronic medical conditions. This is the same thing that happens with dental care now. Last year I was able to get dental care thanks to an agency that helps with things like that, however, this year I am not able to do that not only because that agency can’t do it right now when it comes to some routine dental care so I am not able to get dental care. Plus, I have other priorities that are more of a top priority going on right now that are more important than me getting routine cleanings. I finally had to tell the dental clinic that I was not able to get the regular cleanings and what I am willing to do if something could be worked out. However, it couldn’t be worked out. So until things are sorted out no cleanings or any other dental work that might be necessary for me this year. And unfortunately, I am not the only one in this position where I have had to make choices I didn’t want to make but had to because those other things were more important than getting regular dental care. I am also having to make some similar decisions about healthcare in general even though it may not make my doctors happy. But that’s the way it has to be even though we don’t want it to be this way. But we don’t do it because we want to make these choices, we do it because we have to. When I told the lady at the dental clinic about where my priorities lie and that this is the way it has to be she said “it doesn’t have to be this way, it’s a choice you wanted to make”. Things are not like they were 10 or 15 or even 20 years ago where I could easily stay on top of everything with my health. And again I am not the only one in this position. People all over the country are in this position. And that’s regardless of whether they have so called “luxury items”.

    Until some kind of a solution comes up to make it easier for us to be able to stay on top of everything with regard to our health we will continue to make choices that take more priority than staying on top of our health. It shouldn’t have to be this way like the lady said “it doesn’t have to be this way” but sadly it is for so many of us.

    I wish you and all the others that choose to do direct or concierge care all the best. For me when it comes to my Primary Care Physician I want to get the best care I can get from him whether that visit is for 10 minutes or for 45 to 60 minutes. Which for me my visits with him regularly are only going to be about 10 minutes, maybe even 5 because so many of my other problems are tended to by my specialists.

  • paxf

    A late comment, to encourage the doctors–DPC has been ably advocated, but perhaps I can add a subtle twist or two…

    DPC is great. From my own meanderings through the medical maze, coming from a family of both providers and recipients, medical care in the U.S. could easily cost half what it does today. Half, if patients simply shopped, in an environment that made that possible. Maybe even less.

    At the core, right now almost no one spends their own money, or cares (or even knows) about the price of things. There’s no price pressure, none of the competitive urge toward efficiency, streamlining and improvement that has made every other thing in society better, faster, and cheaper. And virtually no pressure on the consumer to consume wisely, which is a vital component. Consumers have to, by their choices, participate–that’s how useful goods and services are “selected” in a natural-selection sense, and how less-useful items are phased out.

    That’s why stuff costs too much.

    It’s not just about money. Money and profit are proxies and drivers for efficiency and improvement respectively (in the operation of the business), while the consumers’ demand enforces the quality (or whatever other aspects they desire).

    Some decades ago, in a state that allowed it, I had an amazing panel of tests done at a lab–blood panel, type, liver/kidney panel, hearing, ekg, and more. Walked in, got tested on the spot. Paid under $100. Prices for other services were reasonable, and listed on the wall. The lab mailed me my results, plus a photo ID with all my reference values on microfilm, laminated into a wallet-sized card. I still carry it.

    Getting that elsewhere would’ve cost heaps more, and cost me a couple doctors’ visits–one for the tests, one for the results–that I didn’t need, to boot.

    That’s how we control prices–free, fair, and open competition. And it controls the hassle on both sides, squeezes out the paperpeople, and so forth.

    And if we do that–if ordinary care cost half–then whatever problems remain are enormously mitigated. If it cost half, almost everyone could afford it, and tending the few who couldn’t would be enormously easier, a lesser burden on everyone.

    If most people used DPC for ordinary care, their savings would be more than enough to buy a true catastrophic policy to cover…catastrophes.

    Oh, my experience with the lab was great. The people were super, polite, and proficient. And, they were happy, smiling–they were having fun! You could be too.

    Press on! You don’t have to take the govt’s slings and arrows, chewing up your time, getting between you and your patients. There is a better way. You’ll drive down costs for everyone. And, everyone wins.

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