Paying the doctor directly is better for all concerned

Next in a series.

The fundamental problem in health care delivery today is a highly dysfunctional payment system that leads to higher costs, lesser quality and reduced satisfaction. It also means less time between doctor and patient with the loss of “relationship medicine.” The core problem? Price controls and regulations that reduce the trust and core interactions between doctor and patient. The patient is no one’s customer and visit times are all too short. I have argued in the Washington Times as an op-ed that paying the doctor directly is better for all concerned.

I believe that some of the best attempts to improve this dysfunctional delivery system have been accomplished by primary care physicians themselves.   They have essentially said “I won’t take it any longer; this is not good for my patients or for me.” They have also said that it is time to “stop tinkering” and make a fundamental change. They have opted for a new, better system — direct primary care — rather than wait for others to fix it for them.

The concept of direct primary care is to reduce the number of patients in a PCPs practice so that each patient gets added time as needed. Often this means removing the insurance system as the payer from primary care and always it means a payment model that compensates the PCP directly by the patient.

Direct primary care takes many forms. There are two principle payment systems. One is for the patient to pay the doctor directly for each visit, usually at a rate far below what would have been charged in the insurance model since the overheads of billing and coding have been eliminated. Many such PCPs post a defined price list: transparency. This is sometimes called direct pay or “pay at the door,” not unlike the way it was until a few decades ago before insurance morphed from being only for major medical or catastrophic issues to being essentially prepaid medical care.

The second model is for the patient to purchase a package of care for the year paid by the month or annually. In effect this is a form of capitation. This basic model comes with many variations and may be called membership, retainer or concierge.Despite the various names, they all have certain characteristics in common but there are many variations in how the practice functions.

All of these models offer a reduced patient to doctor ratio: Instead of the typical 2,500+ patient panels, the PCP may adjust the number of patients to a low of 300 when the panel is very ill or to a high of about 1,000 for a panel that has mostly low-risk patients. Some accept insurance and also charge the retainer; others just charge the monthly or annual fee.

With a reduced patient panel size, the PCP commits to offering same or next day appointments lasting as long as necessary, a thorough annual examination, email communications, and an invitation to contact the PCP on his or her personal cell phone 24/7. Some make house calls and nursing home visits for no extra charge; others add a modest fee. Some see their patients in the ER and some follow their patients in the hospital.

There may be an arrangement to obtain laboratory testing, imaging and procedures at highly discounted rates from selected vendors. Some practices offer a limited number of laboratory tests at no charge. Some PCPs are supplying medications at no or wholesale costs. For the patient on multiple prescription medications, the savings on drugs can more than offset the annual subscription cost of direct primary care.

Many only work with specialists who are willing to discount their fees for those of their patients who pay cash and have high deductible plans or no insurance at all.

Often regarded as highly expensive and only for the “elite,” the rich, or the “one percent,” in fact membership/retainer/concierge practices can be of quite reasonable cost and very appropriate for those with no or limited insurance and for those with modest incomes: “blue collar” concierge medicine.

Fees range from about $500 to $2,000 or more per person per year. (I will ignore those doctors who charge a very high fee for “exclusive” services.) By some degree of common usage those on the lower price end often refer to their practices as direct primary care or membership whereas those at the higher end often refer to their practices as retainer or concierge. To the extent that there is any real difference, it is probably in the number of patients in the panel or seen per day, the extent of the annual evaluation and added values such as following one’s patients in the hospital and in the ER.

For those who have high deductible insurance policies from work or from the exchanges, connecting with a direct primary care physician can offer a significant savings and the fee can be paid from a tax advantaged health savings account (HSA). The individual and the physician now have a direct professional business relationship. The person begins to take a much more active role in the entire care process. And the doctor can allot meaningful time for patient interaction: a return to “relationship medicine.”

With little to hope that government or insurers will improve the lot of primary care physicians, direct primary care is a rational manner for PCPs to change the paradigm and return to relationship medicine. It means better medical care, less frustration and more satisfaction for doctor and patient alike and an encouragement to medical students to consider primary care as a career option. It also means that total medical care costs go down. A triple win.

Paying the doctor directly is better for all concernedStephen C. Schimpff is a quasi-retired internist, professor of medicine and public policy, former CEO of the University of Maryland Medical Center, senior advisor to Sage Growth Partners and is the author of The Future of Health-Care Delivery: Why It Must Change and How It Will Affect You.

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  • Kristy Sokoloski

    That’s great that there will be those patients that can afford to see their doctor under one of these models. However, for the majority of people they will not be able to afford to go to the doctor. What are those people supposed to do? Dentists already have tried to do this with direct payment and it’s created big problems. They wonder why more people don’t come in for check-ups and cleanings and the answer is because the people can’t afford to pay them. Just for a cleaning just to clean one side of your mouth, or one quadrant it’s about $150 and that’s not including the x-rays and for the dentist to actually check your teeth. I know a number strongly believe that direct pay is the answer but there are going to be a lot more left out in the cold and struggling to get regular care for their problems if one of these type of models occurs. That’s why insurance is necessary for so many of us even though it has its own problems too.

    • rbthe4th2

      Agreed. Too many live paycheck to paycheck. I know quite a few people that way. A better option is to get more docs in primary care. Why we need so many specialists is beyond me. A great PCP is worth their weight in gold and I believe should be paid more. Lots more. The ROAD specialties could stand making less, give that to the primaries.

      • James O’Brien, M.D.

        Primary care will be dead within ten years. Especially internal medicine which is heavily into self inflicted wounds.

        Psychiatrists (using boutique not concierge model) have figured out this problem for decades and most do not take private insurance, and very few take Medicare or Medicaid. We have no problem and long waiting lists. I still have some Medicare patients I continued seeing on a pro bono basis after I dropped Medicare 25 years ago. It made more sense than going through the expense of billing the carrier.

        • rbthe4th2

          You’ll see people using the ER to get out of it. That’s what it is now, as I’ve seen one specialist group that said our policy is office visits and procedures only. Any problem you have outside of that, we don’t resolve, go to the ER. That group isn’t frequented as much as another group that does work with you.

        • buzzkillerjsmith

          And I’ll tramp down the dirt. But give it 11 years so I’ll be retired.

          Are the NPs or PAs dumb enough or idealistic enough to drink from the poisoned cup?

        • Sherry Reynolds

          Psychiatry is the perfect example of what could happen. You end up with the highest trained professionals in the suburbs treating the healthy wealthy while those with the most severe illnesses are left to roam our streets or receive care from bachelors level case managers paid $12/hour.

          Psychiatry has lost its way and has the least number of US students electing to go into that speciality.. Medicare via CMS paid for your residency and internship (if US trained) did you pay them back or just skip out on your obligation to the most vulnerable?

          • James O’Brien, M.D.

            No such contract or obligation exists, except in your imagination.

            So as a “social venture broker”, whatever that is, I suggest you direct your anger toward the mental health courts and Medicare and ask them why they make it impossible to treat the seriously mentally ill.

            Back to the general point. Medicine in 10 years will be what education is today. Poor to mediocre public education free and elite private schools for those who can afford it. Those of you who supported ACA, you should live with the result of your magical thinking.

    • JustADoc

      My last cleaning a few months ago, without x-rays, was $109. You’re going to the wrong dentist.

      • Patient Kit

        Maybe the fee difference lies partly in where you and Kristy live? Living in NYC as I do, I expect the high cost of real estate here to be factored into a DPC (or dentist’s or psychiatrist’s) direct pay fee schedule — which is why it is hard for me to believe that doctors here could offer unlimited care for $65/month (as some have claimed).

      • Lisa

        I think Kristy is referring to root planing and scaling, which is normally done by the quadrant, not a routine dental cleaning.
        My last cleaning was also about the same price as yours. But $100 is a lot when you are living pay check to pay check.

    • Patient Kit

      I agree with you, Kristy. I don’t have fond memories of the good old days before insurance. I grew up in a working class family and, growing up, neither the kids or adults in my family saw a doctor very often. We had to be extremely sick before my parents would take us to a doctor. It was very clear to me, even at a very young age, that my family couldn’t afford doctors and that, if we got sick or injured, we were causing a real hardship for our family. Thus, being a sick or injured child equaled being bad. It caused my parents a lot of stress, financially, if we had to go to the doctor. They rarely went to the doctor themselves. And that was not a good thing. I have no desire to go back to those good old days.

    • SBornfeld

      Dentists with long memories called the 1960s the “golden years”. Patients who were self pay still were self pay. Most didn’t get complete care, but they got what they felt they needed. Dental insurance brought in a whole new population, and enabled regular maintenance and even restorative care they couldn’t afford before.
      Now with employers cutting or eliminating dental and other benefits, we’re seeing the reverse–patients who were not used to self-pay were loathe or unable to pay for treatment, and even people with coverage think twice about elective treatment as copays accelerate out of reach of many in the population.

      • Ladyimacbeth

        I hate dental insurance. When I had it it never seemed to cover the things I needed. We cover this kind of pulp cap, but not that kind of pulp cap. I don’t even have a clue what a pulp cap is, but apparently I chose the plan with the wrong kind of pulp cap. I dropped my dental insurance.

  • futuredoc

    Kristy
    Your concern is valid but there are many direct primary care PCPs that can actually save many people money. Check out the link in the post to “blue collar” in my post above . I plan another post shortly on more of the specifics of costs for DPC but for now – some charge less than $1000 per year for a family of four and that is all inclusive. Some buy generic medications wholesale and make those available at cost; this can be a big savings. Perhaps the ones who will be best served – financially – are those with high deductible policies. They will be paying for primary care out of pocket anyway and this can be a much better financial arrangement than being charged the regular price per visit. Same for the person with no insurance. And if you would otherwise go to the ER, an available PCP could often solve the problem for you at less cost. See Dr Umbehr’s post on KevinMD here http://bit.ly/1k8ehrS

    • HJ

      It’s a myth that direct primary care (memebership practice) saves money for a majority of people.

      I have a high deductible policy, saw my primary care physician once last year. That makes a really expensive visit.

      I take a generic medication and it costs $3 a month. That’s not big savings.

      In my area, a membebership at the direct care practice is $170 a month for someone my age. For a family of 4 with a 10% discount, it would cost $5832.

      • Forthrighthealth.com

        You’re right, it doesn’t save money for a majority of people.

        Yet, our healthcare costs continue to rise 2-5x inflation every year, and is largely responsible for the stagnation in wages over the last 15 years.

        75% of our costs are due to chronic disease. As our system is currently constructed, how does a primary care physician help a person with multiple comorbidities?

        Primary care physicians are only paid if they see patients face-to-face. Plus, the insurance-based system adds 40-50% to their overhead. So their incentive is to see as many patients per day as possible – leading to poor service and inconsistent quality.

        So you’re a physician and a patient walks in with depression, hypertension, and diabetes and you have a 10 minute window to treat them (you can’t call them on the phone because you don’t get paid for that, you can’t text them, you can’t videochat with them, you can’t act like a normal human being with them because our system doesn’t allow you to). What are you going to do?

        The answer to that question is the key to fixing our entire healthcare system.

        • http://onhealthtech.blogspot.com Margalit Gur-Arie

          The answer to that question is sitting in a new CMS proposed rule, practically certain to be adopted in 2015, which will pay primary care physicians $500 per year extra (in addition to regular visit fees) for each Medicare patient with chronic diseases. This should cover a few phone calls and emails here and there…..

          • NPPCP

            Yes, that will help greatly. But for all the employed folks, they may never see it. In our clinic, it will be 85% of that which we will receive ($425). I will pass some of that along to the NP and the physician. Others may not be so lucky. :/

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            You’re probably right. For employed folks it will most likely be swallowed by the efficiency & economies of scale black hole….

        • Patient Kit

          I think the key to fixing our healthcare system is transforming it from the colossal, profit-driven big business that it, first and foremost, is. The #1 goal of healthcare should not be to make a boatload of money for a relative few. Until profit is no longer the primary driver of our system, the costs aren’t going to come down. The powers that be that control our system are too vested in costs staying high.

          For me, that could take the form of converting to a single payer system. Or it could take the form of radical insurance reform. I do not see the American public massively embracing the idea of everybody buy their own. That would be a particularly hard sell in our current economic environment and impossible for much of the working class and many our most seriously ill. And frankly, I don’t think the average American will just trust that doctors will take care of them, even if they can’t pay. That kind of trust between patients and doctors just isn’t there.

          If the only choice I get is impersonal healthcare for all who need it or personal healthcare for those who can afford it, I’m going to have to go with the one where every American who needs medical care can access it. Sure, I’d prefer everybody to have access to good, personal care and for all of us to have great long term relationships with our docs. But until you have actually
          personally faced the prospect of having no access to
          any care, it might be difficult to understand choosing some over none.

      • goonerdoc

        Then it doesn’t work for you. So be it. It has potential to work for some. Perhaps not all, but no model of care works for all.

        • HJ

          Then the title should not be “Paying The Doctor Directly Is Better For All Concerned.”

        • Patient Kit

          Some. Not all or even most. Which is why it is a niche model. And I agree with HJ that the title of this piece should not be “Paying the Doctor Directly is Better for ALL Concerned”. I’m fine with it being niche for those who want it. What sets me off is when doctors start talking about making DPC widespread, reach critical mass or be the dominant model in the US.

          • NPPCP

            Patient,
            Although healthcare is highly regulated and is not truly free market, it seems okay to inject a bit of free market into the system. The push by physicians for DPC, in my opinion, is not equally beneficial for all parties involved – only for those two parties who agree it is equally beneficial. I would not worry about anyone advancing any product that is only in the interest of one (it’s difficult in healthcare, I know). This happened with HMOs and is now happening with DPC and PCMH. These models are both outliers in the answer to the healthcare crisis. Neither will become mainstream. If I were you, I would just sit back and let it all sort itself out. None of us may survive all of this in the end – but these two models won’t dominate either. PCMH is for the academics and grant lovers; DPC is for the free marketers. Most folks fall in the middle. :)

  • http://doctorlamberts.org Dr. Rob Lamberts

    This is the model I use and it works quite well. When people say the “can’t afford it” they clearly don’t understand the advantages. For my population, after factoring in the montly payment to me, the overall cost to my patient population is significantly less than if they had gone to a typical FFS practice. Why? Because I am aggressively trying to prove my value to them so they will continue the monthly payments. I do this by reducing the unnecessary medications and tests, by taking time to find the least expensive medications, by being avaialble to answer questions and so keep problems small, by using virtual visits or other means to increase communication (and so handle problems without forcing a copay for an office visit), and by keeping people away from emergency visits and even hospitalizations through a much more aggressive hands-on approach to communication and care. The net result is a savings to both patient and payor – something that both should be quite interested in.

    • SBornfeld

      My problem with a capitation-type system is that it shifts the insurance function to the doctor. Of course you will only do this by eliminating truly unnecessary tests, but will all be so high-minded?
      The objection for fee-for-service is that there is an incentive to over-treat. Capitation (as run by insurance companies) demonstrably confer an incentive to under-treat. How different is this when the insurer is no longer there?

      • http://doctor-rob.org/ Dr. Rob

        This is me under a different diqus account…weird.
        The answer is that when one works for the patient, the goal is always customer service, so under-treatment is frowned upon by the patient. The capitation model denied care. Now I simply justify the test, medication, whatever to the patient and we move ahead to treat. I am very motivated to keep them happy because if I don’t, they just leave my practice. “Happy” is achieved not by giving in to their whims, but as giving them the best care for the lowest price. I attend to their problems and get questions answered. The difference in this world compared to the FFS or insurance-oriented capitation world is enormous, and can’t be under-stated. I’ve lived in both of the others and the direct connection with the patient in this model is far, far better (as is the quality of care I can give).

  • Patient Kit

    I remain unclear about what part of the population DPC might work for — the basically healthy or those with complex chronic health issues? I can see how it might work for the basically healthy uninsured as long as there are no membership fees and it’s just pay as you go if they only need to go to the doctor rarely.

    But for those of us with insurance, whatever the deductible (which is most of us), if we have to pay out of pocket for primary care, isn’t it better for us if those costs can be applied toward our deductible? And DPC costs would not apply toward our deductible. Why is that a good thing? Are you assuming that most people won’t need to use their insurance to see specialists and for other things not covered by DPC? Because if we will be seeing specialists, isn’t it better for primary care costs to be applied toward our deductible? I just don’t see the financial advantage.

    Also, unless I’m reading what you said wrong, I’m very uncomfortable with the idea of DPC docs only “working with” specialists who do discounts for cash. I want to be referred to the best specialist for my hmedical problem, not to a specialist who aligns with azcash financial model. That paragraph was a definite red flag for me.

    • Jean Oliver

      I agree. With DPC individuals will still have to have insurance to cover any services above and beyond primary care so they will actually be paying 2 fees: their insurance and their primary care payment. Even if you have a high deductible plan and would normally pay out of pocket (and perhaps a higher cost) for primary care services at least it would go towards your deductible. So I agree that this model probably would not work for the average patient. Most probably do not have the extra money in their budget to cover the extra monthly/yearly fee.
      And I agree with Patient Kit about the “good old days”. We also rarely saw a doctor, nor did our parents. Although I do disagree that this was necessarily a bad thing. Personally I am of the opinion that one of the reasons that we have such out of control “health” care costs is that everyone is running to the doctor for every little thing and getting exams/tests that are useless and not evidence based. Save doctors for when you truly need them and take control of your own health. Don’t rely on the health care industry to manage and coach your lifestyle/preventive efforts. The information is out there for free: people just don’t want to follow it and prefer to swallow a pill.

      • Patient Kit

        I agree that we all should take responsibility for our own health. I belong to a gym and use it regularly (avg 5x a week). I eat a basically healthy diet. I do not seek an answer in a pill for everything. In fact, I prefer to be on as few medications as possible. I do not need to pay a primary doc to advise me to eat healthy foods and exercise. I don’t need a primary care doc to take a splinter out of my arm (I performed “minor surgery” myself and took my own splinter out this weekend).

        I’ve also been getting some severe leg cramps lately, maybe partly due to a new exercise routine. I’m not running to a primary care doc for answers. I’m monitoring how much water I’m drinking because I think I might have been dehydrating. Also, since my Achilles tendon surgery, I got into the habit of sleeping with my foot pointed to relax the tendon. I read that pointing your toes can cause leg cramps, so I’m making an effort to break that habit. If I can’t resolve this on my own, I’ll ask my doc about it. But I don’t go running to my primary care doc for minor ordinary things like sore throats, colds, minor injuries, splinters, leg cramps. If I got a splinter in my eye, I’d head to the ER pronto.

        This is all so mystifying to me since more and more primary care docs apparently only want to see patients with uncomplicated problems — which are exactly the kinds of things I feel like I don’t need a doctor for. The uncomplicated problems are often very self-treatable. So, yes, I’m with you on not running to the doctor too quickly.
        Frankly, when I really need to see a doctor, I often need to see a specialist.

        The problem with not being able to afford to see doctors is when people do have something seriously wrong and they put off going to the doctor, for financial reasons, until it — whatever “it” is — gets really bad. When it’s something serious, that can turn into much heartache and even “too late”.

        • Jean Oliver

          Sorry, I did not mean to imply that you in particular are the sort to see a doctor for everything: I was just speaking in general. I have read many of your posts on Kevin MD; you seem smart and your posts are generally spot on.
          One more thing about the “good old days”. I am 61 years old and I do remember going to the doctor as a child but only when we were truly sick: no yearly visits, etc. although we did get recommended immunizations. And my parents were healthy and did not go to doctors as seemed to be the case for most back then. I don’t think “health care” was a big buzz word back then. People only sought “medical” care when they were sick. Now it seems “health care” has turned into a whole industry; something much more than caring for those who truly need it. I always have, and still do, adhere to the “good old days” philosophy and it has served me well so far. Perhaps, also, back in those days people didn’t need to see a doctor as much because of lifestyles back then: more physical activity, less junk food (if any!), etc. I don’t know.

          • Natasha Gajewski

            Health care is quite an industry! Health expenditures represent 17% of the US GDP (World Bank), and the health care industry accounts for nearly 10% of our workforce (KFF). I’m not sure we CAN go back to the good old days…we’re economically dependent on this industry. Let’s just hope that we don’t enter a bubble.

  • Patient Kit

    How can DPC have “widespread popularity” and be “niche” at the same time? They seem like opposite terms. What do you consider to be the barriers to DPC becoming a more widespread model? Would patient resistance be one of those barriers? From my (patient) POV, the idea seems more popular with primary care docs than it does with patients — maybe because it’s a “fix” for primary care docs much more than it’s a “fix” for many patients.

    Since I’ve been involved in discussions about DPC here at KMD, I’ve been floating the idea to people I know to see what they think about. And, so far, nobody I’ve talked to outside of KMD responded positively to the idea — not even people I know who work in healthcare (although, to be fair, none of them work in primary care). Maybe it remains niche because it doesn’t work well for the majority of patients. If it only really works for a minority of patients, I think DPC is destined to remain a niche model.

    • Forthrighthealth.com

      Widespread in that a lot of doctors are practicing in the DPC model across the country. Niche in that it is still very far away from critical mass.

      Out of curiosity, what is it that people don’t like about it?

      My guess is that they would object to having to pay an “extra” fee on top of a high deductible plan.

      They’re right. From a dollars and cents standpoint, that doesn’t make a lot of sense to most people.

      Yet, each and every one of us is already paying for primary care in the cost of our health plans, and we receive terrible value when we go to the doctor – long waits, poor service, inconsistent quality, etc.

      Wouldn’t it be nice if we could strip primary care out of our plan altogether?

      Wouldn’t it be nice if the one part of health care that we all interact with the most (primary care) actually competed for our business based on service, quality and cost?

      The only way that’s going to happen is if we free primary care physicians from the insurance-based coding and billing construct.

      I discuss in great detail a way around the barriers in my website above. You’ll find my email there as well. I’d love to discuss this further with you. You have an excellent assessment of things.

      • guest

        I wouldn’t do it, because I don’t get sick often enough to justify the cost. As someone else mentioned, that would make my one appointment per year crazy expensive and not worth it. I would be more likely (and have) to pay out of pocket for a single appointment, then to pay a monthly fee for a service I rarely use. Might be worth it if I had a chronic illness, but it’s not worth it for people who are generally healthy.

        • JustADoc

          ‘Several years ago’ you paid $75 to an internist for a routine visit. Today, several years later, that internist gets paid approximately $69(there is some geographic variation but woefully too little to account for actual cost of living differences) by medicare for a ‘routine visit’(99213 CPT code for those keeping track).
          His overhead has gone up 3-4%/year x ‘several years’ during that same time.

          • guest

            I would have happily paid more than that for the visit, that’s just what he charged. I was surprised it was so cheap myself. I just think for some people it makes more sense to pay per visit as opposed to a monthly fee. Price the cash visit high enough where you can make the money you want to make. I pay $95 out of pocket to see a specialist, and I really think he’s undercharging. If he charged more, I would pay it. I’m just more likely to pay per visit as opposed to a monthly fee, and if you want to reach the patients who think like I do then offer that option.

            Actually, I noticed my internist charges $50 for cash visit, and I live in a very large city. That is way too cheap. He could definitely get a lot more. That’s less than CVS charges, and he’s got a medical degree. I don’t want to see him go out of business, he’s a great doctor. He needs to raise his rates. People will pay it.

          • Patient Kit

            I think we all understand the concept of our cost of living and expenses going up, up, up while, at the same time, our incomes have not been going up to match those increased expenses. Many, if not most, Americans are living with that hard reality — not just doctors.

            Two years ago, I had a “permanent” full-time job with good comprehensive health insurance and a $52,000 annual salary (the most I ever made in a year). Today, I’m working a temporary freelance job for $19/hr and no benefits and my rent just went up. Go ahead and do the math and tell me exactly how much money I have for healthcare on $19/hr, working 35 hours a week. You don’t even want to know what my rent is here in NYC.

            Also, here in NYC, all government employees have been working without contracts or raises for at least 4 years. That includes the police and firefighters, many of whom worked through 9/11. Now that we have a new mayor, contract negotiations have finally begun. Want another example? The federal minimum wage remains $7.25 an hour and 60% of those working for low wages in this country ($10/hr or less) are age 26-64, not kids working for “extra” money. And the cost of food, transportation, rent and healthcare keeps going up for all of us.

            Maybe this is why doctors are having a hard time convincing patients how hard doctors have it financially.

        • Patient Kit

          This sparks a couple of questions in my noggin:

          1). Would primary care docs who go direct pay only be okay with mostly seeing patients with chronic, complex problems? And would their fee be the same for those patients with chronic illnesses as their fee for mostly healthy patients?

          2). I think you’re right that a DPC membership doesn’t make financial sense for “mostly healthy patients” because of how infrequently they need to see a doctor. But, at the same time, it’s patients with chronic illness and complex problems who need the most comprehensive health insurance they can get. So, for them, DPC is an extra expense on top of the cost of comprehensive insurance. For those who need comprehensive insurance, doesn’t it make more sense for them financially for that insurance to continue to cover primary care?

          So then I’m left once again wondering exactly what patients DPC is best for. I get that it’s good for some doctors.

        • Suzi Q 38

          I understand your point.
          For me, to have a really good GP in my “corner,” as I age and my body “falls apart,” would be worth it.

          I might be able to avoid seeing a few specialists if he/she took more time with me and everything was under control.

          In the long run, it could save me money.
          Remember the doctor will be more available to you when you call for advice or need to come in.

          I could possibly avoid a urgent care or ER visit.
          He/she can also tell me where to get my tests.
          Prices vary, and maybe they have information and have done the research for me. I, like most people, want reasonable prices, even though my insurance may have to pay for it if I meet my large deductible.

          I would be willing to give it a try, as we pay for other things monthly: Cable, cell phones, and gym memberships (actually I paid through Costco and paid cash).
          Sometimes, we even buy cars with a downpayment and monthly payments.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    I think we need to keep our terminology straight here. Direct Primary Care (DPC) means cash going Directly from the patient to the doctor. Corporations that attempt to mediate that transaction by taking money from patients, hoarding it for periods of time, and eventually doling out some of that money to physicians, are called insurance companies.
    The emerging entities, calling themselves DPC, that are employing physicians, or taking equity stakes in their practices or in their future earnings in return for operating capital, are anything but Direct, regardless of how doctors are paid by these entities (e.g. salary, capitation, productivity, quality, value, etc. etc. etc.).

    I think primary care docs trying to escape from the corporate insurance fire are ill advised to hurry up and jump into the frying pans of corporate entities that look awfully like for-profit narrow health systems cross pollinated with underfunded insurance companies. And the same goes for patients.

    I can see the intrinsic value of supporting local independent small physician businesses, and paying a premium for that, but I cannot see the benefits of physician services provided through a distant corporate entity, particularly when paid for by one’s employer or health insurance company. Nothing strikes me as Direct in this model.

    • Patient Kit

      In general, I make a real effort to support independent “mom & pop” businesses over big corporate chains as much as I can. I don’t even understand the concept of a slice of pizza from a chain. I rarely eat in any chain restaurants. And we don’t even have Wal-Marts here in NYC. We didn’t have any of the Big Three drug store chains until they started infiltrating about 20 years ago. I’m a firm believer in supporting local businesses if we want them to continue to exist.

      I hate the whole corporatization of everything. I really do understand and support the concept here. I just don’t know how to translate it to healthcare and doctors in an affordable way.

      • http://onhealthtech.blogspot.com Margalit Gur-Arie

        It may help a little if insurers could be convinced maybe to allow cash transactions to doctors to be counted against deductibles, but even that is difficult, particularly in managed care plans where other considerations come into play. If we all had traditional Medicare, this would not really be a problem, but that’s also not likely to happen anytime soon.

        In the meantime, there are plenty of “mom & pop” doctor shops that do accept insurance, so for now, in my opinion, these are the guys and gals we need to support. And those who can afford, and/or need/prefer, to make cash payments to their primary care doctors, should also endeavor to check and make sure that every cent they pay goes directly to their doctor.

        • Natasha Gajewski

          What about using our health savings accounts to pay cash for our DPC fees? For those years that we are healthy, we pay x dollars per visit to our DPC doctor, leaving the bulk of our HSA funds untouched, to roll over, year after year.

          When a catastrophic event happens, we have the rolled over HSA money to pay down our high deductible. Of course, this requires the discipline of saving one’s HSA money (which I haven’t been able to do).

    • NPPCP

      Hi Margalit, I completely agree. Instead of focusing on being a physician and deserving this or that, focus on your customer base and what they need. Then meld the two together. My clinic is the mother of all hybrids. I looked at the patients in my area and designed plans for all of them. I take Medicaid and Medicare with the strict understanding we both follow the rules. I take private insurance, farm the billing out, and make sure every patient knows that I am providing a service, providing RNs, lights, climate management, and supplies. They know they will be paying the difference. I’m not afraid to use a collection agency because of lawsuit fears. Finally, I use “piecemeal DPC” with reasonable private pay prices. More than a sliding scale ” health clinic” and WAY less than all of my competitors (other NPs, physicians,urgent care, whatever). The patient pays by the visit and they call my cell when they need me. Which is never because I’m open fifty hours a week and have another NP and physician I employ. As I always mention, I need new front doors because mine are constantly worn out. I have none if the worries I hear about on here. I farm out Hipaa and emr and suck it up and pay the fees. But what do I know? I’m just a private clinic owner who answers to the owner (me) and have an unbelievable life. So some advice to the physicians, and other NPs here (and I’m very qualified to give it) – look around you. Find out what people in your area need. Invest with no one but yourself! Love people say thank you – say yes when all the other “providers” in your area b..ch and say no. You will have more respect, friends, grateful people than you know what to do with. And you will do it all by yourself.

    • John C. Key MD

      Agree, Putting a corporate structure in DPC introduces just another “third party”. I fear it is the camel’s nose under the tent wall. And we will be back ad square one again.

  • Suzi Q 38

    I love your idea.
    I would welcome this method of compensating my doctors.
    I know that I will qualify for medicare in a few short years.
    I don’t care who accepts medicare, as I am feverishly saving my money.
    I figure by then we seniors will be paying cash.

    Makes sense to me, as my health is more important than a few vacations or a new car.

    Right now, my deductible for our family plan is $6K.
    I can find money to pay for my PCP directly in that cash outlay.
    I would do this now.

    • Patient Kit

      That’s great for you if you can pay cash out-of-pocket for your medical care, now and through your senior years. But many Americans are not prioritizing a new car or vacation over healthcare. Plenty are prioritizing food on the table and a roof over their heads over healthcare.

      And I sure hope you are wrong about Medicare. Do you really think it’s politically viable to eliminate Medicare for a generation that has contributed to that program for their entire working life? Or are you saying that Medicare will still exist but so few doctors will accept it that it may as well not exist?

      • Suzi Q 38

        Thanks for your post.
        You are right.
        For me it may be doing without the extras, as my house would be paid off and I have other income to support my lifestyle. I could pay physicians directly on my own but not the hospital stays or the major tests like MRI’s and the like.

        At this rate they would not have to eliminate medicare for a generation. The doctors themselves would eliminate it for us by not accepting it, or only accepting a very small portion of the public for medicare or medical.

        Most doctors can not make money on medicare.
        It is a losing part of their business.
        WE may very well have to accept going to PA’s and NP’s for our primary care. When it gets too complicated, we may have to pay cash to get to see a GP or an FP.
        Maybe medicare will pay a sufficient amount for us to be able too see a specialist, not sure.
        At any rate I hope that they can at least double the pay for our doctors so that they will accept more of us. Also, I hope that if we pay cash, our doctors will give us a discounted rate, since they won’t have to wait for our payment for the visit.

        IF not, I will go to the PA or NP and if need be pay cash to my FP or GP…..who knows if this plan will be allowed.

        • querywoman

          Medicare works fine for me. I pay my annual deductible and then just pay my 20%.
          I mostly see specialists these day, and I don’t think they have as many problems with Medicare as general doctors do (again, I hate PCP terminology!!!)
          I do have a managing internist. I suppose she has a mix of Medicare and private insurance. I do know she does some hospitalization and goes to the nursing homes.
          If I couldn’t find a decent private general doctor, I could always find a public or church hospital doctor around here.
          I do not need expensive technology. I need regular doc visits, blood work, and generic and some expensive meds. Victoza and my inhalers are expensive.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Yes, plus, the way it is written now, you will need to use a “certified” EMR to share care plans with other entities in order to be eligible…. Easy for large systems and next to impossible for independents… seems to be a consistent thread running through all these things….

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    If you add 2 to 4 visits per year for patients with chronic illness, you get anywhere between $650 and $800 per year. This is consistent with the low end subscription fees for direct practices, and it excludes all the “free” lab tests some DPC include in the price.
    True, it does nothing for the overhead, but there should be plenty of funds there to cover a few extra phone calls and some emails….
    I am not opposed to cash business, but recognizing that most business is not cash, and will likely never be so, I think it’s a good thing that CMS is starting to think about reimbursing things other than in-person visits. Commercial payers are sure to follow, as they always do. There’s a long way to go, and I wish it didn’t come with all the strings attached, but it’s a start….

  • buzzkillerjsmith

    Works for some but come on. Quite reasonable costs? Not if you barely have a pot to piss in, junior. Perhaps you have seen one or two the these folks over the years.

    Perhaps you no longer do. Good work if you can get it. Pity about that good chunk of society.

    • Patient Kit

      You make me feel…..heard. :-D

  • Patient Kit

    Direct pay psychiatry in this country may work out great for those psychiatrists who only take cash. But for many Americans in need of psychiatric care, access to mental health care has not worked out so well when insurance doesn’t cover it and/or psychiatrists don’t accept insurance. If direct pay psychiatry is the model that some primary care docs want to follow, I’m seeing bright red flags popping up. Do we really want primary care docs to become as inaccessible as psychiatrists already are in this country? Somebody explain to me like I’m a 5-yr old how this will be good for ALL Americans?

    Re the shortage of PCPs, I think the theory is that if we make primary care more attractive to doctors, in the longrun more will stay in or go into primary care. But I think you are right about the short run: If we already have a shortage of PCPs and many of them start seeing fewer patients, the shortage of PCPs will get worse for a while until, hopefully, in the longrun it gets better.

  • HJ

    I have insurance to take care of a catastrophic illness or injury. Paying a membership fee for primary care doesn’t add to that.

    A membership with a primary care doctor doesn’t replace insurance.

    A membership with a primary care doctor doesn’t necessarily save any money.

    I really enjoy my cup of coffee…

  • logicaldoc

    My comment get censored?

  • Suzi Q 38

    I would pay the $50.00 a month. You are asking the wrong people.

    • logicaldoc

      Well thank you for that positive reinforcement of the idea. I am in an economically depressed area so perhaps that has something to do with it. But I have not yet ruled this out as my final curtain call in the profession (going on 23 years now). As more and more people get catastrophic/high deductible plans (even those in their 40′s and 50′s), this may become a possible viable reality for me. Who knows; need to see how the PPACA plays out over the next year or two.

      • Suzi Q 38

        Yes, we just got a high deductible plan.
        Our insurance does not “kick in” until we pay $6K. It is July, and we have paid out the $6K in co-pays and “patient responsibilities” yet.

        My husband is delighted, as we used to have a low deductible and paid $900. a month plus his employer paid $1k a month. Now we pay $450.-$500.00 a month. I will not settle for an HMO at this time, since he works for the public sector.

        He is the one that talked me into this “high deductible” plan, but it seems to be working out.
        I have recently had 3 MRI’s (brain, cervical, and thoracic), and I need a mammogram next month. Not to mention all of my GYN tests.

        If my GP told me tomorrow that he would want me on a yearly or monthly plan, (say $600.00 for the year in two payments), I would make the first $250.00 direct payment now.

        Sometimes, I see that he is so tired seeing all of these Medical and Medicare patients.
        After finding out what the situation is, I wonder how he stays in business. I must be one of the few private pay patients that he has.

        • logicaldoc

          Thank you for your response and encouragement. It is something I think about more and more each day. Good ideas on marketing.

          • Natasha Gajewski

            So nicely worded, SuzyQ! I agree. We must make family/internal/GP medicine viable again. Logicaldoc, blog about it! If you haven’t started yet, start. Then tell us what happens. And subscribe to Seth Godin’s blog post…he’ll inspire you everyday.

          • logicaldoc

            Thanks for the Encouragement. I Blog; I’ve written two books, blah, blah, blah. Unfortunately, like I think I said somewhere, my “Profession” has turned on me and now it’s simply a matter of survival to support my family. If I was alone; I’d drop my M.D. in a heartbeat for a less stressed, warmer climate, fun and spirited social thing to do (even if that means serving up drinks for tips at a Tiki Bar in the bahamas somewhere). Money at this point in my life, if I had no attachments, means nothing to me now.

  • Ladyimacbeth

    Yeah, insurance is crazy expensive. I would prefer it be for catastrophic as opposed to routine medical care. The last thing I want is more insurance which is what paying a monthly fee would feel like.
    I just think people would be more likely to pay cash per visit as opposed to taking on another monthly fee. You can price it high enough to make it worth it. My specialist who does not take health insurance doesn’t seem to have any problem filling the slots. It makes no sense that some doctors are charging so little for cash appointments.

  • Ladyimacbeth

    I guess what I don’t understand is why a physician would prefer the monthly fee versus the set fee per visit. It looks like with the monthly fee and unlimited visits, you could risk ending up with some high maintenance patients who stop by really, really often making that monthly fee you are receiving worth less and less. Whereas with a set fee per visit if someone is high maintenance, and they stop by frequently you still benefit. Is overuse a problem with the monthly fee for unlimited visits?

  • Sherry Reynolds

    This is a flawed model from the 1st day – it doesn’t scale (where did the 1500 patients you used to take care of go to?) We already have a shortage of primary care docs so as long as you don’t look at those thrown out of the boat it works. YEAH.. good for those that can afford it but a short sighted and frankly selfish solution.

    Over-night you would need to double the number of primary care doctors but it is a great way for primary care doctors to dramatically increase their income (that is the real motive behind all of the programs that market this model).

    It also assumes everyone has the extra $500 a year to pay for care that 90% of the population doesn’t use.. Where did the patients who can’t afford this go to? Do the practices drop people on medicare (who actually are very well off) and medicaid.

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