Does direct primary care improve quality measures?

Part of a series.

In earlier posts, I have described direct primary care (DPC) in its various forms called membership, retainer and concierge. There are some concerns with DPC. Does more doctor-patient time really mean better quality care? Does it really mean lower total costs? It seems logical that closer care means better care, fewer referrals to specialists and fewer hospitalizations. Most DPC physicians will tell you this is the case but there are few studies to actually document results. Here are two based on data from a large DPC organization.

MDVIP, which has about 700 affiliated PCPs in 42 states and the District of Columbia. MDVIP is a national company that assists PCPs transition to a form of direct primary care model which puts an emphasis on wellness and lifestyle factors in addition to expanded primary care. MDVIP was founded by physicians in 2000, purchased by Procter and Gamble in 2009 and sold to Summit Partners in 2014.

In their model the PCP affiliates with but is not an employee of MDVIP. The PCP still bills the insurance carrier for visits but also requires a $1,500 to $2,200 annual fee for expanded services. He or she limits the practice to a maximum of 600 patients and generally follows the approach described previously for direct pay practices (same or next day appointments for whatever length necessary, 24/7 cell phone access, etc.)  The PCP includes a very extensive 1½ to two hour preventive medicine annual exam preceded a week before with vision, hearing and pulmonary function tests, an electrocardiogram if appropriate, a survey of dietary habits, psychosocial issues and a large battery of blood and urine tests.

As with most doctors that go with direct primary care, those that affiliate with MDVIP are usually far advanced in their careers and find they are getting burned out by “the treadmill” and the lack of enjoyment and satisfaction in their current practice arrangement. MDVIP has an extensive methodology to transition a physician from the traditional primary care practice to an MDVIP practice. To counter the argument that patients who choose to not join will be left with no physician, MDVIP will not accept a doctor into its program unless it is clear that there are sufficient other PCPs in the area. Although the average PCP converting has 2,500+ patients in his or her panel, it does not turn out to be first come, first served to reach the limit of 600 patients. Instead, usually only about 300 to 350 actually sign up in the first year with more coming on board via word of mouth over time.

PCPs who switch to direct primary care, in general, state that they now can delve into the psychosocial issues that are underlying many trips to the doctor. For example, one MDVIP doctor told of a patient with many difficult to control chronic conditions over the years. Now, nearing the end of the lengthened annual evaluation and, having developed a much closer relationship than ever before with his patient, he asked, “Is there anything else we should discuss?” “Well, yes, I was raped in the concentration camp. I never told anyone before just now.”

With that startling revelation, the doctor was able to finally understand the basis for many of her symptoms and illness problems and was able to rethink the best approaches to her care. He felt that this came about only because he had been able to develop trust as a result of deep nonjudgmental listening rather than rushing the process as he had to do in the past.

MDVIP is large enough, with 215,000 patient members, that it has been able to do some retrospective evaluations of whether direct primary care with limited patient numbers actually improves quality and reduces total healthcare costs. Patients in MDVIP practices studied have had a substantial drop in hospitalizations including a 79% decline for Medicare enrollees as compared to similar patients in regular primary care practices and a 72% reduction for those ages 35 to 64. Elective, non-elective, emergent, urgent, avoidable and unavoidable admissions to the hospital were all lower for the MDVIP members. Hospital readmissions have likewise declined substantially.

Another retrospective review suggests that the MDVIP patients are more likely to have higher quality measures (HEDIS) than are those in regular primary care practices. For example, blood pressure control was better, diabetic HbA1c and cholesterol levels were lower and a higher percentage of patients had mammograms and colonoscopies, as appropriate for sex and age, than national averages.

These are not randomized controlled studies but they do suggest that direct primary care with a reduced patient panel and extensive attention to wellness, prevention and care of those with complex chronic illnesses does result in better health and lower total costs to the system.

Does direct primary care improve quality measures?Stephen 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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  • Lisa

    Thank you for the study. Correct me if I am incorrect, but I understand it to say membership in the DPC practice reduces medical costs to the system, but it does not look at the patients overall medical costs. In fact, the study suggests that one reason the practices are successful is that patients pay an annual fee and are therefore inclined to be more compliant. The study does mention that DPC does not do away with need for traditional insurance.

    As one of the selling points of DPC practice is cost to the patient, I would like to see some larger studies addressing this issue. Does DPC save every patient money, or does it save money for frequent ‘medical fliers.’

    I still think DPC will remain a niche product, for the upper class, until the cost issues are addressed.

    • Patient Kit

      According to the MDVIP website, to see affiliated doctors who. practice in the MDVIP model, there is still a charge for each office visit (that insurance covers). The annual fee, according to MDVIP, is for an annual wellness program that PCPs don’t usually have time to deal with.

      (1) This means that this MDVIP model of DPC is not compatible with cheaper catastrophic insurance but still requires comprehensive insurance to pay for the fee for each primary care visit.

      (2) Don’t we already get wellness visits and screenings included in our insurance?

      I know someone who just got a letter recently from her primary care doc announcing that she was switching to the MDVIP model and requesting the annual fee from my friend. At first she was confused (she hadn’t heard of DPC before), then she was pissed off. Now she’s looking for a new doctor.

    • LeoHolmMD

      Yes, cost to who?
      Lots of people are lalking about reduced medical costs, when they actually mean the costs are unloaded elsewhere.

  • Patient Kit

    MDVIP is owned by Summit Partners, a private equity group whose main purpose is to make money by making a business as profitable and efficient as possible before either leading that company to an IPO or selling it for a major profit, usually within a few years of buying it. “MDVIP-affiliated” would not be a selling point to me as a patient if I was looking for a new doctor.

  • futuredoc

    Good comments. As to MDVIP, it is certainly possible to say it is not true DPC, but my point was simply that in a setting where the PCP has more time with each patient, the care quality goes up and the total costs come down. MDVIP has enough patients that they can do some measurements. As Forthright stated there are other examples such as Iora Health (Yes, it would be good to see the data for us all.) And I would add in AbsoluteCARE as another example where they set the PCP to patient ratio at 300 and place substantial added resources into primary care for Medicaid individuals that have multiple chronic illnesses. The result is better health and although primary care costs much more, the total costs to Medicaid go way down.

    Reduced total costs does not equate to reduced personal costs.Again my point here was that more time with the patient means better care and that equates to ultimately lower total costs becasue of fewer specialists referrals, ER visits and hospital admissions. The beneficiary of lower total costs may be the insurer, the employer or the government. One could hope that this will ultimately result in lower premiums but that is another story.
    Stephen Schimpff

    • Lisa

      Well, as a patient I am concerned with my total health care costs. I just don’t see the increasing my costs in oder to reduce total cost and I suspect many patients will agree with me.

    • HJ

      It seems to me that adding an extra 90 minutes to a yearly physical that has no clinical value isn’t increasing the quality of care.

  • Lisa

    How do total costs for the patients compare to traditional insurance?

  • buzzkillerjsmith

    Retainer medicine might lower total cost per patient. The retrospective evaluations deserve some thought. Of course, a double-blind controlled study would be impossible here.

    As James A rightly points out, there are confounding variables.

    RM comes from docs trying to survive in general medicine without having to work for soul-crushing CorpMed. If the docs’ choice is between retainer medicine and retiring, RM is probably pretty good. If RM induces too many younger docs to slough off a thousand or more sickies, the shortage worsens even faster.

    It is right to distinguish between RM and DPC.

    RM is not a societal solution. Neither is DPC. They are both shelters from the storms.

    Of course there is no societal solution forthcoming.

  • HJ

    From the MedLion website, it looks like it is a company privately owned by physicians. Unless the doctor I am seeing is an owner of the company, it is not direct as the owners of the company become a third party.

  • HJ

    From your website,

    “For doctors who prefer to concentrate on patient care rather than running a practice, MedLion offers unrivaled opportunities at its corporate clinics. A great lifestyle awaits.”

    If MedLion sets policy and prices…like $10 visits and no walk-in care… and receives money from the doctor providing service, then there is a third party involved in my care.

  • Steven Reznick

    The original MDVIP practices were in South Palm Beach County , Florida. The two founders were superb internists with subspecialty training in nephrology. Their patient population was not elderly but severely ancient. Having more time to spend with their patients and coordinate their care, while improving communications between patient , doctor, family and supporting consulting physicians all contributed to a positive outcome. They recruited experienced knowledgable physicians to join them. The extra time is the difference. You can squabble all day about which category to put MD VIP in or any of the hybrid concierge practices but the truth is that the access, coordination of care , availability of the physicians and extra time spent with patients is what heads off crises and ER visits. The cost of the annual membership is offset to the system by the decline in hospitalization related charges.

    • Lisa

      The cost of the annual membership does not necessarily save the patient money, however. Again, the total cost to the patient is important. Why should the patient spend extra money to save the system money? Better care? Maybe, maybe not. I have conventional insutrance and I get good primary care.

      One metric I have not seen is a comparison of health outcomes between members of MDVIP patients and similar patients with conventional insurance. You have determined that the MDVIP patients cost the system less, but do they live longer? How do the outcomes for MDVIP patients diagnosed with a particular disease fare as compared with patients covered by conventional insurance?

      • Patient Kit

        I know that I’m not saving the system any money right now because I’m pretty much limited to hospital-based healthcare if I want good medical care, since most private practice docs can’t/won’t treat me because Medicaid is a hassle and doesn’t pay enough. For example, I have an endoscopy scheduled in a few weeks at the hospital. The doc who is doing the procedure is a very experienced, well-respected attending who has been rated a Top Doc and who is Associate Chief of the GI Dept. A resident did the initial intake on this consult but the attending is doing the procedure. My endoscopy, which is not an emergency, was scheduled for less than 3 weeks from the day I made the appointment.

        As soon as I have affordable comprehensive insurance, I’ll be happy to start saving the system some money by getting some of my care outside of the hospital. But, I gotta tell you private practice docs — I’m getting used to some really good care at the hospital from some really good docs. I understand that it is less expensive to see private practice docs. But given my recent experience, it will be hard to convince me that I’d get better care from private practice docs than the excellent care I’ve received at the hospital. There are some awesome docs working in the hospital. It’s been an education.

  • NPPCP

    Who cares if TRUE DPC improves quality measures? Its nobody’s business. Its a private agreement between two willing parties. If I were ever true DPC, you would never hear ridiculous weasel created government lackey terms like that. I would pitch you right out the swingin doors and into the horse trough.

    • Lisa

      Well, I don’t think can really sell DPC soley on the cost to patients, as it won’t benefit many patients financially. Therefore, things like quality measures and even more nebulous things like the doctor patient relationship become part of the pitch.

  • Lisa

    This is a testimonial. It does not answer the question I asked – how do the total costs for patients in DPC (such as Qliance or Iorta Health) ccompare with those people with traditional experience. I still say unless you have some mechanism for to combine DPC with an insurance that covers major medical expenses, beyond primary care, the cost for the patient will be more, due to the need to maintain insurance for those medical expenses that are beyond primary care. HJ did an analysis based on the cost in her area, which I am copying here:

    From HJ – it is based on numbers from my area…

    A membership practice in my area costs $170 per month.

    For $294 a month I can get a bronze plan with a $5000 deductible and a $6350 out of pocket max.

    For $475 a month I can get a gold plan with a $1500 deductible and $10 primary care visits. With an out of pocket max of $4500.

    Gold plan…
    a good year…$5710
    a bad year…$6150

    Bronze plan with DPC
    a good year…$5568
    a bad year…$11918

    Bronze plan without DPC…
    a good year…$3538
    a bad year…$9878

    it seems to me a DPC plan is generally expensive for the paitent, so proponets of DPC are arguing that DPC saves money for the system. Perhaps, but my question was does it save money for the patient? i

  • Lisa

    The figures were from HJ: there are no DPC practices in my area.

    My husband and I own our cars and house outright. Currently, our largest household expense is food. With regards, you to what you get from a bronze plan – you get ‘free preventative care’ But mostly you get protection against out of pocket medical expenses beyond the deductible. There is a value to that, to the having that protection. Remember that most bankruptcies in the US are related to medical expenses.

    You still didn’t answer the question about total costs. I spent some time reading about individual plans available to people via Qlaince. These plans are available on a state exchange and they sound like an attractive product. But they do not sound like DPC exactly. They advertise 24/7 access to a nurse advice line, not 24/7 access to your PCP. Furthermore, I can’t determine easily the cost for these products as the open enrollment period is closed and I don’t have a special enrollment need beyond curosity.

    Iora Health has an attractive web site. I could find out less about the plans they offer individuals.

    • Forthrighthealth.com

      “free” preventive care is not free at all. You pay for it in your premium to the tune of about $500/year. Plus, it only covers your one preventive visit per year. If you bring up any other problems during that visit, you get dinged for the full cost of a visit. Any other sick visits and you pay the full price. Any warts or lesions – that’s at least a $150 charge. Lab costs – probably close to $100 per draw. Hopefully you don’t need an x-ray or mri, that’ll set you back a few thousand.

      Furthermore, you only get maybe 10 minutes face-to-face time with a doctor MAX. And you wait 2 weeks to set up an appointment and then you wait 30 minutes in the office.

      Yes, you’re protected against catastrophic risk, but for the 80% of people that never use their entire deductible, they don’t get much value at all.

      A DPC practice covers close to everything under the deductible (even imaging if the DPC practice has the technology in-house). Plus, you can get access to your doctor whenever you want, without the wait.

      The typical DPC practice costs about $70/month. Right now, you’d have to pay that on top of your Bronze, Silver or Gold plan.

      You’re absolutely right, adding DPC to an existing policy doesn’t make a lot of sense if you just compare premium to premium-plus-DPC. That’s why I’m working to make it part of one package. Unfortunately, the entrenched interests are fighting hard for the status quo.

      But there is more to purchasing decisions than just cost. If costs was the only determining factor in a purchasing decision, everyone would only shop at Wal-Mart, and Target, Costco and others wouldn’t exist.

      • Lisa

        Protection against catastrophic medical bills is of value. I live in California and was affected of the 1989 Loma Prieta earthquake. We carry earthquake insurance, with a large deductible. I can afford to pay the deductible, but I can’t afford to replace the house. Anyway, after the earthquake, I had to drive home from a friends house. I knew how bad the quake was and was worried about my house. All the way home I told myself, well at least I have quake insurance. At least I have quake insurance. The damage to my house was just under the deductible. I still carry quake insurance.

        DPC when combined with catastrophic insurance is allowable under the ACA, and if offered on a state exchange eligible for subsidy. Is the fight really about the status quo or are people not purchasing such plans, when available, because of the cost?

        • Forthrighthealth.com

          Do you file a claim with that earthquake insurance every time a little rumble knocks a glass off the shelf or pops a screen out of the window? Probably not.

          Then why do you use health insurance to pay for everyday routine primary care things?

          As for the ACA, we are still waiting (now 4+ years after passage) for HHS to determine the final regulations on DPC plus catastrophic. We can’t get listed on a state or federal exchange until those regulations are finalized.

          • Lisa

            I’ve never filed a claim with the carrier of my earthquake insurance.

            I use my health insurance to pay for routine healthcare because such expenses are covered expenses. I have standard insurance because that is what is available to me and because it makes financial sense.

      • Lisa

        Wal-mart, Target and Costco do tend to drive out smaller business, who can’t compete on costs. Costs to the consumer matter a great deal.

        • Forthrighthealth.com

          If cost matters to you so much, why do you continue to support a system that increases in cost 2-5 times inflation every year?

          • Lisa

            My health care/insurance expenses have not gone up 2-5 times inflation every year. Far from it. In fact, the total cost for my insurance went down slight last year. And since 2008 or so, the increases in cost have been less than inflation.

          • Forthrighthealth.com

            Do you buy an individual policy or do you get it through an employer? Have your deductibles, copays and coinsurance levels stayed the same throughout?

          • HJ

            My insurance premiums went down this year.

          • Forthrighthealth.com

            What’s the average over the past 5 years? And not just your premium, but your cost plus the employer’s cost.

          • Lisa

            My insurance is through my employer. When I was talking about the costs, I was referring to the total costs (my employers portion and my portion), but the deductibles, co-pays and coinsurance have remained the same throughout with the exception of this year. This year, providers are in three tiers, preferred, in-network and out of network. For in network providers you pay 20%, versus what used to be a $20 copay. The max out of pocket is still limited. In exchange, my contribution to my isurance cost went down and I get access to several teaching hopsitals as preferred providers. I consider that a wash.

          • Forthrighthealth.com

            I guarantee you that the employer cost plus your cost has not stayed the same since 2008. That would be like finding a unicorn.

            Off-topic, but look up research on quality at teaching hospitals. You’ll find it’s inferior to less “well-known” providers.

          • Lisa

            I said the total cost (me & employers) of my insurance has gone up less than the cost of inflation, not that it has stayed the same. I did say the deductibles, co-pays and coinsurance has stayed the same since that period.

            I think having the teaching hospitals available to me as preferred providers is attractive. Those particular hositals are ones I would want to use if I ever half to have either of my hips replacements revised. And if my cancer recurrs, I would use one those hospitals rather than my local hospital, which is not that great imo. Several of my friends are treated teaching hospital and their care is very good.

          • Patient Kit

            I prefer teaching hospitals. I feel like I’ve gotten excellent care at one of NYC’s numerous good teaching hospitals. I’m in the NY Presbyterian system but there are many other good teaching hospitals in NYC.

      • HJ

        Your argument is that I might need $150 wart removal so I should pay a membership practice $1000 because I will never reach my deductible?

        • Forthrighthealth.com

          My argument is that healthcare costs will continue to go up 2-5 times inflation every year unless we look for ways to innovate. DPC is just one of the ways. There are others.

          And, NO, single-payer will not fix the cost problem. The UK, Can, etc. are all experiencing cost increases just as high if not higher than ours.

          • HJ

            So Kaiser Permanente provides patients with a monthly fee and ALL their health care needs are met. KP has lower premiums than Why is DPC any different from the much maligned KP? Why would I trust a corporation whose main purpose is to make money to do the right thing with my health.

            I thought direct meant the relationship between me and my doctor include no third parties…what you are describing is a relationship between me and the corporation.

          • Forthrighthealth.com

            KP is more like the ACOs included in the ACA. Look them up.

            You trust corporations whose main purpose is to make money with your health RIGHT NOW. They’re hidden behind the guise of non-profits, but go take a look at the salaries of the CEOs and administrators. What do you think they get compensated on?

          • HJ

            So if I mistrust corporations, why would I choose Qliance which received millions of dollars in venture capital. Qliance has a CEO.

            I don’t even know what we are discussing. Independently practicing doctor collecting membership fees is excluded from DPC but those with investors that expect a profit are? And I am supposed to shun the profit making insurance companies in favor of profit making DPC?

            KP is not an ACO. It takes money from patients, gives them access to doctors, pays doctors a salary, tries to keep patients out of the hospital…isn’t that what Qliance does? It was founded in 1945.

          • Patient Kit

            That’s exactly what it sounds like to me: We’re being asked by some doctors to reject evil profit-driven insurance and hospitals and switch to “good” profit-driven DPC. It seems that they want to keep a profit-driven business model — just shift more of the money to doctors. DPC doctors affiliating with private-equity-owned corporations while sniping at how awful academic medical centers and teaching hospitals are is sounding a little — what’s the word I’m looking for? — to me. Not sold.

  • HJ

    We have one concierge practice that costs $170 for someone my age per month. We also have an executive medicine whose current cost is $3300 per year and retainer practice that costs “a little more that $2 a day.” Why would you think that a $1000 a year in Kansas would be the same everywhere?

    In San Francisco, I googled a concierge practice that charges $3000 a year for individuals, $4200 a year for executives whose benefits include that over the top annual exam described above.

    I went to my states exchange website and found the prices for the each plan that Lisa provided. You seem to be suggesting a catastrophic insurance plan isn’t valuable and patients should just buy a membership in a concierge practice.

    • Forthrighthealth.com

      I am not referring to Concierge whatsoever. Concierge and DPC are two completely different things.

      I believe DPC plus a catastrophic plan is the IDEAL healthplan construction.

      • HJ

        Why is it ideal?

        • Forthrighthealth.com

          Because you free primary care physicians (the part of our healthcare system we all interact the most) to start competing for patients based on Service, Quality and Cost instead of having to see 25-40 patients per day. Thus increasing the front-end value we all receive. Then, you’re covered for serious illness with the catastrophic.

          • Patient Kit

            I think that’s a major wrong assumption — that primary care docs are the part of our healthcare system that “we all” interact with the most. Plenty of people self-treat minor issues and only go to the doctor when they need a specialist. I’m not even convinced that most people interact the most with primary care docs vs. specialists, let alone “we all”.

          • Forthrighthealth.com

            It’s not an assumption, it’s a fact: http://www.cdc.gov/nchs/data/ahcd/nhamcs_outpatient/2010_opd_web_tables.pdf

            Furthermore, plenty of people self-treat minor issues because our primary care system is so un-customer friendly that it’s easier to self-treat than see a doctor.

            Primary care can cover 80% of our needs. The more we see specialists, the more cost we dump on everyone.

          • Patient Kit

            Can you name a few things that specialists currently do that you feel like you could do for your patients instead? I’m really uncomfortable with the idea of primary care docs who haven’t been doing this specialist care for a long time suddenly starting to do it again.

          • Forthrighthealth.com

            Largely anything having to do with diagnosing, treating and managing chronic disease (which is responsible for 75% of our healthcare costs).

            What do you think happens in rural areas where sub-specialists aren’t available?

            Primary care is the only specialty that treats the whole person, not just the organ or condition. That’s why you have people who see 4 different specialists end up on 20 different medications.

          • Lisa

            This fact sheet is discussing out patient care, which is part of medical care. But a minority of that out patient care was with a PCP.

            People self treat minor issues because minor issues tend to be self limiting and go away no matter what you do. Why would you go to a doctor if you have a cold? To have them tell you to rest and have some chickensoup? The truth is it will always be easier to self treat a minor illness than to see a doctor, no matter how customer friendly the system is.

          • Patient Kit

            I wouldn’t go to a PCP for a cold, flu, cough, sore throat, earache, etc, unless it lingers too long and I really can’t shake it. But the majority of the time my immune system fights it off quickly with some extra rest and healthy food. A doctor isn’t going to tell me anything I don’t already know about those kinds of things. And way too many docs try to give inappropriate antibiotics. If I don’t want the antibiotics, why go to a PCP for such minor things? There are things I will go to my PCP for, of course. But not this kind of minor stuff.

          • Forthrighthealth.com

            Completely agree. Unfortunately, most in our country do not and many end up going to the high-cost ER for such things. Why? Because they don’t have a primary care physician that will tell them that they’re ok and they don’t need to worry.

          • rbthe4th2

            They go to urgent care. When the flu gets bad, the urgent cares are overloaded.

          • Patient Kit

            I live in a city of 8.5 million people and the competition among doctors and hospitals for patients is pretty fierce here.

          • Forthrighthealth.com

            Among hospital systems, yes, but not among primary care. If there was true competition within primary care, you wouldn’t be waiting 2 weeks for visits and 30 minutes sitting in waiting rooms or on paper examination tables. Hospital systems lose about $150,000 per year subsidizing a primary care office because they know if they keep primary care dysfunctional, they will make up multiples of the $150k they lost on specialist visits, surgeries, imaging, labs and other ancillary services. It’s rigged against you, and you’re happily playing right into it.

          • HJ

            It really doesn’t compete with cost.

            I saw my doctor once in 2014…to fill prescriptions. Paying a membership fee increases my costs.

          • Forthrighthealth.com

            Overall, it will. It might not make sense for you now, but it makes sense for the 50% of people responsible for 98% of the cost. You’re paying for them right now anyway, and they’re jacking up the cost for everyone year after year.

        • Patient Kit

          DPC plus catastrophic is not ideal for me or for anyone I know. There is a lot that is not covered with that combination.

      • Patient Kit

        Most people who have a more expensive comprehensive plan through their employer can’t just change that plan to a cheaper catastrophic plan. It’s a group plan. Everybody can’t negotiate their own terms with the insurance company. Not that I personally would want a catastrophic plan. I will always prefer a comprehensive plan. I’m just pointing out that a lot of people can’t just ask their insurance co for a cheaper plan so they can use DPC.

    • Patient Kit

      We have a concierge practice here in NYC that charges a $25,000 annual fee. You have to pay extra for lots of things though like lab work and house calls. I’m doing some research on both DPC and concierge in NYC and most websites are not very transparent about the cost for patients. These doctors websites are like sales pitches for the model but contain no mention of fees. I can call if I need to know that part. Not a good sign if they’re not posting their fees.

  • HJ

    Expenses…

    1. Mortgage payment
    2. Retirement Saving (Financial Advisor says we should save more)
    3. College Fund (We still will take out loans)
    4. Kids extracurricular activities
    5. Food

    • Forthrighthealth.com

      Do you get your health insurance on the individual market or through your employer?

      • HJ

        I have a high deductible plan through my spouses employer. When we were deciding whether taking the job a good move for us, we made sure we got enough salary to offset a weaker healthcare package. The previous employer was self insured and we didn’t pay premiums.

        • Forthrighthealth.com

          Take a look at your W-2s from last year, your overall cost of healthcare that the employer paid is probably near what you pay for your mortgage. Also, I guarantee you that over a 5 year period your spouse’s employer has seen total healthcare costs increase an average of 2-5x inflation.

          Healthcare costs are largely responsible for the stagnation in overall wages for the past 15 years.

          It sure would be nice to finally do something about healthcare costs and get more in our paychecks.

          • Patient Kit

            If healthcare costs come down for employers, do you seriously think that will result in higher wages for most Americans? My bet is that it will result in higher profits for employers.

          • Forthrighthealth.com

            Do you seriously think higher healthcare costs benefit Americans? My bet is that if they continue to rise, they’re not helping anybody.

          • Patient Kit

            No. I don’t think higher healthcare costs are good for anyone. But I don’t share your faith that employers will share the savings with their employees. The more I read, the stronger my belief becomes that a single-payer, tax-funded healthcare system is the way the US needs to go. I think comprehensive coverage for all will benefit Americans. And it would be great for employers too if we had a comprehensive national healthcare system independent of employers.

          • Forthrighthealth.com

            Someone still has to pay for a single-payer system and the costs in such systems are rising just as fast as our current system. Look at the cost increases across single-payer systems (including our Medicare and VA) and you’ll see rates the same or greater as our “private” US system.

          • Patient Kit

            I want a system in place that guarantees all Americans the medical care they need, whether they personally have the money or not at the time that they get sick or injured — something like Medicaid for All Americans. I think healthcare is a human right similar to our kids having the right to an education through high school. I want healthcare in this country to stop being, first and foremost, a big business.

          • Forthrighthealth.com

            I understand and don’t differ all that much. However, go take a look at the Medicaid Managed Care Organizations that manage Medicaid for the states, talk about BIG Business! Then go take a look at the Medicaid quality measures. The systems in the hands of the government are even more corrupt! I’d rather give the system to the people. Give everyone money in an HSA and let them do whatever they want with it. It wouldn’t be dissimilar to food stamps.

          • Lisa

            HSA are only available to people who are employed. Not retired people, not people who are unemployed. But the major problem with handing people currently on medicade some sort of stipend to buy medical care is those politicians who don’t believe that poor people deserve medical care will cut those stipends. Or else they will provide stipends that are not enough to cover medical care comprehensive medical care. And even worse is business will pop up to separate people from the stipends. And based on what I see here, I fear some of those businesses will be DPC practices who will convince people that if they have DPC they do not need insurance.

          • RES

            When I was a graduate student and our first child was born we were in California. To my great surprise and good fortune MediCal then (unlike any Medicaid now, AFAIK) would pay. Any income over the poverty line was the monthly deductible- we paid that then they paid.
            If there were to be a national health system in the US this might be a worthwhile way to run the major medical part of it. If it did, concierge primary care might work, though I have my doubts.

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