Direct primary care: A response to your comments

Part of a series.

Over the past few months KevinMD.com has posted a series of articles by me on what I call the “crisis in primary care.”  Most recently have been a few posts related to direct primary care. They have generated many comments: some pro and some con. I have greatly appreciated everyone’s interest; it makes it worth the time to write. I am also working on a book on primary care and so these comments have helped to mold my thinking. So thanks.

My fundamental belief, contrary to some comments, is that PCPs are much more than providers of “simple” stuff. They are more correctly specialists that deal with the very complex. Comprehensive primary care includes wellness and health maintenance, prevention and risk management strategies, attending to the episodic events that occur in life, and the care of those with complex chronic illnesses including coordination of care when a specialist is needed. It also includes developing a strong relationship between doctor and patient, building trust along the way and offering true healing. This means that the PCP (I was not a PCP) can competently handle the vast majority of our health needs.

But all of this takes time and when the current practice business model forces the PCP to see 25 or more patients per day, there is just not enough time. Direct primary care (DPC) is one way to regain that time. It is not the only way.

A few themes have arisen repeatedly in comments from these posts about direct primary care. One is that there is a difference among the terms DPC, membership, retainer, and concierge.  But to me, they all mean essentially the same thing: fewer patients per doctor and therefore more time for the patient with the doctor which equates to better care.  There does seem to be a degree of concurrence that DPC and membership are terms most often used for those practices that cost less per month or year and retainer and concierge for those that cost more. Among the most common other themes from the perspective of a patient are: DPC is too expensive, especially for those of lesser means. DPC is an added expense if you already have primary care coverage by your insurance (e.g., Medicare or company policy). The PCP “abandons” patients when converting to DPC and does it because he or she is greedy. And the question, “Is the care quality really better and are costs really lowered?” Some thoughts on each.

First, DPC is certainly not for everyone — patient or doctor. But it is one model and it has proven very effective for some.

Expensive? It’s relative. The average American family spends $2,237 per year for cable TV, Internet and phone. A Starbucks a day adds up. A parking space per month in a downtown lot is probably more than the DPC doctor. It is about prioritizing our personal expenditures. I also posted an article using as examples three practices that have been termed “blue collar” in the popular press because the costs per month are relatively low, the service is high and with the added benefit of generic drugs at wholesale prices many patients can save handsomely. Two of them have noted that they have many uninsured patients. These practices are cheaper than urgent care clinics and much cheaper than the ER.

Why sign up if you already have insurance that covers primary care? The question to answer for each person is whether it is worth the extra money to get more time with your PCP? A lot more time. My PCP converted about five years ago. I was upset that I had to pay an extra $1,500 a year since I am on Medicare and primary care is mostly covered. Some of my friends decided to not convert with him. Others decided as I did to pay up. My wife’s PCP converted to a retainer approach a few years ago. Same thoughts. But it has been worth the price — to us. But probably not for everybody. Again, it is a question of your priorities.

What about abandonment? It is another of those questions where the answer depends on your perspective. A group practice I know planned to convert and announced it to their patients. Soon articles appeared in the local paper about “greedy” doctors and patients who would be left without a doctor. But everyone who wanted to find a new PCP did so quickly — often with help of their former PCP who guided them to an appropriate doctor. Of course, in say a rural community where there is just one provider, it would be a different story. An analogy given me by Dr. Josh Umbehr might be useful. Consider a 60-watt bulb. Try to push more voltage through it and it will burn out and there is no longer any light at all. Run it as it is supposed to be and it will last a long time. If the doctor is burned out and gets sick or just quits, that is not abandonment. It is actually worse.

And the greedy doctor issue? When a PCP with a busy practice converts, they often end up with a much lower income, at least at first. Read some of Dr. Rob Lamberts’ posts about what happened to his income including a recent one about his application for health insurance and for Medicaid. Later their income may rise and sometimes it will be more than before. But it is really not about more money; it is about more time for each patient.

Quality up and total costs down? I wrote about this recently; here is a summary. It is hard to find other than anecdotal data with individual practices or even group practices. MDVIP (which, as pointed out in a comment last week, is not a DPC practice since it still takes insurance in addition to a retainer) is a practice model that lowers the number of patients to doctor to about 500. Among the about 700 doctors there are about 215,000 patient members, enough to do some observational studies. They have found that quality measures like blood pressure control, diabetes control, immunization percentage, screening for cancer, etc. are substantially better than a comparable group of individuals not in their network. Similarly, there is a very substantial reduction in total medical care costs as a result of fewer referrals to specialists, fewer hospitalization and fewer trips to the ER. As to satisfaction, perhaps the most important marker is that few individuals leave the practice.

Similarly, Iora Health, Qliance and AbsoluteCARE, organizations that like DPC practices lower the number of patients per provider, can demonstrate better outcomes with lower total costs. Here again the cost reduction is from fewer specialist visits, fewer hospitalizations and fewer ER visits among other parameters. (And before you tell me, I know that this reduction in costs does not directly accrue to the patient. My point is only that fewer patients means better care which in turn means lower total costs.)

What about doctors? Is DPC for every PCP? I doubt it. When a practice is converted a lot fewer patients convert with it than might be expected — maybe 15 to 20%. Income will probably go down, at least initially. Some patients will feel the doctor is being greedy as noted above. There can be legal issues; the insurance commissioner may say it is essentially an insurance policy for primary care; a doctor is not an insurance company. Some sound advice would be important before embarking.  Doctors are a cautious bunch; this is a big change. My bet is that, until patients actually start demanding more time and agreeing that this is a sensible approach, the total numbers of PCPs who convert will be limited.

Thanks again for your comments and I hope this one engenders as many.

Direct primary care: A response to your commentsStephen 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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  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Let me start by saying that I enthusiastically support genuine direct primary care, where patients pay directly to their doctor, and not so much the primary care corporations you mention, though.

    That said, I would like to point out that the libertarian argument regarding how much people spend on internet and phones and how this is indicative of some faulty set of priorities, is doing more damage than good to the direct primary care argument. I would suspect, Dr. Schmipff, that you did not have to examine those priorities when choosing direct primary care for yourself. If this point is not clear, I would suggest rereading Adam Smith and his explanation of why linen shirts are not to be considered a luxury for laborers.

    As to quality of care, it is difficult for me to ascertain from these studies whether the cause for better quality at lower cost is due to the concierge effect, or more likely due to the small practice effect (more on this here http://onhealthtech.blogspot.com/2014/08/the-study-youll-never-hear-about.html ) Most likely it is a combination of the two.

    • Kristy Sokoloski

      You are correct about that saying that how much people spend on internet and phones is indicative of some faulty set of priorities is doing more damage than good to the argument about Direct Primary Care. The reason I say that is because of the fact that there are plenty of people in this country that not only can’t afford to go to the doctor, but they can’t afford to have a cellphone or internet access, and that’s even with living in a society now where you have to have the Internet now to do most things. Also, the reason so many are going to cellphones instead of landlines like it was when I was a kid 43 years ago is because those landlines many times are not cheap either.

    • JR DNR

      I imagine people who are willing to go to a direct pay practice, in general, are also the kind who are going to be compliant patients and take care of their health in general. They are choosing to form a long term relationship with that doctor, not just swinging by because they have a sore throat and aren’t expecting to ever come back.

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

        Very good point…..

      • rbthe4th2

        So those who don’t are not compliant? See http://jme.bmj.com/content/19/2/108.full.pdf. Also http://blogs.law.harvard.edu/billofhealth/2014/03/31/a-case-against-the-noncompliant-patient/.

        In my case, money and work issues prevent me from taking full advantage of everything my doctors want for me. That and a doctor blocking my care.

        I had a doctor refuse to recognize those issues. How did that doctor help me?

        • JR DNR

          Meaning that those who pay for direct primary care are generally the kind of patients the doctor likes to work with.

          Many doctors can’t handle patients who have illnesses they can’t identify or problems they can’t easily solve. When faced with such patients, they blame the patient. “Lazy, non-compliant, etc”. If you have a doctor that blames you for your illness, or doesn’t believe you are ill, you’re less likely to go to the doctor. If you’re less likely to go to the doctor, you’re less likely to pay for direct primary care as it’s a waste of your money if you aren’t going to the doctor.

          Unfortunately, I know many people in that boat.

          • rbthe4th2

            Just about a good # of people I know in that boat.

        • Lisa

          Thanks for the links!

  • Kristy Sokoloski

    I think it’s interesting that you are writing a book on the subject. I think that one thing that is going to be necessary to help make this successful is that of talking to us the patients to find out what we would like to have from our Primary Care Physicians as well. One thing I frequently see in articles that come here is that it talks about what the doctors think and might want in order to make Primary Care work better. Nothing wrong with that, but what about what we the patients think? This matters because we come to you for the different things you mentioned and then some. I have a very good relationship with my Primary Care Physician and many times my visits with him are only about 10 minutes, and in some cases 5 and that’s fine. We get the things accomplished. I recently had my physical done and I think we were in there together talking and going over things for what felt like an hour if not a bit longer but it felt like it was time that dragged on and on. Even in spite of that it was a very good visit. It doesn’t matter to me whether the visits I have with my Primary Care Physician are 5 minutes long (and this is the case in the UK where people only get 5 minutes with their PCP but if the visit goes longer than that they don’t get thrown out) or whether I have one hour long. I just want the time with my doctor to be a quality visit and one that I am able to afford to have of which my insurance allows me to have. I feel badly though that some days he has about 30 or 40 patients that he takes care of if not a bit more than that. And that’s between the patients he sees in the office and the other charts he has to tend to as well as his other responsibilities which include rounding on patients in the various nursing homes in the community. I can see where it is easy to make mistakes at times so I try to do my part in this partnership to help him remember things that we have already done or discussed. Even in spite of all that is going on as I said I have a wonderful relationship with my PCP and that he is trying to be my friend. That is important to me regardless of how much or how little time we have together. But please as you continue to do your research for your book include talking to us the patients and asking us what we would like to see happen, what our needs are for our PCPs and how we think it might be able to work it so that it is affordable for us as well.

  • HJ

    I could afford the smart phone, the coffee at Starbucks, the internet and the concierge medicine practice…but why would I pay $2000 to see my doctor once a year?

    I take a generic drug that costs $3 a month. Why would I pay $2000 to get a wholesale discount?

    Yearly physicals have no clinical value. Lifestyle counselling would be cheaper and better provided by a personal trainer or lifestyle coach at a fraction of the cost.

    • Lisa

      I also could afford a smart phone, cable tv, daily coffee and a retainer fee for a concierge medical practice. (We do have internet but that is bundled with our home phone and a necessity as my husband works at home). I don’t pay for these things because I don’t consider them necessary or desirable.

      I don’t see why I should spend more money than I do on my medical care. And DPC would cost me more money than I currently spend on insurance and co-pays. Your example of the cost of DPC plus insurance versus the cost of insurance, in a good year versus bad year is very telling. Until there is a way to combine DPC with wrap around insurance, so the DPC fees are credited towards a deductible, it just doesn’t make sense for most people.

      • rbthe4th2

        Dead on the money.

  • rbthe4th2

    “Expensive? It’s relative. The average American family spends $2,237 per
    year for cable TV, Internet and phone. A Starbucks a day adds up. A
    parking space per month in a downtown lot is probably more than the DPC
    doctor. It is about prioritizing our personal expenditures.”

    We don’t have cable TV, the lowest phone & internet. We don’t do Starbucks, we make coffee (not Keurig). The parking space is mandated where I work. We don’t have those big $60 a month smart phones.

    Next, it is not up to a doctor to dictate to me or any one else where my personal expenditures go or my priorities in that they are wrong or misplaced. I’ve seen that in a doctor before and we parted ways. Or even to question them because if people have determined that its not worth the money for them, then so be it. For those people who only got to docs once a year or less, it is not worth the money. For those who can’t afford it oh well. All it does do is those who are in those groups are fit in the ones who are overburdened by the system.

    • Lisa

      Some doctors can’t drop the habit of being paternalistic. Saying that paying for DPC is a matter of prioritizing personal expenditures is paternalistic and not at all appropriate. Most people are, as you, totally turned off by that approach.

      • rbthe4th2

        Not just me. I want to know the bang for the buck. I’ve got others who have opted out of certain “luxuries” or only do them maybe 1x or 2x a week. I had a friend who did Starbucks maybe 2x a month and it wasn’t for $10 drinks but $3-4 coffee of some sort. If someone gets more out of their cable TV than paying extra for health, that is their choice. In no way, shape or form is a doctor to tell me that priority is wrong. They were given knowledge over the body, not a mandate to dictate right or wrong. No graduate degree in college gives someone that authority or right. Certainly the spate of HCP’s like Charles Cullen, Christopher Duntsch, Michael Swango, J. Patel, Harold Shipman should tell us that the medical profession needs to take a look at itself. A good long hard look at itself and tell us why a science graduate degree gives them the right, the morals, and the authority, to dictate where our priorities should lie.

        • Lisa

          My husband calls doctors medical deities. I agree that being a doctor does not give doctors the right to tell us what our priorities should be. What having a medical degree means, to me, is that the holder is qualified to diagnosis and advise me on treatment for my illness. Period.

          I wasn’t familiar with an of the names you mentioned above. And yep, clearly the medical profession protects its own, which is not good for anyone. While doctors who murder are extreme cases, I think there are cases where doctors are aware of doctors who are sloppy, who have more than the average number of misdiagnosis and who commit malpractice and things are swept under the rug. Medical societies should take such matters seriously. I read (on this site, I think) that there is a hugh difference in how nursing boards versus medical boards approach such matters and it is easier for a nurse to loose their license than for a doctor to loose their license, which just seems wrong to me.

          • rbthe4th2

            I once got told that a doctor has other priorities (when I said here are mine) and that he has my health to think of first. In other words, I dont care what your priorities are, mine are this and that is what rules my decisions. Not that I can’t pay for or take time off for treatments, etc. Any time a doctor drops someone for non compliance, I would say that is questionable because you truly need to find the reasons (lack of transportation, $$$, work, etc.) as to why the person can’t do it before they’re dismissed.

            Yes, way too often I hear “it could be me” etc. as a way of excusing doctors. Its one of the main reasons trust in them is so low, outside of seeing too many have lawyers and risk managers step up to them rather than fixing the problem in the first place. If the profession would make missed and delayed diagnosis their mantra BEFORE complaining about patients, their work environment, etc. then I would believe them. But until then, after having Dr. Wible saying we deserved what we got because we didn’t support physicians (see the suicide article if the comments haven’t been erased) and you’ll understand where a lot of people come from in terms of the attitude of docs. You can’t sit there and beef about pay, work life balance, etc. and not fix problems with delayed/missed diagnosis and tell me you care about patients first and its not your wallet.

  • futuredoc

    Thanks for all the comments. I don’t necessarily agree with each of you but all the comments are appreciated. This is a good way for learning how others perceive the issues and whether the argument expressed is solid or not. And it’s a good way to hear patients’ perceptions.
    Stephen Schimpff

    • Patient Kit

      I, for one, appreciate your willingness to hear where we patients are coming from on this issue and to answer our questions. And for doctors who are serious about converting to DPC, hard and frustrating as it might be to hear, it’s no doubt useful for them to have a handle on why many patients are resistant to the model.

  • Lisa

    One major illness or injury, beyond the ability of a primary care doctor to treat, would probably convince you that insurance is a darn good idea.

    • Patient Kit

      It amazes me how DPC enthusiasts push the idea that most people don’t really need or use their insurance and most people won’t ever get seriously ill and most people won’t ever need specialists. It’s like they are asking us to gamble — with our lives — on them.
      I’m also not buying the idea that primary care docs can treat almost everything (especially if they haven’t done so in a very long time now). Medicine is only getting more complicated, not less complicated. I understand the value of having a primary care doc who sees us as whole people and oversees our care with specialists. But I am definitely not buying that, after years of referring us out, primary care docs can now suddenly be the specialists (without any special training).

      • April

        But you have to consider that the REASON so many problems get referred out to specialists is not because a specialist is actually needed as much as the PCP does NOT have sufficient time to sit and think about the problem. If you only have 2 minutes to analyze a complicated medical problem – you’re far more likely to conclude it’s too complicated to fix and you need a specialist. If you have half an hour to sit down, read, and work it out yourself then you’re far more likely to be able to work it out – no additional “special training” needed, just more time.

        • Lisa

          I really would rather see a specialist if I am dealing with a complicated medical problem. I don’t want to be diagnosed by some one who was to sit down and study to make the diagnosis and come up with the appropriate treatment. I want to see someone who sees and treats other people with the problems I have.

          Many problems really are beyond the scope of a PCP.

        • Suzi Q 38

          You make a good point.
          I have students who are on welfare for their medical care. The doctor just divides one visit into 3 and they have to get to his office 3 times.

    • Suzi Q 38

      You are so right. Hospitals, tests, specialists, etc. cost so much money.
      I plan on still having my insurance even though I believe in paying out doctor directly. It is the least I could do after 12 years.

  • Patient Kit

    Re savings, how much money do you think a person should have in an HSA to be able to weather a serious illness or injury? And how do you propose that the millions of Americans who are living paycheck to paycheck get that money into their HSAs? I’m not talking about the poor with no or little income, who would qualify for Medicaid. I’m talking about working people who make just enough to pay their bills and keep a roof over their heads and food on the table. How can we save enough?

    When I was diagnosed with ovarian cancer a year and a half ago, after a layoff and the loss of employer-based insurance, my savings went quickly. I worked for a nonprofit org for 18 years prior and live in NYC. It wasn’t easy to save but I had about $25,000 in my savings. It went quickly, not for medical expenses but for basic living expenses like keeping a roof over my head. Once that savings was gone, I qualified for Medicaid and got excellent care. A savings, even a much better one than my pathetic but hard-earned savings, could never have paid for my surgery or specialists. And I was lucky enough to not need expensive chemo.

    I think it’s a fantasy to believe that the average American can save enough to cover the
    medical care that they and their families might need.

  • Lisa

    1) I would not qualify for membership in a health sharing ministry as I am not Christian. I guess if you are not Christian, you don’t server to have medical care.

    2) I think that membership in such a ministry is a risky business as there is nothing to assure the ministry will retain enough money to cover all of the ‘medical needs’ of their members. If several of their members are diagnosed with cancer, the ministry might be in trouble. Assess members more or prorate the amount the member with medical needs will receive seems to be the solution,

    3) Anther objection I have to health sharing ministries is they do not cover prior conditions or any preventative services. Furthermore, the list of reasons that will cause a ‘medical need’ to be denied is fairly long. Oh well, if my cancer recurrs, I must not deserve medical care or there must be an error in my faith. The sarcasm is fully intended, byw.

    4) As far as I can tell, most health ministries require you to pay the bill upfront; they also strongly encourage you to negotiate the amount of the bill. I don’t think negotiating the amount of a bill is bad, but in several instances I read about, members of health ministries basically strong armed health care providers in an attempt to get them to negotiate.

    5) Most hospitals and specialists in my area will not work with patients on making payments after services are given. It is cash or credity card up front. If you are a cash patient, the local hospital will give you a discount, but that discount is minimal compared to the negotiated prices obtained by insurance companies. And if you are going to arrange payments, you must do so before the service is given.

    A real solution might be DPC with wrap around insurance. I have seen a few companies offering this, in Nevada and Oregon. But so far, that model is not widely available.

    • Patient Kit

      I actually never heard of healthcare sharing ministries and know nothing about them. CuriousPatientKit adds this to her Google list. (yes, I am related to CuriousGeorge).

      • Lisa

        I think there are three or four that you can belong to and therefore do not have to be covered by insurance under the ACA.

        LOL, about CuriousPatinetKit and being related to CuriousGeorge.

  • Suzi Q 38

    Jason,
    Have you ever spent time in the hospital with an acute but major condition that necessitated extensive treatment, surgery, several specialists, and other medical personnel and tests? I have.
    The cost can get to $50K or $100K in no time.
    If you do not have insurance, you will probably pay double of what the insurance pays.
    There are two prices the hospital charges….the uninsured price, and the insured price. Unfair, but true.

    I would be glad to enlist the help of a really good PCP and pay cash, in addition to the $550.00 or $600.00 a month that we pay for our PPO insurance. I am going to try doing this. I think that it is worth the extra money. The PCP could end up saving me money in the long run.

    In addition to paying about $6K for our premiums, our deductible is sizable…it is about $5K. In other words, I just need the insurance in case I need medical care that costs over $5K, and for the hospital fees.

  • Lisa

    Except that Suzi will probably find, if she carefully parses the numbers, her health care costs will go up.

    • Suzi Q 38

      You could be right. Time will tell.
      Also, one year of costs could be very different from the next year.
      All I know is, I will not have a doctor, who controls my heath care direction, look at me for 5 minutes and send me on my way.
      I am willing to pay a monthly fee for access to my doctor by phone, email, or in person whenever it is needed.

      If it ends up costing me a little more, so be it.
      If I am happier, and feel more medically connected and secure, I think that it might be worth it.

      I say “might” because I really don’t know. I have never tried it. I don’t think that there are many physicians who will do this for a fair price in California. Office space is very expensive here.

      I think that doctors should go back to having practices in small little buildings in front of their homes. This way, they could work, take a break in between patients and see the family, and maybe the cost of the building would not be so much so that they could survive having the type of practice that they want.

      • Lisa

        Well, I live in also live in CA, have comprehensive insurance and have access to my pcp when I need to see him. I can get a same day appointment if needed and have 24 hour phone access. When I do see him, he normally spends more than five minutes with me. The last appointment I had with him was over half an hour, supposedly an annual physical, but mostly we talked about diet. I honestly don’t feel I need to spend more money than I already do to receive good medical care.

        I’ll be very interested to hear what you think a year from now.

        • Suzi Q 38

          It is nice that you have that good service with your present doctor.

          I have experienced being rushed and don’t like it.
          I have the convenience of same day appointments when I need it as well.
          I am not sure why that is, because when I go in to see the doctor, he seems very busy with medicare and medical patients. I am private insurance pay.
          He used to give me the 5 minute treatment about a year ago. At the time I naively didn’t know what his problem was. I just knew that something had changed.
          After a few months of this type of treatment, I “got in his face” and told him that I was very sick, and I needed more time with him.
          To his credit, he stopped rushing and sat down and talked to me. He has been the same way ever since.
          I don’t have to change until he retires.
          I want to look out for a new PCP for the future, though. I want to have one in place before I make the change.

          Yes, it would be interesting to see what happens after a year of direct pay. If the direct pay doctors do not deliver a better medical service model than what I already have, I will quit the direct pay and realize that it was a good idea but failed with me.

  • Suzi Q 38

    Great idea about the connections.
    This would save me money in the long run.
    My deductible is $5k, so that may hold us for a year.
    I like good, solid care and am willing to pay a little more for it.
    I am frugal to a fault, except when it comes to getting a good doctor. My friends AND family members think that I am fairly frugal, and sometimes they are annoyed by this trait of mine.

    At first I thought that paying extra for more access to my doctor was stupid.
    I had to realize what was happening in my health “world” of physicians.
    I am so grateful to our discussions, because so many people have different viewpoints and different ways to solve their problem. These “patients” and “doctors” are asking questions and making statements that I never thought of. Thank you!

    I think that for my PCP of 12 years, going concierge would not happen. He is about 62 or so, and I do not think that he will change his old model of what his practice is.
    I will. though, shop carefully for a new doctor within the next couple of years. I am fairly sure that I will give a fairly priced, concierge PCP a try.

    I have some income with which to do so, because I am fairly frugal with most things that I do.
    Fortunately, my husband and I are employed tight now and we have insurance, even though it is expensive.

    If I did not have assets or own property, I would try doing this without insurance. Right now, I have too much to lose should a major illness or surgery become my reality. I can not rely on the
    empty promises” of hospitals to reduce my bill after the surgery. They would take a look at my assets (which are not huge, but more than some people) and say: “Let’s let our attorney handle this outstanding bill.”

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