Can direct primary care solve the physician shortage?

One of my main interests in primary care is providing care to all people, regardless of their income or ability to pay. In my limited experience with health care, I have found it most rewarding to work with the underserved and underprivileged, those who do not have their own money available to allocate to health care. These patients are on Medicaid or are at the mercy of free clinics. This is why I have always had a poor opinion of concierge medicine. In this model, patients pay an annual fee or a retainer to their primary doctor in exchange for their medical care, and they may incur additional charges for labs or when their care exceeds the retainer. This is care for people who can pay for it.

The first time I heard of direct primary care, I thought it sounded like concierge medicine disguised by a friendlier-sounding name. I attended the Direct Primary Care Summit in Washington, D.C., in June with the hope that I was wrong.

Two major themes prevailed at the summit: money and physician happiness. It’s not a bad thing that physicians want to keep more of the money they charge for care rather than spend it on the overhead associated with billing and coding. Who doesn’t want more money? Wanting to be happy at work, regardless of your profession, isn’t a bad thing either. Increasing physician happiness could be an effective way to improve patient outcomes.

I am not yet a practicing physician, and money and happiness are not obstacles I battle daily, but a few aspects of direct primary care started to concern me. Although I will concede that there are many differences between direct primary care and concierge medicine, there are still many similarities, some of which, in my opinion, are the most negative aspects of concierge medicine.

First, though direct primary care fees are drastically lower than those associated with concierge medicine, they are still relatively high. A common monthly price that I’ve heard is about $100. Although $100 per month may be nothing to many people, to those who struggle most to access health care, particularly those with the greatest medical needs, $100 is a lot. As a student who spends about $155 a month on insurance, I would be hard-pressed to spend an additional $100 for direct primary care. In addition, I would have to continue to pay for my insurance because of my next concern.

It’s not comprehensive care. I can’t go to my primary care doctor for emergency care. If a car hits me, I will want to be at the emergency department and not my physician’s office.

Many direct primary care supporters would argue that I could purchase the lowest-priced, highest-deductible insurance plan and use the money I save on insurance to pay for direct primary care. But insured people who are not quite poor enough for Medicaid, or who live in states that did not expand Medicaid, are already buying the cheapest possible insurance plan because that’s all they can afford, and those “savings” are going to their daily living expenses. They will continue to avoid going to the doctor because they cannot afford any more out-of-pocket costs, whether in the form of a deductible or a direct primary care subscription.

Finally, direct primary care shrinks patient panels. I imagine, to many physicians, this is a good thing. Fewer patients equal less burnout, which equals a happier physician, which equals better patient outcomes. It does sound great, except we are already in the midst of a physician shortage.

Some physicians at the conference talked about cutting their patient populations to a quarter of the original size. If all physicians downsize, what happens to the new excess of patients? We already have a population of patients who aren’t being treated because they can’t afford it or they live in areas where doctors are scarce. If direct primary care becomes the national gold standard of practice, don’t we exacerbate both of these problems?

I am not a public policy expert. However, I brought up these concerns to family medicine physicians at both the summit and my school, and no answer was given, though some said my questions are valid and need to be addressed.

Despite these concerns, I believe there are good aspects of direct primary care. At its core, the goal is to increase physician and patient satisfaction. However, there must be some way to accomplish this goal without creating such an exclusionary system. Direct primary care may or may not be an answer to the current U.S. health care crisis, but many of its principles, such as better technology use, could be utilized in the creation of a better health care system.

Brett Clark is a medical student who blogs at Primary Care Progress.

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

    “If all physicians downsize, what happens to the new excess of patients?”

    They go to Walmart. That’s our national grand vision….

    • Patient Kit

      But….we don’t have any Walmarts in NYC! What are we supposed to do?

      • Lisa

        And no Walmart in my area either…

        • querywoman

          Lucky you! No Walmart. In Texas, Kroger, Tom Thumb, Brookshires, Target, and a few independents also have the $4/$10 meds.
          Costco is supposed to have started it. In Texas, you don’t need a membership to buy prescriptions or booze in Costco or Sam’s. That may vary by state.

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

        Do you have CVS or Walgreens or anything that is a chain, preferably with concrete floors and bare metal shelving? :-)

        • Patient Kit

          Yes, we do have the big three US drug store chains (Walgreens, CVS and Rite Aid), although I do remember a time, not that long ago, when none of them were in NYC either. And maybe Walgreens or CVS will eat Rite Aid and then there will be two. So, my future may be Dr Walgreen and, of course, Dr Google? The self-treatment movement beckons.

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

            Empowerment… :-)

          • Patient Kit

            Dr Oz is accessible to all — as long as you or someone you know have a TV (I don’t have a TV). You don’t even have to live in NYC to “go to” Dr Oz. He has a panel of millions but peeps can always get in to see him. I prefer Dr Google but, at least, there is choice for the masses.

          • querywoman

            If you have an email address, Oz will spam you up!

          • Patient Kit

            I have email, of course. But I never get any spam from Dr Oz.

          • JR DNR

            I still think this is on of my favorite comments ever.

          • querywoman

            The Walgreens of my childhood was really different. It had an old-fashioned lunch counter bar with the best tasting ice and water glasses, free!

          • querywoman

            Is NYC one of those areas that has few chain grocery stores?

    • Dr. Drake Ramoray
      • Lisa

        And CVS has over 900 Minute Clinics and is planning on opening new ones.

        I was just reading about the services they offer, which are very well defined. One service was splinter removal, which made me laugh. I once got a splinter under my thumbnail and was forced to go to my pcp to remove it. I felt like a fool, but one pull with his specialized forceps/pliers and it was out. I think I’d go to Minute Clinic for something like that.

  • Patient Kit

    As a patient, I have a lot of similar concerns about DPC. It’s good to see a med student asking these questions. I really think that many docs really struggle to understand the concept of $100 being “a lot of money” to many people. It drives me crazy when they tell us to just give up the daily Starbucks, as if Starbucks is a given for all Americans. For too many, it’s more like give up the milk or give up the bread or give up the rice & beans.

    • Kristy Sokoloski

      I agree with you Patient Kit. He’s voiced my concerns exactly that I have been trying to make a point on here as well.

  • NPPCP

    Hi Brett, I have been staying back on this DPC and reading all the articles and posts over the last few weeks. I really think this is all about physician independence and trying to find a way to take back control of their lives. Now, not their profession – their lives. The AAFP tried and failed miserably to reassert physician “cap’n of the shipology” with the PCMH. The AAFP degraded NPs and did everything to every other profession but call them stupid idiots to control that magical medical home. They have already found out in just 1.5 short years that they will not control health care that way. Now, you see articles on the PCMH dwindling. It’s now time to try and find the next option for physicians to control their own lives, happiness, and income. Well, the only true way to do this is to remove everyone and everything but the customer and the service provider from the equation. So, (Patient Kit and others), you will save a lot of time ignoring the DPC proponents on here. I’m not insinuating or saying at all it is bad. It just is what it is – a way for physicians to control their own lives and income. They can TELL you it’s better for patients or this or that; that is fine. But, like all of us and our personal pursuits of happiness – it’s better for them. It’s one last way to maintain control of their lives. It’s a poke in the eye of the man and one of the last ways to show they need no one to care for people. They are the provider of a service and the patients with monthly fees are the widgets. It’s the same with me and insurance payments. So, don’t fret – just let them get all of the Amway/DPC out of them. Some of it will stick and some of it won’t. But there will always be people like me to pick up the slack and care for you. Now there is about 3 cents…..

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

      That may not be the case in the long run. If Walmart and Walmart type operators can establish their pricing as the reference price for whatever they call primary care, it won’t be long before insurers decide that they will not pay more for “the same thing”, and I don’t see how anyone stays alive at $40 per visit.

      • Lisa

        I was just checking out the pricing for CVS minute clinics. The cash prices seem quite high to me, but that they will accept most insurances and their interface allows you to determine what your co-pay will be, before hand.

        I think they stay alive at $40 per visit because they use NPs and PAs. Also, I suspect many of their treatment plans will involve over the counter items. The patient will be sent to the correct aisle.

        • NPPCP

          Bingo – however, NP pay is only about a third less than family practice physicians. They aren’t saving much there. So that isn’t why they are cutting the price. It’s the Coors Light.

          • Jason Simpson

            Wrong. According to US Labor Dept, average FM doc makes 190k per year. You think family practice NPs AVERAGE 120k per year? Nonsense. Average family medicine NP makes about 80-90k

          • NPPCP

            Wrong. Not in my world. And not in any of my colleagues world. Average statistics are nice. But they are much more desperate for us than that. Sorry.

    • Patient Kit

      LOL! You don’t think I’m obsessed with this topic, do you? I prefer to think of it as immersing myself in learning everything I can about something that’s new to me. ;-)

      • NPPCP

        Mmmmmmmm…maybe? :)

        • Patient Kit

          I’ll admit to being passionate about a lot of things. ;-)

  • Forthrighthealth.com

    You make some excellent points, Brett! That’s why I think the DPC movement needs to get better at messaging and understanding exactly what they’re trying to accomplish.

    Most consumers of healthcare will view DPC as an “extra” expense, despite all the table pounding from DPC providers. That’s why DPC needs to come in the same package as the comprehensive insurance wrap. Unfortunately, many things must happen before we get to that point. But that’s one thing Forthright Health and others are trying to make happen.

    Also, DPC providers aren’t going to win any battles when one cuts a 3,000 patient panel to 500. That means they’ve just pissed off 2,500 patients! The other 500 could be extremely happy with their care, but they’ll be outweighed by the negative feelings of the 2,500 that were cut loose.

    DPC is simply an mechanism to allow PCPs to practice the way they want, without coding, billing and mandates. What PCPs really want is to remove 2 things: 1) the coding/billing/paperwork that adds 50% to their overhead, and, 2) the face-to-face in-office requirement in order to get paid.

    DPC is one way to remove those two things. But it’s not going to gain widespread popularity with each PCP going it alone and abandoning patients in the process.

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

      and HMO capitation is another way…. If that’s all it is, then what’s the difference?

      • Forthrighthealth.com

        It doesn’t fix #1 I listed. The billing/coding/paperwork is even greater with HMO capitation. It is hated by PCPs. Each visit requires enough paperwork to rival a car loan application. Then you’re dealing with preauthorization and all that headache.

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

          What happens when you want to order some high-end tests, order expensive meds, refer to physical therapy, refer to cardiology, or admit your patient? It’s not like the insurer will forgo preauth just because the orders/referrals were made by an out of network concierge doc…. Who deals with all that stuff in these scenarios?

          • Patient Kit

            Good question. I think the DPC fantasy seems to be: (a) they won’t need to refer us much because they can do a lot of specialist stuff themselves or (b) they’ll develop a network of direct pay specialists and ancillary services that they can refer to. We pay them cash too and get a discount.

          • fatherhash

            That is where the smaller patient panels comes in. Smaller panels = more time for physicians to deal with referrals/pre-authorizations and less overall patients to actually have to refer/pre-authorize. Currently, physicians have to deal with all that in addition to seeing larger amounts of patients.

    • NPPCP

      As I said above, this a way for physicians (and me too as a Nurse Practitioner if I want to go DPC) to take back control of their own personal lives. One cannot blame Mr. forthrighthealth for his pursuit. It is AN option. He is going to like it as the best option as it provides him with the most cash, least headaches, and least work. Who wouldn’t want it?

    • Patient Kit

      Cutting panels from 3000 patients to 500 happy patients and 2500 pissed-off “cut loose” patients sounds almost symbolic of a healthcare system that’s great for some and inaccessible for many. Those who have money will be the happy patients. I wonder why many of us are not embracing this vision.

      I actually never heard of DPC until a few months ago. But learning about it has only pushed me deeper into the tax-funded universal comprehensive healthcare for all Americans camp. There will be plenty of pissed off patients to organize toward that goal, if doctors start abandoning us massively. DPC will mean Dumped by Primary Care to many.

      I do understand and care about doctors’ frustrations with the current state of our healthcare system. I don’t think DPC is the answer though. Certainly not widespread DPC and widespread patient abandonment. And I can’t imagine that most docs will be happy with the idea of widespread patient abandonment either.

      • Dr. Neu

        https://www.youtube.com/watch?v=TvwGb_S5r-E

        https://www.youtube.com/watch?v=A9V7T45fTVU

        I have about 300-400 uninsured similar patients whom have no other affordable options for care. Maybe I should just tell them to write their congressmen? Hopefully their rash, diabetes, migraines, Chron’s disease, broken arm will wait for your single payer utopia.

        • Patient Kit

          No, of course not. But the various short term ways many of us are scrambling to survive with and talking about long term solutions to reform our system so that all Americans can get the medical care they need are two very different discussions. So many other countries have managed to do it. Why can’t we?

          • Dr. Neu

            Different discussions indeed. One that tangibly produces better care for my patients, the other fanciful, ideologically-driven wishful thinking.

          • Patient Kit

            I think the big picture and the little pictures are all important. You do the best you can for your patients. I do the best I can to get good medical care in a dysfunctional system. But not caring about reforming the whole system is a big part of why our system has been able to be highjacked by big business interests. When people ask how we let it get this bad, that’s one of the reasons right there: Your attitude toward anyone who dares to say that we can find a better way. I think I’ll hang on to my wishful thinking. Better than apathy or a totally defeatist attitude.

          • fatherhash

            I don’t think Dr.Nue has said anything against single-payer system(which I actually favor)….merely that it is a different discussion. This topic was about DPC(which maybe could be done in single-payer I suppose) and lower patient panels.

            I agree/understand that when doctors “convert” their practices to lower patient panels, the ones “left out” may be unhappy. But what is the solution to that?….keep the larger panels and take care of more people than the doctor feels they can handle? Don’t see how the single-payer fixes that.

          • Dr. Neu

            Amen Father :)

          • Dr. Neu

            I’m not against civic involvement or discussion, at all. However, I think that individuals actions everyday on a local level are much more powerful than bickering about the “system” or arguing political theories about how it would be best.

            I have worked 80+ hours/week – and made huge financial sacrifices – in the past 3 years building a practice to serve my community and patients. I have a weird way of expressing apathy. Maybe I should’ve been more productive organizing demonstrations demanding Obama implement a single payer?

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

            Shame on you.

            It’s funny how we, who are perhaps risking the most for the sake of serving patients, are subject to such criticism. We are the ones who see the faces of people each day affected by the system. We are the ones who took the huge risk to try to do things better (and have done so in the spotlight of the online world). We know first hand what a difference good care makes. Yet folks just don’t believe us and want to call us “quitters” for deserting our patients, “selfish” for not accepting Medicare payments, and “greedy” for not subjecting ourselves to the abuse of our broken system. People think I betray my obligation to my country because I don’t honor all the money CMS put out to fund my education (not mentioning the $100K debt I had or the $25K salary I had as a residency, with an 80-100 hour work week).

            The good news is that we have the trump card: we can prove ourselves right. We don’t depend on arguments about single-payor systems (the idea of which makes me want to vomit) versus the crap-care system currently out there grinding doctors and patients to a pulp. We don’t talk in hypotheticals. If we can build something that is truly reproducible in a bigger scale which can:

            1. Save money

            2. Give better care

            3. Make things better for patients

            4. Make things better for doctors

            we win. We are not just the “blah blah blah” of opinion; we are living out our ideas and ideals. I’m OK with folks questioning me because I will have an opportunity to answer those questions when my practice vindicates my ideas. We are right, and a growing number of people are agreeing with us. I am confident that this approach is the right one and that we will have a very good chance to silence those critics with something novel: health care that actually works.

          • Dr. Neu

            Yeah. What he said.

          • Patient Kit

            You have the trump card? You will win? DPC believers, from what I can tell are still very much a tiny minority. don’t understand why you are so surprised that the masses of Americans who are left out by your model aren’t applauding you and treating you like heroes for saving our healthcare system for some (but not many).

            Nobody has convinced me so far why DPC is best for most Americans. I thought I understood why it is good fore some doctors. But you told me in another thread (under your recent OP about your day with three cancer patients) that you, a practicing doctor, currently qualify for Medicaid yourself. If true, that is shocking to me because, in GA, that means you are a working parent of a dependent child and you make less than $10,000 a year working as a doctor. Meanwhile, elsewhere on KMD, other doctors say they see DPC is their way to get paid as much as specialists. So, now, not only do I not see why DPC is best for patients but I’m confused about how it works for doctors, financially.

            Trump card? Win? Are we in a competition or are we discussing very complicated issues trying to piece together possible solutions that might work for everybody?

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

            Anyone who has done a start-up can tell you that there is a gauntlet to run through before tasting success. I am certainly gaining income as my practice grows, and hope to eventually equal or surpass my income in my practice previously. But why would you measure success simply on income? Can you see that me sacrificing over the past 2 years is for a really potent reason? My life in my practice — the quality of care, the quality of interaction, the fact that I don’t have to go home feeling burnt out — all make it worth sacrificing and going through very hard times. I am building a business (am up to 500 patients) and am doing so carefully so as to build a system that will tolerate higher patient numbers without compromising what is good in the business.

            To illuminate what is better for patients, here is my list of what $30-60/month gets my patients.
            1. Direct access to their doctor via phone, email, or messaging. They often send pictures of rashes which can help avoid coming to the office.
            2. No copay for office visits.
            3. Labs, immunizations, and eventually medications at cost ($4 for a CBC, $15 for flu shot).
            4. Interaction via other means leads to very quick office visits. When I can’t give good care via email or phone, the visit is often extremely quick (5 minutes to check an ear, listen to lungs, or look at a rash – that’s 5 minutes total in the office, not with me.)
            5. We take time to find ways to save money. It’s in my business best interest to get free meds from drug companies or use online resources to save money, as it justifies the monthly payment.
            6. Average wait time in the office: 30 seconds.
            7. We call people to check up on them or remind them of care they may be missing.
            8. Access to me means we can keep people from unnecessary ER visits. I’ve probably saved the system tens of thousands of dollars (probably much more, actually) by redirecting people to my office when they were going to the ER. There are many, many examples of this in the past 18 months.
            9. I have many patients who track their blood pressure, weight, and diabetes numbers on spreadsheets that I see on a daily basis. This allows me to manage them on a daily basis.
            10. We make house calls if that’s the way to get people the best care.

            The biggest thing people see as the difference is that they have access to me and my staff. Very few folks have left my practice after experiencing this difference. Some who did leave ended up coming back and telling me I’d spoiled them.

            I do believe that I can get my patient panel significantly higher than 500, and so increase my income and my overall reach. If we can keep this incredibly high quality of care, save the system money, have a good income for docs, and make it so it can be scaled up to the general public, then we’ve got a game changer. You may still not get it (probably don’t, from what I’ve gathered). If not, then I just say: wait and see. Ryan and I will show you care can be far better than you think it can be.

            People aren’t screaming for a radical change in care because they don’t realize just how terrible their care is. They don’t realize how terrible their care is because they have never seen how good it could be. You can have your single payor code factories. I would far rather work for my patients.

          • Lisa

            Saving the system money doesn’t really count for anything unless you are part of the system. I think DPC will not work unless a way is found to wrap DPC with insurance, DPC will either cost patients more (or if they choose not to carry insurance) expose them to the risk of bankruptcy.

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

            No, that’s wrong. Patients with insurance still pay more with ER visits (many have deductibles, pay a percentage of their bills, or have large copays). Avoiding ER visits, unnecessary procedures, and preventable disease means that they don’t spend money they would otherwise pay. Many of my patients with insurance say that I am saving them money in the long run. Furthermore, with me patients can choose insurance with higher deductibles and lower cost. They pay less in total for insurance. Finally, people can pay for my care through their HSA or flex-spending accounts, so not dip into money not earmarked for health care.

          • Lisa

            I) It has not yet be determined that HSA accounts can be used for DPC fees. I think they should be able to, for now that hasn’t been (unless something has happened recently that I don’t know about).

            2) If your patients parse the numbers, I think they will find the numbers aren’t in favor of DPC if they are paying for insurance and DPC fees. HJ did and found that it was more expensive to pay for insurance and DPC than it was to carry an insurance policy (available on a federal exchange) under both good and bad scenarios.

            3) I have comprehensive insurance. My pcp is available 24 hours, via phone, if I need to talk to him. I never have, in 18 years. He also has same day appointments. I don’t have to pay over and beyond my insurance (and co-pay) for the privilege seeing him.

            Personally, I think the whole ER thing is exaggerated. I took my now 34 year old kid to the ER twice when he was growing up. My husband has never been to an ER. I’ve been to the ER twice in the last 30 years. One visit was unavoidable – I thought I had broken my hand. My PCP has an x-ray machine in his office, but they wouldn’t have called a tech in. The other visit would have been avoidable if I had been in state (cellulitis, received IV antibiotics). The amount of money I’ve spent on ER care wouldn’t justify fees for a DPC practice.

            I hold with my original statement.

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

            1) My patients use their HSA/FSA’s to pay my fee, and have done so since the start. Legal counsel for both doctor and patients say it’s fine.
            2) My patients parse numbers each month when they choose to pay the fee, and the number continues to grow steadily.
            3) If your PCP is available like me, then they are probably being overwhelmed with messages and calls. My office for the past 18 years had about 3000 patients on my panel, and there were other docs. We rotated call and used a nurse triage system. If we had opened to what I have now, I would be spending a huge amount of my time answering after-hours messages. If your doctors rotate or if you have a nurse triage system, you don’t have what I offer. If your doctors don’t answer questions directly to you during office hours (relaying things through the nurse), then you also don’t replicate my experience. I did the other for 18 years. It’s not even close.

          • Lisa

            Regarding the use of an HSA account, I think your legal counsel is incorrect:

            http://www.dpcare.org/#!specialties/ctnu

            I will also point out that paying a fee every month is quite different than sitting down and figuring out what your medical costs would be under different scenarios and different combinations of insurance. People pay for many things on a monthly basis; that does not mean they compared the costs with other alternatives. Some people will do this but many won’t.

            My pcp rotates call with the other doctors in his practice. But as I said, in 18 years I haven’t need to speak with him or (any medical personnel) after hours. I haven’t ever wanted to speak to ask a question in 18 years; what I want and what I get the ability to make a same day appointment. I have had many phone conversations with my oncologists and my gyn. No extra charge.

          • lurking for answers

            The IRS is being decidedly vague on HSA spending for direct primary care. Several congressmen have asked for clarification earlier in July of this year. So far, according to the IRS and my CPA, a concierge fee (payment for access in addition to treatment) is not eligible, but Direct Primary Care fees CAN BE covered IF a bill can generated for the visit (acting like a reimbursement) or if your doctor specifically states that you NEED the additional care for a medical condition.

            My CPA andI look forward to additional clarification on the matter, but we are not hopeful. Many will be audited and fined and many will be deemed proper use, it will depend on who looks at your numbers and will be completely arbitrary for several years into the future.

            The specific (if it can be called that) IRS publication that deals with this is: http://www.irs.gov/publications/p502/

            Letter from congressmen: http://www.dpcare.org/#!blank/c1op5

          • Lisa

            If the DPC model involves paying a monthly fee for medical care, how can you generate a bill for each visit? You can’t have it both ways, imo. Snark aside, I do think DPC fees should an allowable expense for those with a HSA.

          • lurking for answers

            If you consider the DPC fee as a “prepayment plan” and you go see the doc for “legitimate, qualified (by IRS) medical treatment, your physician can generate a “receipt” for your records. You would keep that receipt in your tax records just as you should for any HSA expenses and then it can be deducted. Just paying the DPC fee does not qualify, you have to use it for it to be deductible. Thank you, IRS, for add complexity to a very simple model!

    • Dr. Neu

      Abandoning patients?

      Regardless of how things are paid for, who gets to determine how many patients a single doc can manage? If they take less than that amount, is that abandonment?

      I started with 0 patients but capping my panel around 700. Am I abandoning another 2300 theoretical patients I’ve never met?

      What about a doc whom decides to retire “early”? or take a non-clinical position?

      I appreciate you trying to help out the DPC movement Tom, but labels like that won’t curry much favor with the docs I’ve met.

      • Patient Kit

        What about doctors who convert to DPC and send letters to all of their current patients informing them of their new monthly or annual retainer fees? If the majority of patients can’t do that, should they feel abandoned by their doctor? Or is it that they had the choice to pay to stay but they chose to leave, abandoning their doctor who is only trying to start a new business? I know a few people who got those letters recently and they were really pissed off. And I think their general opinion of doctors suffered in the process too. Of course, doctors retire and move and get sick and even die. But switching to a different pay model with little notice may feel like abandonment to many patients.

        • Dr. Neu

          I feel a very strong ethical obligation to each and every single one of my patients. However, I will not set up on a moral high-horse dictating exactly how other doctors do business.

          But since you will willingly do so . . .

          Is it ethical for a doctor to change jobs? What if that new practice has different insurance contracts that may “exclude” some of their previous patients? (This routinely happens in case you didn’t know)

          Do you know any “traditional” medical practices/hospitals that will routinely allow patients to continue receiving care without paying co-insurance portion of the bill? (I don’t.) Are they unethical to deny a visit if a patient “cannot” pay a copay?

          • Patient Kit

            Yes, I am aware of how patients lose their doctors and doctors lose their patients because of insurance changes on either end. That’s why, ultimately, I would like to see a single payer system in this country and eliminate the insurance companies completely. There are way too many different insurance companies and plans. It’s daunting from both the patient and doctor perspective.

            Of course doctors can do whatever they want to with their careers. But, at the same time, docs shouldnt be so surprised at how little the public trusts doctors anymore. We all live in a healthcare system in which we know we can’t count on doctors being there for us.

            I really don’t think I have all the answers. That’s why I’m here talking with both doctors and other patients.

          • Dr. Neu

            Sadly, I would agree that the current system has lead to a decline in the public trust in my profession. However, that is due to the increasing distance between doctors and patients – and confusion that ensues.

            To me, trust can only be had through a personal relationship, not top-down systemic edicts.

            Why would you trust doctors more under a single payer system? The biggest fraud in the current system is greedy docs bilking government administered plans for billions of dollars yearly.

          • Patient Kit

            I’m at the hospital right now, where I just had an appointment with my GYN ONC, who I trust very much with my life. It would be devastating to me if I had to stop seeing him soley because of the insurance merry-go-round causing insurance changes on either end. Single payer wouldn’t solve all problems bur it would eliminate the insurance slot machine game of do we still match or not?

            I agree that trust is not automatic. It has to be earned and maintained in any relationship and the doctor-patient relationship is no exception. Also, once lost, it is hard to win trust back. I think trust is one of the key elements of good healthcare. And trust is not treated like the valuable precious asset that it is. It may be intangible and unmeasurable but it is key.

            As for single payer vs. our current system of thousands of payers, it kind of has to be one or the other. I guess I trust evil government a smidge more than evil Big Business. Actually, trust is the wrong word there. It’s the lesser of two evils, I guess. Wer’re never going to a system of direct pay for all healthcare. So pick your poison — government or big business?

          • Maddie D

            To suggest choosing between government and big business implies there’s a distinction between the two. If you, or anyone else, can think of how those two entities can be disentangled enough to make single payer work, I would love to hear how.

          • Patient Kit

            First I would look at the many countries in which it does work. Then I would ask what is so different about government in the US than anywhere else in the world that makes it so impossible for a single payer system to work here. Then I would work on changing that. I never said it would be easy or doable overnight.

            But when people say they want government, insurance and employers all out of healthcare, who are they saying should pay for healthcare? Every individual pay for themselves, if they can?. Only those with enough money get (deserve) healthcare in this country? Is that what some consider to be the American way? If so, that makes me sick.

          • Dr. Neu

            Enjoy fighting your strawmen

          • Patient Kit

            I’m actually too exhausted from fighting for my life and fighting to survive to enjoy any fights.

          • Dr. Neu

            Conversations are much more productive, and less exhausting, when you don’t constantly portray the other person’s position in a totally false way.

            “Every individual pay for themselves, if they can?. Only those with enough money get (deserve) healthcare in this country?”

            I never said that should be the case. In fact, I said things to the contrary on many occasions. However, it’s probably easier for you to promote your desire for single payor IF your (imaginary) opponents are okay with poor, sick folk dying in the street. Not productive, but perhaps easier.

          • Patient Kit

            Nothing about anything in our healthcare system is easy. I’m not wedded to the idea of single payer. I’m open to any ideas that would cover all Americans comprehensively. I am not open to catastrophic insurance as an answer.

            If I misconstrued anything that you personally said about DPC, I apologize. But you should be aware that some of your fellow DPC enthusiasts are promoting DPC as a way for primary care docs to start getting paid as much as specialists. As a patient, how do you expect me to react to that when, at the same time, I’m constantly being told that most Americans can afford DPC if we would just give up our daily Starbucks. It makes me feel like a lot of doctors are very unfamiliar with the world that many of us live in. I don’t have any Starbucks to give up. And if DPC is being presented as a way for primary care doctors to make as much as specialists, how I am supposed to translate that into affordable for me?

          • Dr. Neu

            I only speak for myself, but believe you are confounding – lumping together – many issues discussed here. Healthcare, insurance and government assistance are 3 separate, distinct entities.

            Whenever I advocate for removing “insurance” from “primary care”, that doesn’t mean inherently that we end all public assistance for anything but catastrophic health events.

            Although the current system provides public assistance exclusively with (micro) managed care – either gov’t managing all payments itself or subsidizing private companies to do so – there are other ways this assistance could be distributed to help patients.

            My preference would be to give patients on gov’t programs the option (not even forced!) to personally control a small % of the money allocated to them. This subsidized savings/spending account could be used for most outpatient care, namely primary care services, without lots of red tape for docs or patients. Of course, managed care (insurance) would need to come in to play for certain types of expensive care. this type of system has proved far superior when providing food assistance – i.e. foods stamps are better than government cheese programs. Why should primary care be any different?

            Again, the question of who gets subsidizes and how much is a political question. However, micro-managed gov’t or CorpMed “insurance” are not the only choices we have.

            If you’d like a good read, I highly recommend Catastrophic Care by David Goldhill. In my opinion, he has a better grasp on American healthcare that 99% of talking heads.

          • Dr. Neu

            Also, I believe many of our systems ills are due to the huge disparity in pay between PCPs and specialists. So, I don’t think PCPs making more money is a bad thing. In fact, it’s probably needed to persuade more students to choose primary care. Of course, I’m a greedy PCP, so I’m spending my time here talking to you so that I can eventually afford that second yacht I’ve had my eye on. :)

          • Health is Wealth

            Government single payer system only works in those countries where the taxes on everything can be as high as 20%, sometimes higher. Take the UK’s VAT tax on everything, or Canada’s added sales taxes. Or the many countries in Scandinavia who have enormous taxes.

            Are you prepared to pay an additional 25% on everything, and force the rest of the country to do the same to get your government single payer system, which will be horrible anyways???

          • Lisa

            And what is wrong with paying higher taxes and having universal health care in return? Now, we pay more for medical care than countries with single payer systems and get worse care. And if you really look at single payer systems, they may have problems, but no more problems than medical systems in the US.

            Lowering tax rates in the US has not worked to improve the economy. Wealth does not trickle down.

          • lurking for answers

            The government should be good stewards of the PEOPLE’s money. They are not. There is waste, corruption and abuse.
            Don’t bother to mention Big Business, at least their goal is profit FROM the people, NOT control over the people like “government.”
            I trust my money in my hands.

            If single payer comes to pass, big illness groups will lobby just like businesses to get a bigger share of the collective pie. Certain illnesses will get more because they have celebrity names attached or a congressperson’s relative has the disease. Rarer disorders will be forced to find gimics to raise funds (ice doesn’t work for everyone.) The popular illness poster children will get marathons and grants and mass screenings, but others like Lupus, and Turner’s syndrome and others just aren’t flashy enough to warrant funding.

          • Lisa

            Big Illness groups are already lobby to pass laws that benefit them: Look at Komen, BRA Day (to make sure women are informed about their reconstruction options after mastectomy-promoted by plastic surgeons. Look at the laws that mandate informing women of their beast density. All of these laws are generated and movements are generated by big Illness groups. So what you are saying isn’t an arguement against tax financed single payer health care. Not at all. It is a comment on how movements are able to influence law.

            I think there is less waste, corruption and abuse in the medicare system than there is in the for profit medical system as a whole. Providers are audited. I trust big business much less than I go government; I benefit from the infra structure provided by government (and that infra structure should provide health care). I don’t see that I really benefit from much of big business.

            Keep your money in your hands; but when you need expensive medical care, it won’t stay in your hands, but will go into the pocket of corp med.

          • lurking for answers

            When the government proves that it can spend my money with responsibility, I will gladly let them have more of it. FIRST, they need to show that they can handle what they have. A blank check will not help anything.

          • Maddie D

            Kit, my concern is that our government designs policies that overwhelmingly favor enrichment of big business to the detriment of physician autonomy and patients’ physical and financial health. Mandatory EMRs that aren’t required to be interoperable, reimbursement dependent on patient satisfaction scores, inability of Medicare to negotiate drug prices (the US pays more for medications and medical devices than any other country), direct-to-consumer pharmaceutical advertising, hospital facility fees driving up costs, a ridiculous malpractice system, taxpayers subsidizing multi-billion dollar private insurance companies, etc. are a few things that strike me as unique to the American health care system. Behind each of these pieces of legislation or policy decisions or “unintended” consequences is a lobbyist bearing gifts, a large campaign donation, and/or a multi-million dollar private sector job awaiting our elected officials once their term is complete. My fear about single payor in our culture is that it would combine the worst of capitalist/big business approaches to health care being delivered by algorithm-driven, government-employed healthcare “providers” who are powerless to do what’s best for their patients.

            I have no desire to live in a society where one’s chances of surviving a life-threatening illness is dependent solely upon their ability to pay for treatment. But I also know that the cost of our current system is unsustainable. Reducing overhead seems to be one of the best ways to make medical care affordable, but that involves reducing the role of insurance in routine care, enacting meaningful tort reform to decrease costs associated with defensive medicine/overtesting and malpractice insurance fees, and reducing regulatory burdens. I share your concerns about the ability of many Americans to pay out of pocket for DPC in our current system, but I do think that changing our system so that some of the money we pay for insurance is given instead directly to individuals to pay for their medical care would make a difference.

          • Patient Kit

            Maddie, I do hear and agree with a lot of what you are saying. I’m not nearly as naïve about the relationship between big business and our government as some might think. Maybe some of those relationships are what we should be tackling. Medicare not being able to negotiate drug prices with Big Pharma would be a good place to start. You’d think we could engage the American public/patients/voters on the issue of out of control drug prices.

            I realize that we’re talking about some very powerful lobbies. Maybe some success against Big Tobacco gives me (false?) hope that we can take on those powerful lobbies of Pharma, Insurance, Corp Med.

            I don’t know. I know I don’t have all of the answers and that there really are no easy answers. What I do know from very recent very personal experience is that it is both inhumane and terrifying to be uninsured (or underinsured) and diagnosed with cancer in this country. Nobody should have to go through that. I also know that most Americans cannot go it alone, financially or otherwise.

          • Dr. Neu

            I’m the one with the defeatist attitude? Haha.

            I am NOT advocating direct pay for ALL healthcare. That wouldn’t be feasible. Nor, have I advocated for ending government assistance to help people pay for health care.

            You are providing a false choice. There are dozens of variations of “universal” health coverage around the world.

            I would also agree with Maddie D below, as well. I don’t see much of a distinction between Big Govt/Business.

          • Health is Wealth

            America will never have a single payer system.

            If it ever does, that single payer needs to be the consumer when it comes to primary care.

          • Patient Kit

            Maybe you’re right. Maybe the US will never have a single payer system. But we’ll also never have a system in which each individual pays directly for their healthcare, primary or everything else. That is never going to happen. So, I guess that leaves us with a system dependent on insurance and employers.

        • querywoman

          I’ve always wondered how the “abandoment” issue plays out legally in areas where there are plenty of other resources, like public clinics and hospitals that take everyone.

      • Forthrighthealth.com

        I’m a big fan of yours, Dr. Neu, and my whole life right now is dedicated to helping primary care physicians and DPC, with great sacrifice to my entire family, so I certainly don’t mean to offend.

        But the fact is, I’m out meeting with physicians everyday and most don’t want to “leave” their existing patients, especially if they have to opt out of Medicare. These patients have been with them for decades and these docs are part of the community, abandonment is a real fear.

        I simply do not believe that we’re going to achieve the kind of change we all need by simply converting doc after doc with full patient panels to DPC. It’s going to cause more angst among the public than benefit.

        Instead, we need to incrementally change the system.

        We both have the same end goal, just different means to get there.

        • Dr. Neu

          I can’t deny that some physicians have that sentiment. It’s completely rational as we all care for our patients and want the best for them. However, sentiment doesn’t make it so.

          It is a very physician-centric to have that view. I see new patients routinely in my practice who had to leave their previous primary care doctors because they could no longer afford their services – either because of losing insurance or having very high out-of-pocket costs. Of course, docs don’t see that type of “abandonment”. The patients just don’t return.

          I understand your statements were probably just reflecting some of the sentiment you heard. But you stated it as a fact that it was a case of abandonment to see fewer patients.

          I do not think DPC needs to be a monolithic movement and any type of innovation is good with me. Best of luck in your efforts.

          • Forthrighthealth.com

            Certainly not fact, let me make that clear to the record. And, abandonment is a big and harsh (and technical) word that I shouldn’t have used.

            You’re right, it happens even though physicians don’t realize it. But for whatever reason it occurring indirectly or through omission is easier for the doc than perceiving that they’re doing it through commission.

            I’m not a physician so I’ll never truly understand, but I enjoy learning as much as I can from trailblazers like you. Ultimately, I’m trying to be helpful. I hope I can make a difference.

          • Patient Kit

            Regardless of what abandonment is technically or legally or ethically, abandonment is a very emotionally loaded situation as experienced by both patients and doctors. There is no way to de-emotionalize abandonment. If that’s what patients perceive is happening, we’re going to react to it emotionally. I think that’s unavoidable.

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

    I hope you are right, but I doubt it. These retail “clinics” are signing agreements with health systems all over the place. Sure, they say it’s for simple things and urgent care, but in the long run, why would a hospital system choose to employ primary care docs, if they can get all their referrals, including tests and procedures, at a fraction of what they pay a PCP? And if they skim all the simple stuff, even better, because whatever they don’t skim goes straight to specialty service. I don’t see insurers objecting too much either, because it’s really a wash at the low end of the market.
    The Uranium plans will probably sport the much touted wrap around traditional primary care, or what they now call DPC, and the usual suspects will have their private doctors as they always had….

    • NPPCP

      Hahahaha!!!!! OMG! Uranium plans! Okay, I see your point. Yes – didn’t want to hear that. Thanks.

  • Close Call

    “Can DPC solve the physician shortage?” Nope. But solving the physician shortage problem is not the responsibility of physicians.

    Physicians are responsible for their patients. If they don’t feel like they’re taking good care of a panel of 2500, they shouldn’t be doing it.

    I don’t see why this is so controversial.

    And the author’s perspective isn’t that surprising. When he is responsible for a panel of 2500 (or more), I fully expect his viewpoint to change.

    • buzzkillerjsmith

      Ding! Ding! Ding! We have a winner. The best comment of the thread, with the extra virtue of being short and to the point.

      “But solving the physician shortage problem is not the responsibility of physicians.”

      Curious how many hammerheads think that family docs and general internists could fix all this if we just tried harder–perhaps in our free time.

      I am making no comment on the merits or demerits of DPC.

      • Joe

        “Curious how many hammerheads think that family docs and general internists could fix all this if we just tried harder–perhaps in our free time.”

        I am often reminded of the character Boxer the horse in Animal Farm whose solution to everything was “I will work harder.” This was his solution right up until they sent him to the glue factory.

  • http://doctor-rob.org/ Dr. Rob

    To me, the only argument that resonates with me is the smaller panel. Certainly if DPC docs cannot carry 1000+ patients in their panel, the system will implode. That is why technology and information organization is really important in allowing efficiencies. I do believe that some sort of “organic medical home” is the way to extend the reach of DPC physicians and improve their care. I plan on adding a dietician, pharmacist, counselor, and others who will meet the needs of my patient better than I can.

    The entire focus of my practice on conserving resources and keeping patients well is so stark of a contrast to my previous 18 years, and my quality of care/life is so much better, that I now am convinced that there is no way change can ever happen in the current system. We must find a way to re-align physician priorities with patient needs and finanical responsibility. DPC does all of these things incredibly well. It really does give better expeiences to my patients, better life for me, and saves money for the system. The contrast between my two work worlds (past and present) is hard to describe. It’s going from a life where I was constantly pressured to short-change my patients and left the day feeling depressed to a life where I don’t have to feel guilty for spending extra time with people, don’t have to worry about an empty office, and constantly find my patients delighted and surprised with the care they get from me.

    The reality to me is that we MUST make DPC work for the masses. If we don’t, the system will die. We can’t fix the old system. It’s far too broken. We must make it new. DPC is the best possible chance for us.

  • fatherhash

    The author discredits smaller patient panels, but doesn’t seem to understand simple math. More patients per physician = less time per patient. Obviously, he hasn’t been a PCP in private practice seeing 35 patients per day….otherwise he wouldn’t be criticizing the ones cutting back to 15 patients per day for exacerbating the PCP shortage.

  • Lisa

    I think this plan would tend to increase medical costs. There were some comments on the blog article you linked to that bring up legitimate concerns about this plan.

  • HJ

    Qliance is a company supported by venture capitalists. I don’t consider that direct primary care.

    While it seems like a great idea to get rid of the fee for service payment method in primary care, I haven’t seen a lot of support for this model from doctors. Mention Kaiser or Group Health and all the insults come out. I remember reading an idea of primary care vouchers…All these types of things that have the potential to reduce cost and paperwork…like Qliance.

    Why aren’t doctors flocking to this model?

  • buzzkillerjsmith

    Two words: sub specialty.

  • buzzkillerjsmith

    Maybe not “know a guy.” But how about “every family doc guy I know?”

    If you’re a med student you’ll find out in time.

  • buzzkillerjsmith

    7 minutes/pt is 60 in 7hours of face time with pts.

    Come on. Most of us know arithmetic here.

  • Lisa

    The amount you mention wouldn’t buy all that much primary care in my area. There are no DCP practices & one concierge practice (hefty monthly fee and they bill your insurance. Your plan doesn’t offer me anything that my comprehensive insurance doesn’t offer me (and my cost for primary care would go up) because I would have to supplement the amount you mention.

  • pjp

    There’s alot of negativity in these comments. To provide a contrasting voice: Brett I agree with you, and I hope you strive to make it a reality, as I have.

  • lurking for answers

    Congratulations. I hope you are serious. I also hope you are successful if you are serious.
    The other advantage of DPC is that the PCP can spend more time with the complex/chronic patient, hopefully allowing that person to become healthier, less complex and no longer chronic.

  • Lisa

    I work for a university – salaries for instructors and professors cost the institution much more than slaries for administrators and staff. What you are saying is not true. The cost of education in this country reflects the willingness to support, or more accurately not support, education institutions through taxes. Since states have been cutting funding for higher education, tuition rates have gone up.