Direct primary care physicians are not concierge doctors

I recently received a scathing email criticizing an article I wrote about the care of patients in underserved areas. “Should you really even get to write articles about poor, underserved populations when you run a concierge practice?” the author wrote. “This is called hypocrisy. You are what is wrong with the medical field.”

What the author of this email didn’t know was that I spent six years working for the underserved as an employee of a federally qualified health center in a poor, rural area. But more importantly, she missed a very important distinction about my current practice. You see, I am not a concierge doctor. I am a direct primary care (DPC) doctor.

Across this country, DPC practices are filling an important niche by providing care for underserved patients. But rather than indenturing themselves to a government or corporate entity, physician-owners of DPC practices are providing care on their own terms, without bureaucratic headaches and red-tape frustrations.

Direct care cuts out third-party payers like Medicare, Medicaid, and insurance companies. Instead, patients pay the doctor directly, usually through a monthly fee, which averages $77 for DPC practices.

Because direct care doctors are not beholden to the insurance company, they spend less time on unnecessary documentation and more time on patients. And because doctors don’t have to spend a fortune trying to get paid by an insurer, they can often keep their overhead remarkably low, passing savings along to patients.

Affordable health care is critical — especially to those paying for medical care out-of-pocket – like the 28.5 million without insurance, and the increasing number of Americans with high-deductible plans.

At my practice, 75 percent of patients are uninsured or underinsured. Most of these patients tell me that they cannot afford insurance because they are self-employed or work for small businesses that are not required to provide insurance for employees. Insurance premiums on the health exchange are simply not affordable for these patients, but they can afford our average monthly charge of $64 to ensure adequate primary care.

Paul Thomas MD, physician-owner of Plum Health, a DPC practice in inner-city Detroit understands the needs of economically disadvantaged patients. “I intentionally selected a health professional shortage area as a place to start and grow my medical practice,” he says. “I believe that the DPC model gets us closer to the goal of truly affordable health care for our patients and communities.”

But DPC practices don’t just serve patients in inner-cities and suburbia. Donna Givens, MD, is the physician-owner of Grant’s Pass Family Medicine in rural Oregon. “Most of my patients are in the gap between qualifying for Medicaid and being able to afford insurance,” she says.

DPC practices can also provide a safety net for minority patients. Belen Amat, MD, the owner of Direct Primary Care of West Michigan, estimates that 70 percent of her patients are primarily Spanish-speaking.

And although my area is only 14 percent Hispanic/ Latino, because I speak Spanish and Portuguese my practice attracts many non-English speakers — comprising 27 percent of my practice.

Some of these patients lack health insurance because their legal status is in limbo — and with the Trump administration now considering public assistance as a factor in determining legal status for immigrants requesting green cards, many are wary of utilizing community health centers or emergency rooms and look to DPC as an alternative.

Other DPC doctors specialize in vulnerable populations, like Elizabeth Eaman, MD, with Oodle Family Medicine in Renton, Washington. “My biggest underserved population are transgender and LGBT patients — 40 percent of my patients are transgender, and 50 percent of my panel is LGBT.”

It is easy to criticize a new model if you don’t really understand what DPC doctors do. The Journal of the American Medical Association (JAMA) argued that DPC is structurally flawed, in that it incentivizes physicians to accept healthier patients.

But this argument does not match with the reality that many DPC practices experience. In my practice, most patients have multiple chronic illnesses — the very reason they see the benefit in paying a monthly membership for care. New patients have sometimes been without health care and off medicines for months to years, and require frequent visits to get stabilized.

And many times, rather than being “cherry-picked,” patients come to DPC practices because they have been dismissed from conventional practices. For example, Tiffany Blythe, DO, the owner of Blue Lotus Family Medicine in Kansas City, will accept unvaccinated children who are often unwelcomed into other doctors’ offices. “I’ve found that many anti-vax parents really are trying to do the best they can for their child. They just need education, patience, and support to find their way.” And with the additional time that DPC offers, Blythe has been able to convince some parents to vaccinate their children ultimately. “It takes time to overcome fear with facts,” she notes.

In my practice, I have several patients who were dismissed from their regular doctors. One 80-year-old Medicare patient came to me tearfully with a dismissal letter from her previous doctor in hand. She was “fired” from the practice, she said because she refused to talk to a chronic care coordinator. “I was just tired of them bugging me all the time,” she told me. “They kept calling me, and a nurse would come to my house and tell me the same things my doctor did.”

If you talk to DPC doctors, you will hear many stories like these. Inspirational stories not only of patients accessing affordable, quality health care but also of physicians who are happy to practice medicine again.

DPC offers an alternative practice model for doctors to regain the joy in practicing medicine. When medical students and residents hear DPC doctors talk, they get inspired to practice primary care. And studies are clear: more primary care docs equal better health care across populations.

Affordable care, better patient experiences, better patient outcomes, and physician well-being: the quadruple aim. And this is exactly what direct primary care provides.

Rebekah Bernard is a family physician and the author of How to Be a Rock Star Doctor:  The Complete Guide to Taking Back Control of Your Life and Your Profession.  She can be reached at her self-titled site, Rebekah Bernard, MD.

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