The Only Good Idea to Change Health Care that I’ve Heard – Direct Primary Care

The buzzwords of health care reform we focus on – Accountable Care Organizations (ACOs), Patient-Centered Medical Homes (PCHMs), Health Information Technology (HIT), Medical Loss Ratios (MLRs), etc. – are all ideas with (mostly) good intentions but none of them will change health care in America to actually improve patient care and reduce health care costs.  Direct Primary Care (DPC) is the only good idea I’ve heard with the potential to ensure access to health care, decrease health care costs, and improve health outcomes.

The idea behind DPC is simple: pay your doctor a monthly fee for your care.  In other words, your doctor charges you say $50-$100 per month and provides your care. Usually when this model is discussed, it is in the vernacular of “concierge” medicine.  The word concierge brings with it a sense that such a health care system is only available to the wealthy. However, DPC is actually a way in which we can help everyone care regardless of their socioeconomic status. It’s like a membership.  You already pay (or your employer pays) insurance premiums each month and those premiums are well over $100 per month.  In fact, on the individual market, insurance is easily above $400 per month per person.  If employers and government invested in this model of care, the savings would be overwhelming.

The benefits of DPC are not just monetary (which seems to be the only thing anyone is concerned about these days) – it takes out the middle man, insurance.  Thus the administrative burdens are gone – allowing doctors to focus on patient care instead of fighting for reimbursement.  Patients in these practices often receive better care.  Patients who wouldn’t have access to care because of the prohibitive cost of insurance have access to care.  And the DPC model can incentivize med students to actually choose primary care over other specialties in a time where of dire need for primary care physicians (PCPs).

Insurance companies are for-profit companies.  Make no mistake, they are not primarily interested in improving health outcomes.  They are focused on increasing profits.  As such, they direct your care, not your physician.  The physician can recommend treatment, but this has to be approved by the insurance company.  Insurance companies waste money (as I talk about in this post on Health Insurance).  More than 19% of claims are incorrectly processed according to the American Medical Association (AMA) a cost of about $17 billion annually.  Insurance companies deny claims which are then appealed or insist on further review for claims that could be easily processed, wasting more money and time (time being of the essence when health is at stake).  That burden gets passed on to employers and individuals who see higher premiums and doctors who spend 10-14% of their operating costs on fighting insurance companies to get paid.  Insurance places a burden on everyone in the system, except for themselves.  Patients receive care at the whim of an insurance claims specialist and providers divert their attention from patient care to administrative matters (see also A Culture of Change).

To paint a picture, consider the diagrams below from

Taking out insurance companies, eliminates the middle man.  Insurance companies no longer determine what care is appropriate.  That is left to the treating physician. Providers have more time to spend with patients instead of squeezing in 25 to 35 patients a day (national average for insurance-based practices).[1]  When providers have more time to spend with patients, they can actually listen to and address the issues the patients put forth.

Ostensibly, putting patients first is the idea behind ACOs and PCMHs, that medical care is patient-centered.  But those models cannot possibly be focused on the patient as they are set up because the primary concern is cost instead of care.  Particularly with ACOs, the focus is on meeting certain “standards” (standards that are far too low and measure the wrong things in my opinion, standards that were created by the government and insurers and big lobbyists who are not doctors) and tying these standards to payment incentives and business models that will drastically harm our health care system (primarily by creating monopolistic health care structures).  Essentially, other models neglect actually addressing patients’ needs as they express and as doctors think are in their best interest.

Furthermore, ACOs and other models set forth (HMOs, PPOs, etc) do not do anything to tackle the issue for the 50 million uninsured who are unable to receive care at all who rely on hospitals or free clinics and resulting in increased health care costs to everyone in the nation.  These models will not provide care for people who are poor.  DPC does, which I find the most compelling argument for switching to this model of care.  And DPC provides a benefit option for employers who couldn’t offer such benefits otherwise – meaning fewer uninsureds and stimulating the economy by reducing costs to employers who can then attract and hire employees and expand their business.

The argument that will receive the least public sympathy is how this practice model is best for primary care doctors.  Most people do not realize that doctors’ income is never certain.  Every few years, the government threatens to cut payments to doctors who take care of Medicare patients.  Right now, the Medicare cuts are up for debate with the payroll tax cut, yet most people don’t even realize the incredible impact these cuts can have on physicians.  As I mentioned above, it is a fight for doctors to have insurers pay claims appropriately.  While primary care physicians make a lot of money, they make far less than any specialist.  Though physicians pursue medicine to help people, they still have to consider the loans they accrued during medical school and the costs of running a practice, costs that are increasing as doctors need to implement expensive health information technology and will soon face updating the way they code procedures to get paid.  I don’t know any millionaire PCPs.[2]

Already we have a dire shortage of primary care physicians that is only getting worse.  According to projections released last fall by the Association of American Medical Colleges (AAMC) Center for Workforce Studies, there will be a shortage of about 63,000 doctors by 2015, 91,500 by 2020, and 130,600 by 2025 – most of which will be in primary care.[3]

Med students have no incentive to go into one of the most difficult professions – primary care which pays less, requires more hours of work, and has the greatest administrative burdens with the fewest resources. And thus fewer and fewer med students enter primary care.

Talk to primary care physicians and many lament choosing to practice primary care medicine because they are burnt out (not because they don’t like being a doctor or because they want more money).  As I mentioned above, they may need to squeeze in 25-35 patients a day, seeing them each for about 7 minutes, spending all night updating patient charts, on-call to be there for patients in the middle of the night, and being hated.  Patients are frustrated with their doctors because they don’t feel that the doctors give them enough time or the doctors are running late or the doctors are visibly burnt out from trying to see enough patients to keep their practice afloat.  In a DPC model, physicians can cut their hours and have a better quality of live, thus decreasing burn out.  In a DPC model physicians can make higher incomes which they can put back into their practices to provide the newest technology available.  And in a DPC model, doctors can have an actual relationship with their patients, listen to and address patients’ needs and ensure patients are cared for holistically instead of a contentious, rushed interchange.

Now, will this work for all forms of medicine?  Of course not.  DPC is only a piece in the puzzle of affordable health care.  We wouldn’t pay memberships to hospitals we don’t use (though essentially we do pay membership through taxes).  We wouldn’t pay memberships for surgeries we won’t have.  That’s why we rely on insurance so heavily – if such costs arise, our financial responsibility will theoretically be less.  Though the truth be told, having insurance doesn’t always insure that your financial responsibility will be less

Because Direct Primary Care improves patient care, provides access to care for those who would otherwise be without, is a unique solution for employers to offer medical benefits to employees, allows physicians to be physicians the model can really make a difference.  ACOs will not improve health care costs or actual patient health.  PCMHs are a great idea, but will not change the payment structures and administrative burdens that are the biggest problems with our current health care system (in other words, insurance companies will still be in control).  HIT is important and necessary but is expensive and doctors cannot count on payment from insurers or the government.  MLRs will change the way insurers have to spend the money they take in but will still not allow doctors to be doctors in charge of the care for their patients.  And none of those ideas do anything for people with no insurance.

Health is a human right.  Every person deserves to have access to affordable and quality health care.  Direct Primary Care makes this a possibility.

[2] Though I’ve met a select few doctors who deserve millions and more considering their dedication to patient care

[3] Addressing the Physician Shortage Under Reform

See these articles on DPC and this blog which got me thinking about DPC.


4 Responses to The Only Good Idea to Change Health Care that I’ve Heard – Direct Primary Care

  1. Ron says:

    Fantastic post. It will be interesting to see if primary care doctors start to go this route. Reminds me of musicians (and now comedians – see Louis C.K.) going directly to the public rather than through record companies/stores.

  2. […] Primary Care over insurance in her Health as a Human Right blog site. Here’s an excerpt from her article: “The idea behind DPC is simple: pay your doctor a monthly fee for your care.  In other words, […]

  3. […] Erin Gilmer has written an informative article about the benefits of Direct Primary Care in her Health as a Human Right blog site. Here’s an excerpt from her […]

  4. […] Erin Gilmer has written an informative article about the benefits of Direct Primary Care in her Health as a Human Right blog site. Here’s an excerpt from her […]

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