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Is Direct Primary Care the Solution to the US Healthcare Crisis? Print E-mail
Written by David Fater   
Thursday, 23 January 2020 11:19

Healthcare policy is often portrayed as a fight between government and insurance companies. But one of the most effective cost-saving measures is to cut out both and allow patients to deal directly with doctors. This can be accomplished in a variety of ways, one of which is referred to as Direct Primary Care (DPC), a concept that has been around for several years but is gaining traction. As with any facet of healthcare there are advantages and disadvantages and one has to understand the concept, as well as the benefits and the pitfalls. It also is important to differentiate Direct Primary Care from Concierge Medicine.  There are similarities but there are also significant differences.

Also, it should be kept in mind that many of these groups are pioneering next generation care models as well, incorporating nutrition, mental health and coaching services into holistic treatment plans that strike at the root of chronic disease. These integrated care teams design plans and wellness environments that are about as similar to traditional healthcare as was to Barnes and Nobles.

Let’s look at Todd Gibbons (Patient) from Any City, USA. When he has an aching shoulder or needs a physical, he can call and schedule an appointment on a day’s notice, maybe the same day. His physician is also available for phone consultations and even makes house calls. It all costs Mr. Gibbons $150 a month to cover his family of five. Costs are so low and coverage so good because the Gibbons family goes to PTC Direct Primary Care—a medical practice that treats patients for routine care and procedures for a monthly membership fee. Virtually every routine service—from electrocardiograms and pap smears to stitches and physicals—is included. There are no office-visit fees or copayments. All physician services and procedures offered at PTC are covered, and all without the use of health insurance.

Without third parties taking money and adding overhead, PTC can offer medications and lab tests not covered by the monthly fee at wholesale prices. A cholesterol blood test is $3.20 for a PTC member, but $22 at other in-network providers.  Drugs are cheaper. PTC buys directly from three national wholesalers, which compete to provide medications at the best possible price for any given patient, and PTC resells them at cost. A 30-day supply of the generic equivalent of 40 mg Lipitor for cholesterol is $3.30 at PTC. At Walmart it’s $9. Sildenafil, the generic for Viagra, is 37 cents a pill. The next cheapest option is Safeway at $2.13. Over-the-counter drugs are also cheaper and available in-house at PTC. Cetirizine allergy pills (the generic version of Zyrtec) are 6 cents a tablet at PTC, about half the Walmart price.

Costs are low and transparent. The monthly fee, whether paid by employer or individual, is predictable and easy to budget. It is important to bear in mind that patients still need high-deductible insurance or cost-sharing pools to cover nonroutine procedures and care. But complementing a direct primary care plan with one of those two options still can produce the cheapest coverage.

One of the negatives is that tax incentives currently discourage employers from switching to direct primary care plans. One possible fix would allow patients to use health-savings accounts to pay for membership. The IRS could make this change by redefining a direct primary care membership as an eligible HSA expense. Cutting the middlemen out of daily health care won’t solve all of the medical system’s problems. But altering the tax code to encourage employers to use direct primary care could help control or even shrink costs. Most important, it would improve the quality of care by letting doctors spend less time filling out paperwork for reimbursement and more time helping patients.

Direct primary care could be viewed as yet another in a long line of ideas to help reinvigorate primary care for both doctors and patients. Some view it as a panacea, others as snake oil. I am not sure what it is exactly, but I do know it is not a transformative innovation for making primary care more relevant, responsive, and affordable on a large scale. Simply put, direct primary care is a model for delivering primary care, and only primary care. The doctor charges each patient a monthly fee, generally ranging from $50 to $200, in return for timely, convenient access and a buffet-like menu of mostly basic primary care services. The amount of the monthly fee is presumably set in relation to the scope of services covered, though every practice may do it differently. For services that aren’t covered under the fee, like more extensive management of a chronic disease, the patient’s insurance — if it exists — must be billed to pay for the service or, in some cases, the physician or practice will charge the patient extra fees to cover those services.

On the physician side, direct primary care is appealing to a growing number of doctors. Many are burned out and dissatisfied working in traditional primary care practices, where the administrative hassles are high and physicians do not get to spend enough time with their patients. Many want to return to a time when Marcus Welby, MD practiced and the doctor-patient relationship was more central to the delivery of primary care. Many want greater predictability and control in their work lives.

Five Factoids About Direct Primary Care
1. DPC physicians foster an enduring doctor-patient relationship
Developing an enduring doctor-patient relationship through adequate appointment time is a hallmark of Direct Primary Care. A typical Direct Primary Care practice has about 600 patients, compared with 2,500 patients for an average fee-for-service primary care practice. Instead of seeing up to 30 patients or more a day, Direct Primary Care providers typically see less than 10. Many physicians believe a lot of medicine can be done electronically. It should be noted that most Concierge Medicine practices limit their patients to 600 as well; However, the Concierge Fee is greater than the Direct Primary Care fee-ranging from $2,000-$2,500. (Interestingly enough, if you add up 12 payments of $150, you are close to the Concierge Fee-but recognize the Concierge physician does not have a "Family Plan).

Additionally, Direct Primary Care physicians profess that they know their patients by name and have time for them. These longer appointments in the DPC model allow time for discussions between a physician and patient that encompass lifestyle choices with the aim of long-term health and well-being.What everyone really needs to know is that patients do get better care when their doctor is more satisfied with what they are doing. And that takes time. That is what the [fee-for-service] system cannot provide -  time with the patient.

2. DPC is growing and DOs are joining in
In the past decade, the DPC model has grown from just 21 practices to over 1,000 practices in 49 states that care for an estimated 500,000 patients, according to the Direct Primary Care Coalition (DPCC), an advocacy group. The movement has been particularly popular among DOs who estimates that 30-40 percent of the group’s members are DOs, osteopathic residents and medical students.The high level of interest in DPC by DOs may be attributed to an already higher percentage of DOs practicing primary care- But DOs also tend to be a bit more entrepreneurial and independent and their training includes some additional non-traditional treatment techniques.

3. Efforts are underway to enhance DPC
The American Osteopathic Association supports the DPC model, and has urged Congress to support a Primary Care Enhancement Act (PCEA) that includes a DPC model which would allow physicians to provide health care to the full extent of their scope of practice, including providing diagnostic services and dispensing prescription drugs. Currently, the IRS views DPC as a type of health insurance and bars the use of health savings account funds to pay for DPC. The PCEA would allow patients to use the funds from their HSA to pay for DPC. One of the downsides of direct primary care is that it can be challenging to find patients who can afford their membership dues, particularly in medically underserved areas.

4. DPC offers upfront pricing
DPC practices offer transparent pricing upfront. A monthly membership fee (typically under $100 per member, often with family discounts) covers unlimited primary care office visits and services. Patients are encouraged to buy a complementary insurance plan, such as a high deductible health plan, to pay for any complex or catastrophic medical services outside of primary care.While both concierge and DPC charge a periodic membership fee to the patient, most DPC physicians don’t accept insurance. Concierge practices, on the other hand, typically still bill insurance and often add an annual retainer fee that is usually higher than the DPC annualized membership fee.

5. DPC embraces the ‘quadruple aim of medicine’
The triple aim of medicine—to enhance the patient experience, improve population health and reduce health care costs—is well-documented and embedded in the triple aims promulgated by the ACA. DPC providers are focused on “the quadruple aim of medicine” which acknowledges that improving the work-life balance of physicians is necessary in order for the other three aims to happen.

Direct Primary Care will continue to evolve (as will Concierge Medicine). It probably will not be the solution to our broken healthcare system but it does provide some interesting alternatives both for physicians and patients. Primary Care Physicians should consider this concept to include in their practice as the crisis continues to evolve; but this will also entail a change in the mindset of physicians.
Mr. Fater is CEO, Alda & Associates in Delray Beach, FL.

Last Updated on Saturday, 01 February 2020 14:54

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