This post was contributed by Ripley Hollister, MD, board member of the Physicians Foundation.
America’s current healthcare debate is plagued with confusion and misalignment. We have a diverse landscape of players and agendas where legislators, multi-tier bureaucracy, health insurance companies, hospital systems, the pharmaceutical industry, patient advocacy groups and organized medicine all take part in deals that have replaced your healthcare with a “qualified health insurance plan.”
As our ACA matures, medical care has become an even more complex and expensive industry, representing 18 percent of the United States’ GDP. Amid all this, primary care physicians are losing their autonomy and instead have become a tool of the entities that pay them for patients’ care: Medicare, large insurance companies, hospital systems and employers.
With Medicare’s newest mandate – MACRA – critical concepts like quality and value are now defined by labor intensive metric measurement (box checking). As a result, most of a physician’s time has shifted from patient care to administrative duties. This “corporatization” of medicine focuses on populations rather than individuals, where data is valued above patient wellness. Primary care needs new concepts, innovations and partnerships to fight the rising costs of healthcare under government mandated insurance. It needs a plan that does not have at its foundation the influence of huge power lobbyists. It is not surprising that a new concept will likely be distressing to those power players like large insurance companies and hospital systems, but such is the disruption that is needed.
Direct Primary Care (DPC) is a practical solution that supplants the craziness in the current debate and, in a simple way, provides a clear path for patients to beat all the rhetoric with something valuable, practical, coherent and concrete – the physician-patient relationship. To put it simply – it aligns the incentives of physicians and patients to 1) take care of the patient and 2) fund that care.
As a recent survey by Health is Primary shows, American views on primary care are clear. Eighty-six percent agree that primary care leads to healthier patients, higher quality healthcare and lower costs, representing the triple aim of healthcare. Not only that, a primary care physician saves money (about 33 percent in some studies) and reduces hospital and emergency room utilization and surgery. The truth is that the large, third parties are not necessary or wanted in primary care. When big business invades the exam room, the simple cost-efficient space for primary care devolves into an opaque, confusing, frustrating and expensive morass that invalidates the triple aim. Let’s discuss DPC, agree about our motives and bring transparency to the topic.
Motives of Direct Primary Care
First, DPC is NOT insurance and does not cover medical costs outside the primary care practice. Generally, patients have a high deductible or “health share” plan to be an ACA qualified healthcare plan. The DPC monthly fee (under $100 / member, commonly with family discounts) is a reasonable monthly retainer contract between the patient and physician that covers primary care office visits and services.
Time efficiencies like electronic communication, texting and emailing are encouraged under this model. Depending on the contract, other services are often included, such as flu shots, annual blood tests and common office procedures like minor skin surgery, laceration care, EKG’s and pulmonary function tests.
DPC does not bill insurance. The practices have low overhead costs, fewer patients in the practice (typically 600 – 1,000, as compared to traditional models with 2,000 – 3,000) and fewer office staff. This all means more time for the physician to collaborate, educate and treat patients.
DPC excludes huge third-party interests that do not belong in the exam room. This model of care is based on the power of human interaction and creativity that is born out of the necessity of the physician-patient relationship. It is an alternative to the fee-for-service merry-go-round that leads to complicated, often erroneous billing and escalating healthcare costs. It puts the onus on the people directly impacted to determine quality and value, and as a result, incentives are aligned.
It is easy to see how DPC aligns incentives between the patient and the physician. Patients are encouraged to get their needed preventative care, manage their chronic conditions and evaluate new issues in a timely fashion – before they become an emergency. Specialist care is not discouraged, but appropriate (not excessive) use is guided within the primary care home. Healthy lifestyle and reasonable prescription choices are a collaboration. Time is given for two-way communication, education, explanation and negotiation using up-to-date medical information, creativity and empathy in an atmosphere of respect, compassion, partnership, fellowship and comfort. Barring the big third parties means their oppressive requirements for reimbursement go out the window. Their senseless definition of quality that results in excessive administrative burden is gone, and the physician’s attention can be focused on the patient, not the laptop computer.
Under our current system of ACA required insurance, the physician has become beholden to large third parties who pay for care. Our current system allows insurance companies and hospitals to effectively “employ” the very physicians who direct and provide a patient’s care, often conflicting with a patient’s best interests. Practices must submit tons of information about patients to those companies to prove quality care was provided.
All that data and coding comes at a tremendous cost – current estimates are that over 50 percent of the physician’s time is spent in administrative duties. As a result, codes and documentation prove quality, regardless of how the physician patient relations succeeds. Another result is physician burnout at a monumental rate – 50 percent of physicians feel it most of the time. Wouldn’t it be better if the patient “employed” their primary care physician?
Numerous examples including DPC practices in California and North Carolina put DPC right on track with the Triple Aim, improving the patient and physician experience, while lowering total medical care cost and improving outcomes.
Amid all this we also see some difficulties. As one might expect, when the DPC model for small practice is expanded to a large scale, new issues arise. While over 90 percent of the new DPC practices are doing well, there are some exceptions. For example, two of DPC’s biggest large-scale practices recently closed their doors.
Thankfully, favorable DPC legislation is progressing. To date, 21 states have passed laws indicating DPC is not a form of insurance. This exempts small practices from being required to comply with that mammoth body of law and regulation.
In conclusion, DPC is the new kid on the block: innovative, disruptive and promising. Investigate it. While it is not necessarily the answer for everyone, it is certainly an answer for many.