Direct Primary Care from the Patient’s Perspective

We’ve known our doctor has been unhappy for at least a year. She spent more time doing paperwork than seeing patients (not an exaggeration, unfortunately), the Centers for Medicare & Medicaid Services were planning to pay her less every year because she refused to send them the patient files of all her patients—payments would be 20% less by 2020, if I recall correctly—and her workload was crazy trying to see enough patients to keep her doors open. She was one of a very small handful of independent providers who hadn’t sold out to the local hospital (which promptly raised rates in their newly bought practices because hospitals are on a more generous fee schedule. Yay, higher prices! Sigh).

So as of January, she switched over to Direct Primary Care (DPC), which means she has opted out of Medicare/Medicaid and doesn’t take insurance anymore. Patients can still submit to their insurance company separately (though not to Medicare or Medicaid).

Sounds like a few decades ago, right? When you saw your doctor and you paid your doctor, with no one in the middle. Well, almost.

Since DPC physicians are competing against “subsidized” insurance-paid physicians, many of them see a transition to a simple fee-for-service setup as dangerous. Even if they charge, say, half of what the other doctor charges, the DPC doctors aren’t competing against the total charge but against the patient’s copay. They appear to be more expensive. If not enough people are willing to pay the unsubsidized amount, they’ll go out of business.

What irony. The reason that I put the word “subsidized” in quotes above is because most people still pay their doctor’s fees, only through their insurance premiums instead of directly to their doctor. Insurance payments to your doctor are not insurance per se; they’re prepaid healthcare services, a far more expensive proposition, especially once you include the insurance company’s mark-up. (This is not an example of insurance company greed, by the way. This is how prepaid healthcare works, and should work. But that’s a post for another day.)

Very few providers will take that risk. I personally know one doctor, James Brook in Idaho Falls, who has created a successful fee-for-service practice. He has also written great book on our healthcare system and why it is so expensive: The High Price of Socialized Medicine. It’s worth far more than its $4.99 cover price.

To protect against this risk, many physicians have chosen to follow a concierge version of DPC, where patients pay a monthly fee. Some fees are outrageous, some are nominal, and some are on top of a fee for service. Our doctor chose a lower-end monthly fee that includes our office visits. This means my husband and I get to shell out even more money on top of our insurance in order to keep our current doctor.

That’s the bad news, but there’s also good news. She offers more in-depth services than before.

  • We have unlimited visits included in that fee, including a wellness exam that includes certain lab work.
  • We get same-day appointments if we call in the morning, or next day if we call in the afternoon.
  • We get access to labs at her cost. Sometimes that cost is less than the after-insurance fee.
  • We get access to cheaper prescriptions–in some cases much cheaper. Did you know that the copay on prescriptions is sometimes more than the cash price? It pays to shop around.
  • We get 24/7 access and can chat via email/phone/IM and resolve medical issues that way instead of going to her office.
  • Family members visiting us can go see her during a two-week period on a fee-for-service basis.
  • We can make appointments and get prescription refills online.
  • If we need her to, she’ll make house calls.

House calls. I feel a nostalgic sigh in the works, and I’m not old enough to remember when doctors made house calls.

Once we start using our doctor’s services, I’ll post on them. The doctor has also agreed to an interview once she has more time. Her office is busy arranging access to the pharmacy.

Yes, I’d prefer Dr. Brook’s setup, but I’m not going to complain. If this is what it takes to convince doctors to jump through the innumerable regulatory hoops to become DPC physicians, I’m willing to pay extra as an early adopter.

Cross posted at the The EclectiSite.

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