Direct Primary Care Offers Cost Savings, Privacy, Personalized Care
Editor’s Note: Direct primary care (DPC) has proven to be a viable, quality-based solution to soaring health care costs, but government policies stand in the way of the growth of this option.
Health Care News talked with Marilyn Singleton, M.D., president of the American Association of Physicians and Surgeons, about why her organization supports DPC and how it can help solve the nation’s health care problems.
HCN: DPC is subscription-based, not a form of insurance. What is the importance of that distinction?
Singleton: The model is a monthly subscription consisting of a monthly payment. It is not an insurance premium and is not subject to insurance regulations. It is a direct payment to the doctor and is done monthly.
Part of the reason it is done monthly is to avoid the concept that you are pre-paying for something that you might never receive. It’s subscribing to a service. The fee can range anywhere from $40 to $140, and the fee is dependent on age, not the health condition of the patient. That’s very important because some people say, “Those doctors could cherry-pick and won’t take sick patients.”
HCN: If the service is based on a flat fee, how does it deal with sick people who are heavy users?
Singleton:Sick patients benefit because they can go into the doctor however many times they want, and that’s the key. When the concept was first beginning, everyone thought people would go to the doctor every day. Well, no one wants to go to the doctor every day. As it turns out, people don’t abuse it. They have a good relationship with the doctor and often feel embarrassed if they would abuse the privilege.
The unlimited nature of visits helps the doctor, because they can easily monitor treatment protocols, such as when medications need to be adjusted on an ongoing basis. [In the traditional model] one of the reasons patients don’t come back to get this really individualized monitoring is they don’t want to have to pay for every visit required for readjustment.
HCN:How can DPC practices afford to provide unlimited visits?
Singleton: One of the reasons DPC physicians can survive with lower prices is that they need fewer employees. Imagine if you’re [a physician] using the insurance company, you have to pay a “coder”—the person who has to go through the thousands of codes, line it up with what you did that day, and submit it to the insurer in order to get paid. The insurance company may then take up to three months to pay you.
HCN: Can DPC help cut costs in other areas?
Singleton: A very big deal is that most states allow physician dispensing [of pharmaceutical medications] in DPC practice. A DPC physician can go to various drug wholesalers and obtain prescription drugs in some cases for as little as one-tenth the price compared to a patient with insurance coverage who went to the drug store.
For example, hydrochlorothiazide, the most common drug used for blood pressure, can be purchased for $14 for a bottle of 1,000 pills. But most people are getting a prescription where their copay is $10 and all they’re getting is 100 pills. Most DPC doctors will charge the patient their cost, plus a minimal amount—$1—to cover the cost of the bottle, label, etc. So basically, the doctor breaks even and the patient pays next to nothing.
HCN: Can this model work for specialty care?
Singleton: Yes. Doctors like endocrinologists, who treat diabetic patients over and over, tend to act like a primary care doctor. The same is true of neurologists, because the patients who have those kinds of conditions need continued care, so these doctors can have the same kind of model.
HCN: What are some other features of DPC that attract patients?
Singleton: More and more studies show, and the Kaiser Family Foundation did a big study where they asked patients what they wanted out of their medical visits, and what they found was that personalized care was the number one answer. Also, having that opportunity to have a patient-doctor relationship where you feel you can tell the doctor anything without being hooked up with a big electronic medical record system that goes God knows where to the “federal office of data,” is something else that draws people.
They feel they have more privacy. With all the news about Google and everything else coming out, people realize they have no privacy. At least the one place you should feel like you have privacy is in your doctor’s office. And as doctors, we want the patients to feel like they can tell us anything. If the patient thinks everything they say is going to ‘the great computer’ in Washington, D.C., they may not tell you important things about their history.
So, most importantly, this is a model that helps establish a great patient-doctor relationship that helps patients feel comfortable confiding in their doctor.
HCN: You say DPC brings us back to a time when health care worked pretty seamlessly. What was that like?
Singleton:I think back to my father, when he was a general practitioner way back when. When Medicaid came out, he didn’t take it, because he would have to hire another person and raise prices. He would charge people whatever they could afford to pay—really good, old-fashioned medicine.
Now, if you take federal money, it’s a fraud if you don’t charge everybody the same thing. But if you’re outside the system and you take a patient who is very poor, but they want to stay with you, you can charge that person whatever you want. You can do it for free, if you want, since you’re not constrained by the ‘fraud and abuse’ rule.
These are the sorts of things that are helpful to doctors and are also incredibly helpful to patients. It’s a win-win.