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Can Monthly Subscriptions to See Doctors Work for Patients?

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Dr. Lorraine Page with one her patients, Ann Caponio, 59, in Half Moon Bay, Calif.  (David Gorn/KQED)

Anyone who has ever waited 45 minutes past their official appointment time for their doctor, or gotten tangled in the branches of an insurance company phone tree, has thought something along the lines of:

"There's got to be a  better way."

Well, some primary care doctors say there is. It's called direct primary care, a business model in which doctors drop off the grid of the traditional health care system by refusing to take insurance--any insurance. Instead, they charge patients a monthly fee for as many visits as needed.

Our recent story on the topic from David Gorn rapidly became one of the most popular we've ever posted, and we received many, many comments from both doctors and patients about this growing trend in primary care.

We've decided to pass on some of the more interesting responses (edited for length and clarity), and some new thoughts on the model from a consumer advocate.


For doctors, the great benefit of direct primary care is freeing their practices of the copious paperwork required by insurance companies; the lack of bureaucratic overhead ostensibly allows physicians to take better care of fewer people. The upside for patients is they get  more of their doctor's time, more personalized care and perhaps even house calls.

Some patients think this is a nice idea -- for those who can afford it.

I don't see this working with low-income populations. Will all the doctors be moving to the rural burbs now to take advantage of those who can afford their services? By abandoning the 'system,' they abandon all those who rely on it for care."

And from another reader:

The article cited one doctor charging $59 a month for unlimited visits. That's over $700 a year! I don't see this as a cost-effective alternative to insurance. ... What happens when these subscription doctors inform their clients that they can't make a competent diagnosis without a referral to a specialist?"

Another patient also can't see the financial sense in paying extra:

My primary care physician recently did this. Guess what? I still have to pay for insurance. I'm not paying a retainer on top of that just for the right to see one doctor.

Others think insurance companies are requiring so many out-of-pocket costs, the extra price of a "subscription" to a primary care doctor makes sense:

These insurance companies have such high co-pays and deductibles, more people are going this route! You do need a basic plan for the unexpected hospital stay, surgery, etc., but this makes sense.

Some patients are already experiencing this type of system:

Our physician works on a business model very similar to this. We pay a monthly 'member' fee and he accepts whatever Medicare Advantage Plan pays. The real plus here is he is always on time, his waiting room rarely has anyone else in it and your visit is as long as it needs to be. Our annual checkups last two  to three hours, include a treadmill stress test, an ultrasound and lots more poking, prodding, asking, talking. Great doctor, too.

Among comments from doctors, there were stories of dissatisfaction and anger at the current system of insurance-based care:

If my husband and I and our daughter closed our outpatient internal medicine office and went to a no-insurance model we would certainly be happier and healthier in the long run. Our average work day is 14 hours, seven days a week, as we do rounds at the hospital on our own patients, and many have our cell numbers so they can call us. Only about 55 percent of what we do every day is billable.

It is horrifying to have to call an insurance company to get authorization for a procedure and to have to provide my full name, title and training but not be able to speak with anyone on their end who has one whit of experience, and to know the decision will not be based on medical complexity or necessity but on a check-the-box form.

And many patients were sympathetic to their plight:

The doctors and patients are caught in an insurance nightmare, but the doctors do have more power than we do. Two of my longtime doctors went to very part-time. One retired at 58 and another sees 32 patients a day and knows he will leave to teach by 45. Sixty thousand billing codes--it seems insane.

Yet, even some doctors have concerns:

Though I have lots of colleagues going this route, I have an ethical dilemma with it. So many of my patients can't afford the $1,500 (sometimes more) annual fee, just for the privilege of being a patient. I'd lose people I've cared for for decades. Often the people who need me the most wouldn't be able to afford it. As bad as the Medicare fee schedule is, I couldn't bear the thought of giving up so many of my patients. Could I make more money? No doubt. Would I be more satisfied? I don't think so.

A Consumer Advocate Weighs In

We wanted to hear what someone who works on consumer health issues thought about the direct primary care trend. Betsy Imholz, director of special projects for Consumers Union, has worked intensively on health reform. And she has a number of concerns.

Imholz says that while she understands why both doctors and patients are attracted to direct primary care -- "the old Marcus Welby model," as she puts it -- she thinks it's a move in the opposite direction of the current push for an integrated health care system. Ideally, doctors would have access to patients' electronic health records, and all-payer claims databases, at least theoretically, would allow purchasers of insurance to compare costs.

"It goes against this coordinated care model that the Affordable Care Act and the U.S. is coming to," she says,  "having things not fragmented but coordinated [in a way that] enables us to check, make quality assessments."

Another potential problem, says Imholz: If healthier people are looking at direct primary care as a substitute for insurance rather than an augmentation, it could drain the ACA risk pool of the very type of patients needed to keep cost increases manageable.

She also agrees with a point health policy professor Janet Coffman made in Gorn's article: Any trend toward this model would reduce the number of primary care doctors available in insurance plans, already a growing problem.

"Primary care is one of the least lucrative areas for doctors to go into," Imholz says, "and therefore sometimes difficult for insurers to get sufficient numbers of."

Imholz stresses that consumers in California, where Gorn's report takes place, should keep in mind a little-known benefit of the plans offered on the state's health care exchange, called Covered California: Those plans are required to offer three visits outside of the deductible, costing only a co-pay.

Ultimately, she says, if patients do want to go the route of direct primary care, they should create their own personal health record for each visit, in case at some point they need to visit a specialist for a serious health problem.


Here are more curated reader responses to the original post:

My doctor started doing this. He hasn't seemed to have lost any patients. His waiting room is always crowded. He has big signs everywhere: WE DO NOT TAKE INSURANCE! I wish every doctor would do this. The insurance companies are the ones stealing from us.

Please don't ever do this. My husband has sickle cell anemia and after seven years of care his PCP switched to this model and we can't afford to continue to see him anymore. So now we are shopping for a new PCP in a city where very few doctors have even treated sickle cell, much less specialized in it.

It is increasingly difficult for doctors to get paid. Patients have no idea how much we do for free. Hours on the phone answering questions; just calling in an Rx for a urinary tract or sinus infection; $200 of mine and my staff's time spent getting prior authorization for a $10 medication because the insurance company wants me to use a $9 one instead. In the private world, I had the option to simply not charge patients I knew had no resources, because it was the right thing to do. But to balance that out I had to limit my practice to no more than 40 percent Medicare. Medicaid I essentially did for free--it cost more to bill and collect for those patients than I actually got paid.

Ultimately, after 14 years of private practice, I had to close my office and go to work for a hospital-based clinic that happens to be faith-based and has a great policy for providing care to all patients. That has allowed me to continue taking care of all patients without considering their ability to pay. The problem is not with health care, but with insurance. A single-payer system can work, but not until we take out the bureaucracy that managed care has brought into health care.

The bottom line is a medical practice is a business, and if you can't get paid you can't keep the doors open. Medicine is the only industry that people expect something for nothing. Make a five-minute call to an attorney, you get a bill for 15 minutes minimum and nobody bats an eye. Ask for a $10 co-payment and we get stared at like we have three purple heads.

Nope, you'll still need insurance coverage for everything else. This is a slick way to cull Medicare patients out of the practice. I just experienced this and it would cost $130 monthly. Time for a new doctor!

I worry about cherry picking, selecting people who have disposable income and don't need to be seen all that often. I was part of a group that had such a concierge option and it was not for the common folk.

When my first child was born in 1981, her pediatrician offered a monthly fee plan, and for $15 per month, a monthly well-baby visit and all immunizations included, plus anytime she got sick. For the first visit, the pediatrician came to our home. I wouldn't call it boutique medicine, but it was a big help to our young family.

That small fee for "members" will rise just as medical costs rise. We need to fix the paperwork situation to keep good doctors around

Volume is the name of the game today. New doctors employed by hospital-owned practices also face that same pressure to see as many patients as possible and to order whatever tests, procedures or whatever in order to generate the most income for their parent company. It might be a good business model, but it's not good medicine. Look at how happy both the doctors and patients are with this personal service. It's a win-win for the patient-primary care doctor team.

A doctor I used to work for has done this, but she charges per visit and per procedure or test. She has contracted with other labs for cheaper tests. By cutting out the insurance she can charge less. She still makes a profit but her patients are able to afford her visit and tests, not including radiology. I think it is fantastic! The retainer or monthly fee doesn't seem like a good route for those unable to afford it, though.

I work with a great doctor that's doing this for $60 a month, $50 for small business owners. Personally, paying the retainer as well as the annual fine for not carrying insurance stills ends up being more affordable than carrying commercial insurance. Between premiums, deductibles and co-pays, it was ridiculous. In this new system, patients love getting the one-on-one time, and the number of referrals drops dramatically due to the primary having control and being able to make the decisions. Also there's no longer the pressure of seeing patients every 10 minutes -- patients are no longer just a number.

My pediatrician in the '50s made house calls. My dad had union insurance that seemed to cover everything. I remember going to see my pediatrician on Saturday when I had an emergency. There needs to be room for this kind of medicine. In the long-run people will be healthier and doctors will be more satisfied. I feel so sad for the medical people who take care of me. They look at their watches when they think I'm not looking and still try to do a good job. There has to be a better way.

My doctor did this, and I couldn't afford it. I still had to pay for hospitalization and prescription medicine insurance. It would have added $140 a month for my husband and I. I miss my old doctor.

My problem with this is Obamacare requires me to have health insurance! So.... If I didn't have to pay almost $600 a month for family coverage this would be great! Unfortunately, it's not a feasible option under the current rule of law.

I love this idea but do not have enough income to pay such a monthly fee. I would love to see some accommodation regarding sliding-fee scale for those of us with little income or social security.

"As for the effect on patients, Stanford health professor Laurence Baker says it’s not clear whether or not the longer office and home visits end up providing better care."

Really? I would love to have my doctor's undivided attention. As it is now, I can request to have a test done or a referral to another doctor a and he'll say OK and then it doesn't happen. I requested to see a pulmonary doctor four months ago and he never followed through. I finally made my own appointment and found out I have emphysema.

I don't blame my doctor. He's a good man in a bad situation. He's the herder and I'm sure he worries every day about what he might have missed.

I love this. It is what has become more and more diminished in patient care over the years: actual interest in the work. The doctors I see now seem like robots, and I feel like a piece of machinery on the assembly line.

I think this is a great concept, but I wonder how the insurance companies will respond to this. My worry is that, although many can afford to pay for PCP care as they go, they could not afford much in the way of major testing, additional medical procedures or medications for chronic conditions. My guess is that the insurance companies may balk at coverage when referrals come from a non-participating provider.

This is what my new doctor does. Seventy-five dollars per month is pretty much less than my copay anyway. And I love my doctor!

Looks like the doctors are going to reform the medical system for us. Can't blame them; they spend more time filling out forms than on patient care.

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