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.
