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Direct Primary Care Model

The Direct Primary Care Model In The Shadow of Telemedicine

I was helping a friend by covering their shift at a new clinic and in the process got a chance to meet a new colleague. She has worked in various clinical settings as a primary care doctor and is looking to soon go on her own. She mentioned the direct primary care model which she wants to adopt, a term I wasn’t familiar with.

In order to research this post, I must have visited 50 different websites. There are more websites on DPC than actual docs practicing DPC, so it seems.

How Direct Primary Care works

A patient may or may not have health insurance but can still purchase a monthly subscription to a primary care doctor’s services. Instead of being billed per visit, they have an ongoing monthly subscription service which pays for office visits, point of care testing and most of the lab/imaging and offers major discounts on medications.

The idea is that if the patient has more easy access to the PCP then they are less likely to fall through the cracks and by having the billing be more transparent, the patient doesn’t have to worry about unforeseen expenses.

Often, these practices are solo doctors with or without any back office staff. They make themselves available to their patients almost 24/7.

The monthly subscription can be canceled at any time. It will include most of the basic lab and even imaging and of course, office visits and other interactions with the clinician.

The customers of DPC

It’s not just patients but also employers who are turning to DPC in order to save on costs of providing healthcare to their employees.

The average patient who subscribes to DPC has a high deductible health plan. Some, have no health insurance whatsoever. They will have chronic medical conditions which need routine monitoring.

Employers are all over the idea of DPC and here is why; it costs a lot of money to have an employee be out of work for days at a time and providing affordable health insurance for employees is becoming increasingly expensive.

Employers want to curb costs by offering higher deductible health plans (HDHP) while knowing that their employees can actually afford the office visits.

I went online and checked out Amino which allows a patient to enter the condition they need treated, find the physicians who can deal with that diagnosis and then estimate the cost of the office visit and services.

Well, with a high deductible health plan, if I wanted to just have a routine primary care visit to have the doctor look at my knee, I would have to pay $240.

3rd party consulting companies…

So, how did employers come up with this super complicated idea of providing HDHP’s to their employees and combining it with this DPC model? Because of 3rd party consultants!

A consulting group is hired by a large company that wants to cut back its healthcare overhead. The consultant then hires a health insurance consulting group who suggests that the employer switch to a HDHP but then, to cut on costs for the out of pocket expenses for their employees, also pay the monthly dues for each employee to a direct primary care clinic.

So, now the employer can drop the Cadillac plans, switch to HDHP which are exponentially cheaper and for a few more dollars a month, provide affordable access for their employees.

Why? Because employees who have HDHP’s know that they will get financially destroyed every time they have to take their little one into the office.

How much? Imagine that the normal group health insurance premium was $250 per employee. By switching to a HDHP, it will go down to $130 and an extra $25 for access to a DPC service.

When you save a company with 5,000 employees $100/month, that’s $500k/month or $6 million a year. Consulting companies get to keep a percentage of whatever they save their clients – which is the motivation behind finding such concepts and, of course, pushing the DPC model.


The problems with current primary care model

  • Primary care doctors can earn more income by ordering more tests and seeing the patient more frequently.
  • The fear of lawsuit pushes PCP’s to order more tests and be generally more aggressive with interventions/management.
  • PCP’s have less and less time to spend with patients which make ordering tests a quicker way to complete the interaction.
  • Patients demand a lot of tests out of fear of the unknown which can take a long time to dissuade them of.


DPC vs Concierge

The difference between direct primary care and concierge medicine is that one is generally more costly than the other.

Both involve the retainer model, paying a monthly or annual fee to the clinician or the clinician’s practice in order to secure access.

Both will allow much easier and more frequent access to the clinician’s service.

DPC focuses on lowering costs by charging a monthly fee which can be canceled at any time and most costs are covered by that payment model without using the patient’s insurance.

Concierge services charge an annual retainer and will charge extra for the office visit and extra for lab/imaging. It’s geared slightly more towards a wealthier client who has more money than time.


DPC and telemedicine

Remember that extra $25 the employer pays per employee for access to the DPC?

That same 3rd party consulting company that used to suggest DPC for employers is now suggesting telemedicine, instead.

Rather than the employer paying an extra $25 per employee per month (PEPM), the cost will drop down to $6-10 PEPM.

For this amount, the employee will have unlimited access to the telemedicine services and the employer will save 30-50% on monthly premiums.

Now that telemedicine can replace DPC for an even lower fee, these 3rd party consulting companies will be pushing telemedicine even more. Venture capital will be fed into telemedicine companies which are marketing to employers and that’s how the money is shuffled around.


Is DPC sustainable or feasible?

There is nothing unique about DPC. Instead of charging the patient cash for each visit and bypassing insurance, the patient’s out of pocket expenses are divided up into equal monthly payments and billed to the patient.

The concept breaks down because patients can cancel their premiums at any time. And the PCP still has less of an incentive to want to bring the patient back for follow-up.

Also, the whole concept of DCP is based on the premise that patients are unhealthy due to lack of access. False, patients are unhealthy due to their lifestyles (mostly) and lack of education.

Patients will also demand test after test. Sure, the total cholesterol might be included in the DCP model, but will the provider pay for the $3,200 viral culture panel of the nasopharynx which the patient is requesting?

In the past, when technology was guarded and accessible only to a few, it was imperative for patients to have access to their PCP in order to get the right information needed to manage their health.

Information democracy has revolutionized all fields, especially medicine. If you want to control your health all you need to do is subscribe to the podcast, blog or YouTube channel of your favorite physician. You can read Pubmed and WebMD etc.


Is telemedicine a realistic practice model?

After nearly a decade of practicing medicine, I have come to the realization that there is an umbrella diagnosis which encompasses all the most common ICD diagnosis – it’s being a patient.

Our society will always have “patients”, the group of individuals who are looking for a diagnosis, looking for an intervention and wanting healthcare above and beyond what’s necessary.

The quality of healthcare isn’t measured by articles published in journals, it’s measured by the power of the placebo in the patients’ heads.

The paternalistic, condescending, and bullying method of western medicine has created a generation of these worried well patients.

The impression of health isn’t a 30-year overview of a person’s health or the expertise of a physician but how long the person had to be on the phone before getting an appointment, how long they had to wait in the waiting room and how quickly they could get their prescription.

In short, telemedicine is here to stay and every single “hidden” literature which I have uncovered points to medicine going the way of Amazon. Save for surgeries and physical exams, most of medicine will be practiced behind a keyboard in shorts and a tank top.


The ideal scenario for the DCP model

I see a place for the direct primary care model in the current healthcare scene. For the savvy individual, a HDHP and a subscription to a DCP could essentially replace the old “catastrophic” health care plans which were actually incredibly effective.

These catastrophic plans were taken away by the ACA because of user error. Households that didn’t understand health care well enough would purchase such plans, only to be left with massive medical expenses which would bankrupt them later in life.


What are your thoughts on this DCP concept? Do you think it has a sustainable future? 

What are your thoughts on the traction telemedicine’s traction?

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