Updated: Oct 26, 2019
The Direct Primary Care Model
What is direct primary care and why are physicians switching to this model of care?
The direct primary care (DPC) model gives family physicians a meaningful alternative to fee-for-service insurance billing, typically by charging patients a monthly fee that covers most primary care services. Direct primary care benefits patients by providing substantial savings and a greater degree of access and time with your physician (AAFP, 2019). The American Academy of Family Physicians supports the physician and patient choice to provide and receive health care in any ethical health care delivery system model, including the DPC practice setting (AAFP, 2019).
Direct primary care rewards family physicians for caring for the whole person while reducing the overhead and negative incentives associated with fee-for-service (billing insurance). Other benefits to physicians include:
§ Decreased practice overhead
§ Fewer medical errors / less exposure to risk
§ More time with patients
§ Reduced patient volume
§ Zero insurance filing
Direct primary care and concierge care are not the same. In practices offering concierge care, the patient typically pays a high retainer fee in addition to insurance premiums and other plan obligations (e.g., copays, out-of-pocket expenditures), and the practice continues to bill the patient’s insurance carrier. DPC practices do not bill your insurance (AAFP, 2019). “The data and coding required by insurance companies comes at a tremendous cost – current estimates are that over 50 percent of the physician's time is spent in administrative duties. As a result, codes and documentation prove quality, regardless of how the physician patient relations succeeds. Another result is physician burnout at a monumental rate – 50 percent of physicians feel it most of the time. Wouldn't it be better if the patient "employed" their primary care physician?” (Price & Norbeck, 2017).
Physician burnout has been on the rise since the induction of EMR into the patient and physician relationship. Documenting in the EMR has become a means to obtaining insurance reimbursement. Physicians spend 2-3 hours outside of seeing patients daily on charting in the electronic medical record in order to obtain insurance reimbursement. This is time that physicians could be spending with patients during the day or at home with their families at night. Every year, insurance companies chose to reimburse less and less for services which has led to hospitals and corporations creating patient schedules for physicians that aren’t humanely (or humanly) possible to maintain. This is the hospital created RVU physician compensation model which forces physicians to see as many patients ‘as possible’ forgoing lunch, bathroom breaks, and staying late in the evening. Physicians that cannot keep up with this insane pace of 20-30 patients a day often find their salaries slashed as punishment for not keeping up and are labeled as "the problem physician". Patients suffer in the current healthcare system as well. They are unhappy with the long waits created by unrealistic patient schedules. Often, when patients do finally get to see their physician, they get 5-10 minutes only. Physicians (and patients) today have no control over their schedules, rather hospital administrators have the control over the schedules.
Patient and physician satisfaction is greatly suffering and it all boils down to money…money that neither the patient nor the physician obtains, but rather the hospital and healthcare system obtains. Patients increasingly have had multiple physicians in a small amount of time because physicians are leaving hospital owned medicine. The current healthcare system is breaking physicians and what patients don’t see is the horrible treatment and huge pay cuts that force physicians to leave…over and over again. Have you noticed that you have a new physician every year or that “physicians never seem to stay here?” It’s a system problem, not a physician problem. I often get asked, “You are the 4th physician I have had in 3 years, Are you going to stay?” The odds are that in the current system….probably not. So, what can be done? For one, complain to hospital administrators about how little time you are given as a patient for care. Hospital systems do not care about what physicians have to say about this system they created. Physicians have been complaining to administrators who do not listen for years. If they listen to anyone, it will be the patients. Patients will have to to fight back for the time they deserve with their providers. Second, hit insurance companies and hospital conglomerates where it hurts. Leave this rvu generated, insurance created, broken healthcare system and try something else.
Try DPC and get your moneys worth and time with your physician. Ten minute appointments are ridiculous. Why do patients and physicians put up with it? I guess only you (patient and physician) will know when you have had enough of RVU medicine. Try DPC, and once you have committed to a DPC practice that gives you all the time you need to see your doctor… you will wonder why you ever did anything differently. If you are thinking about changing to a DPC practice (either physician or patient), read this physician’s thoughts about his practice. It may make your decision easier:
Five years ago, I left “normal” fee-for-service medicine to start a direct primary care practice. Most people have no idea what that means, and my colleague, who was calling me for a recommendation on a nurse practitioner student I’d precepted, didn’t know either. He asked me how my practice was going.
“Great,” I said honestly. “Life is really so much better, and the care I give is so much better than it used to be. I’ve got time with people.” I normally try not to get too enthusiastic when talking to colleagues, as it sounds either too good to be true or like I’m rubbing in how good my life is now. But for some reason I added, “Even after five years I’m not insanely busy; I saw just two patients this morning.”
There was a brief silence on the other end of the line. “Two patients?” He asked, sounding stunned. Then he added quietly, as if talking to himself, “I just can’t imagine that.” Feeling a bit guilty (I was taught to never brag), I changed the subject and talked about the nurse practitioner, asked about his life, his family, and ended the call.
I was struck by just what a gulf lay between my life and his, and between my life now and the one I had just five years ago. I had been in my old practice for 18 years when a disagreement with the other doctors led to my departure. I had loved being a primary care doctor and had built a thriving (and very busy) practice. But over the last few years, my joy in practice had been hacked away by the increasing requirements of the government, computerized records, data submission, insurance harassment, administration rules and regulations, and shrinking time with each person. By my last year I was becoming increasingly aware of my ineffectiveness as a doctor. I didn’t feel like I was able to give truly good care to anyone.
I was burning out.
So it was a blessing when friction with my partners ended up in an all-out break up. I could hit the reset button and do things right. I had no desire to rejoin the hamster wheel of fee-for-service primary care. I didn’t want to fight the battle between what was best for my business and what was best for my patients. Things had to change, or I’d have to find another profession.
I considered working for a hospital, joining another group practice, or even working for the VA. But all of these options seemed to reproduce the problems that were burning me out in my old practice. I also considered “concierge” care, and even spoke to one of the companies that helps with that transition, but it just didn’t feel right. I cared deeply about my elderly and low-income patients who couldn’t afford the monthly subscription fee, and wanted something that would be more within their reach.
There was one solution that seemed right to me: direct primary care. This practice model has two main differences from fee-for-service care:
• Payment is from the patient (no insurance or other third-party payments accepted); and
• Patients pay only a low monthly fee covers all of their primary care.
As I considered the repercussions of each of these differences, I realized that the care I could give in this model was radically different and much better. Despite having few examples to learn from (there were around 100 practices in the U.S. using this model when I started), I opened my practice in February 2013 and have not regretted the decision since. (Currently there are well over 900 DPC practices nationwide-Oct. 2018).
~Rob Lamberts, MD, is a board-certified internist and pediatrician who runs Dr. Rob Lamberts, LLC, a direct primary care practice in Augusta, Ga.
Direct Primary Care. (2018). Retrieved January 2, 2019, from https://www.aafp.org/about/policies/all/direct-primary.html
Price, G., & Norbeck, T. (2017, June 28). Direct Primary Care Trumps The ACA For: Value, Quality And Satisfaction. Retrieved January 2, 2019, from https://www.forbes.com/sites/physiciansfoundation/2017/06/28/direct-primary-care-trumps-the-aca-for-value-quality-and-satisfaction/#71b993d1dad5#71b993d1dad5
Lamberts, R. (2018). A reasonable defense of direct primary care. Medical Economics,95(21), Unknown. Retrieved January 2, 2019, from http://www.medicaleconomics.com/business/reasonable-defense-direct-primary-care