PART 2 of 2: The Unlearning Process of Direct Primary Care
By Kenneth W. Rictor, MD, DPC Journal Contributor | Scotland Family Medicine
JULY 21, 2014 – After 25 years as a fee-for-service Family Practice physician in private practice I have made the change to a Direct Primary Care model. I have been envisioning this model for the past 10 years and seriously planning for the conversion over the past 2 years. As I have been discussing this new model with my existing patients, it has become increasingly apparent that in order for patients to accept and be educated about Direct Primary Care there also needs to be an unlearning of conventional fee-for-service insurance medicine.
We have all been living with insurance-based primary care for the past 30 years and it has become second nature with both physician and patient behavior. We have become a population of over insured, under covered people. To suggest that there would be an alternative model of care free of insurance that provides for more comprehensive care with increased access and reduced overall medical cost is paramount to blasphemy to the current system. Immediate incorrect assumptions and suspicions are the natural first knee jerk reaction. The fear of not being covered by considering a new model of health care is as unfounded as believing that having insurance coverage will guarantee good health and complete coverage.
The unlearning begins:
There is only one fee for lab tests, medications and imaging services
Realistically, doctors and patients have not realized the costs of these services. The insurances have always taken care of this and bundled these services. As profit margins shrink and bureaucracy grows, more of those costs will fall to the patient via higher deductibles or more denied services. By freeing itself from insurance controls, the direct primary care office has been able to negotiate dramatically discounted services for those patients under the model.
This service rarely exists with hospital owned practices. These practices are loaded with overhead expenses that create a negative balance but it is expected that the ancillary services will more that make up for the deficit. It is a hidden fact that physicians are under the unwritten edict that all ancillary services will come back to the ownership organization/hospital. How can you trust the necessity of a lab test or imaging procedure when incentive or punishment is built into the decision? Direct primary care has NO secondary gain for tests and imaging. In many cases, the tests completed in the office are included with the membership.
The only way that a doctor can care for my needs is with an office visit
It is thought that over 50% of office visits are unnecessary. It’s not that the care was unneeded but using the office visit as the only vehicle to provide that care is unwarranted. What is the office visit in the insurance model? Simply, it is the only way to get paid. The office visit has degenerated to be a charge center with the mastery of codes and notations to justify the charges and avoid penalties. Quality patient time with limited notation does not get reimbursed but limited time with extensive notation gets the maximal reimbursements. It only logically evolves that the physician spends more time with notations, charting and coding then with the care of the patient.
This won’t work with Medicare
Direct Primary Care is the perfect partner with Medicare. Medicare remains as the catastrophic care plan and the outpatient care is managed through extensive and thorough review and care of chronic conditions. Labs are discounted and are free from Medicare regulations that would limit access and increase out of pocket expense. Transportation difficulties are overcome with home visits and telemedicine. With reduced out of pocket expenses for labs and meds, the Medicare patient can effortlessly have chronic and acute conditions managed without deductible, copay or denied service.
I already have insurance, why would I pay again for Direct Primary Care
Here is a great irony. The Direct Primary Care patient’s total out of pocket expense over time is actually less than the comprehensive premium based insurance coverage for outpatient care. This happens because of co-pays, hidden fees, denied services, increased deductibles and individual contribution for the premium cost. Most patients will not look at the price tag of their coverage and will hesitate for direct primary care as an upfront cost. When considering increased access, increased quality, increased patient satisfaction and decreased overall cost, the hesitation is short sighted.
The biggest challenge to the Direct Primary Care model today is not implementation or management. Educating America is the goal and greatest challenge. Restoring respect and patient responsibility follows the education. As I have experienced many times over, once the patient understands the aspects of Direct Primary Care, the look of anger and fear is replaced with reassurance and satisfaction and discovery. Our goal is not to turn people into patients but to free the person to maximally enjoy life with a healthcare system that encourages their pursuit of happiness rather than our current system that complicates compliance, limits access and continues to increase in cost with decreased value.
About Dr. Kenneth W. Rictor, MD