Thursday, November 18, 2010

Direct primary care: health reform's missing piece?

Last year, in a blog post titled "the 'single payer' should be you," I profiled the innovative Seattle-based practice Qliance Primary Care, which, rather than billing private or public health insurers, charges patients a flat monthly fee for unlimited access to a broad range of primary care services:

Previous medical groups that utilized this business model often charged exorbitant fees, leading critics to label them "boutique" or "concierge" medicine, available only to the wealthy. In contrast, Qliance's fees are quite affordable: from $49 to $79 per month. This fee, combined with a catastrophic health insurance policy to protect against unexpected ER visits or hospitalizations, is significantly less expensive than traditional insurance policies - which makes sense, since 100 percent of payments go directly to the practice rather than being filtered through insurance bureaucrats. So why aren't there more advocates for a "single payer" health system in which the single payer is you?

The October 15th issue of Family Practice News featured a front-page article about Qliance and its practice model, termed "direct primary care." Although this model was absent from the "Affordable Care Act" law (which instead emphasized accountable care organizations and multi-disciplinary patient-centered medical homes), it provides benefits above and beyond simple cost savings: all in-person appointments are scheduled for at least 30 minutes.

One obvious objection to implementing the direct primary care model nationally is that there are certainly a few people for whom spending even $50 a month out of pocket for basic medical care is a hardship. But consider the comparison: at my wife's nonprofit medical clinic for uninsured patients, the monthly payroll deduction for no-frills, employer-subsidized health insurance in 2011 starts at $281.50 per month, not counting a $350 annual deductible and 20 percent co-insurance for most services. These charges amount to more than 10 percent of many employees' salaries, and has actually led some of them to seriously consider declining health insurance benefits so that they will be eligible to be seen at their own clinic.

Making more low- and middle-income people eligible for government subsidies and tax breaks so that they can afford the skyrocketing cost of traditional health insurance isn't the long-term answer to this problem. By cutting insurers out of the equation, and lowering the cost of basic health care for individuals, direct primary care models offer a real, affordable health reform solution.


  1. Dr. Lin:

    I find it hard to understand why more people don't understand this very basic economic model that benefits both patient and physician. Thanks for bringing to light the many benefits of direct pay in primary care.


    Tom Furr
    Zepherella, Inc.

  2. Direct primary care started as concierge medicine, where the patients would pay a "membership fee" to "retain" a personal physician for more time, better access, and an all-around nicer medical experience. As competition grew, a few visionary doctors started realizing that the same "subscription medicine" principle could be applied on a larger scale, mainly to uninsured and underinsured patients. The key was keeping the membership costs low, and ensuring that the model did not become health insurance.

    Our practice, Access Primary Care, started the first such practice in Monterey, California in 2009. We are opening our second location in busy Silicon Valley next month. Access Primary Care charges a subscription of $49/month regardless of age or previous condition. In return, patients receive doctor visits for $10 a visit, up to 50% off on labs and imaging, and discounts for specialist appointments whenever possible. Our patients are encouraged to obtain catastrophe insurance, and we help them do so.

    Who do we cater to? Patients who want to pay less out of pocket for primary care, whether insured or uninsured; employers seeking to lower healthcare costs for employees; and primary care doctors who want help setting up their own practices to provide such services.

    Check us out at!

  3. In terms of subscription medicine and Qliance, I am fairly familiar with this model, but it still has problems which include:
    *not enough p care docs to go around for 30 min visits for everyone (need to train more of them and and reimburse better them at much higher rates, with accompanying significant decreases in specialist salaries)
    *would likely only be equitable for the whole population if everyone followed such a model, but then competition would divert resources toward advertising/marketing (and away from pt care and provider salaries) and some clinics would begin to cherry pick healthier and/or wealthier pts, thus ultimately leading to a replacement, in part, of insurance companies, by such clinics
    *no cross-subsidization for poor, indigent, or academic facilities
    *doubtful specialists would buy into program, given archives paper re their desire to protect their incomes, and unclear if catastrophic care covg would cover specialist visits, which would place greater burden on p care docs to try to manage complicated conditions outside their scope of practice (with associated liability concerns) or to have to ration which of their pts in need of subspecialty consultation they will refer each month (as i had to do when i worked at a homeless clinic, and we had one slot per month for colonoscopy, etc.)
    *financially good idea for those with insurance, but for those without, who already avoid needed care due to copays smaller than 49/mo, a problem
    *also, poor pts ineligible for medicaid would still go without catastrophic covg
    ultimately, single payer seems like the only rational solution

    For more details see the luxury primary care and universal health care page of the public health and social justice website at, specifically my book chapter from Ideological Debates i Family Medicine on this topic at


    Martin Donohoe, MD, FACP
    Adjunct Associate Professor, School of Community Health
    Portland State University
    Chief Science Advisor, Campaign for Safe Foods and
    Member, Board of Advisors
    Oregon Physicians for Social Responsibility
    Senior Physician, Internal Medicine, Kaiser Sunnyside Medical Center

  4. Good post, Dr Lin, many physicians and patients will love this business model for part of their health care strategy. I think Americans are too diverse to ever be fit into only one model for primary care, so variety is needed. Qliance is a bright message about how this type of practice works. Health Access Rhode Island uses a similar model in addition to many others around the country. I'm excited about offering many of my pts the Direct Practice option. Thanks.

  5. Such a plan would be a competitive alternative to the current insurance coverage plans and as such could drive their prices back down as well. Let the people pick for themselves. Just give us alternatives. For too long the definition of health Care has had very little to do with health or care. I for one would rather be paying my Dr then some huge insurance agency.

  6. I suspect that the reason more physicians do not adopt this type of model is a combination of inertia, fear, and comfort. Inertia is powerful. This model required a huge effort to set up the fairly comprehensive model of extended primary care. Fear of the financial investment in setting up this model in an environment where the future is so uncertain. Could this model survive in a government single payer system? Comfort comes into play because despite all the stress and uncertainty of the current primary care model most primary care physicians are comfortable that they at least understand how to survive in the current model.

  7. Excellent post! Thanks for sharing this insight.