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.