This is the second of two guest posts by Dr. Marguerite Duane. Part 1 is posted here.
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What about specialty care? In the Direct Primary Care model, physicians have more time to spend with their patients to diagnose and treat problems appropriately; therefore, specialist and emergency visits, surgeries and hospitalizations are all significantly reduced. Also, specialists are willing to reduce their fees when they are guaranteed timely payments without insurance processing delays.
So, if direct pay models could provide affordable, personalized primary care for the poor, why are more physicians and/or practices in underserved communities not moving to this model? I think there are two main reasons:
1. Physicians may mistakenly believe that poor people can’t afford direct primary care because they do not appreciate that these models are different from concierge medicine. Concierge medicine usually involves cost-prohibitive retainer or membership fees that guarantee 24-hour physician access. However, these fees often do not cover actual physician visits, which may still be billed separately. On the other hand, monthly membership fees in direct pay models of primary care are far more affordable, typically costing less than a monthly cell phone bill. More importantly, these fees cover physician visits.
2. It may be difficult for patients and physicians to move to direct pay models of care because they are trapped in the current insurance model. Physicians are accustomed to being paid by insurance companies, so they provide and document the "care" that insurance companies require in order to be reimbursed appropriately, rather than the care that patient actually needs. Many poor patients are accustomed to being covered by Medicaid which allows them to access care without co-payments, so in their mind it is “free.” However, since fewer and fewer physicians accept Medicaid, patients “spend” a lot of time and effort just searching for care rather than receiving the care they need. While change is difficult, physicians and patients alike must move beyond their dependence on health insurance for primary care, because with the insurance company as the payor, the patient will never really be at the center of care.
Patients who pay for primary care through direct pay models can choose physicians who provide high quality, satisfying care. The smaller patient panel sizes facilitated by this model of care make it possible for physicians to form stronger relationships with patients who benefit from the extra time and attention.
Insurance is designed to cover unpredictable, undesirable or expensive events. Primary care is none of these. In my view, Direct Pay practices are viable primary care options for patients of all income levels.