Friday, September 6, 2013

Guest Post: Why the Direct Primary Care Model would benefit poor patients (1 of 2)

Dr. Marguerite Duane is the past medical director at Spanish Catholic Center of Catholic Charities of Washington, DC; a member of the Folsom Group; and co-founder of the Fertility Appreciation Collaborative to Teach the Systems (FACTS). She will attend the Direct Primary Care National Summit in October. This is the first of two guest posts. Part 2 is posted here.


When most people hear the term Direct Pay Primary Care, they presume that it refers to a high cost, “concierge” care model for the wealthy and is not a realistic option for poor people. That presumption couldn't be farther from the truth. Here’s why.

Five years ago, I became medical director of two community health centers that serve an almost exclusively poor and uninsured population. More than 90% of our patients earn less than 200% of the federal poverty level (about $47,000 for a family of 4 in 2013). So if our patients have so little money to spend, how could direct primary care work for them? With direct pay models, actual health care costs can be kept much lower and made much more affordable. Also, since direct pay models typically care for smaller patient panels, patients have more time with their primary care team to address the myriad of life issues that affect their health.

Some direct pay models charge patients a monthly or yearly membership fee that covers all primary care office visits and even some basic or in-house lab tests. For example, at Qliance in Seattle, depending on the patients’ age, members pay a fee that ranges between $54 and $94 per month, which includes:

• 7-day a week access to the Qliance health care team
• Same or next-day appointments for urgent care
• 30 to 60 minute office visits
• Phone appointments and electronic visits
• After hour phone access to a physician for urgent medical needs
• Basic x-rays onsite at no additional charge

This care would cost my family of five $3,780 annually, less than a quarter of the $16,000 our employer-sponsored health insurance actually costs. Patients can then purchase a separate catastrophic health insurance policy for significantly less than a traditional insurance plan that also requires co-payments for primary care. Monthly membership models work particularly well for patients with chronic conditions, eliminating the potential financial disincentive of paying a fee for each office visit.

But how will poor patients pay for labs or specialty visits? It may surprise you to learn how inexpensive most basic lab tests are when they aren’t paid for by insurance middlemen. Here is an example of tests at my community health center for a patient with diabetes:

Lab Test                        Actual Cost to Us           Patient Paid

Hemoglobin A1C                 $8.72                             $10
Lipid panel                        $3.47                             $5
Metabolic profile                $4.21                             $5

This patient would pay $20 for lab tests that actually cost $16.40. While a profit margin of $3.60 may seem small, it worked for us because neither the clinic nor the lab had to pay anyone to process insurance claims or send follow-up reminders for un-paid bills months later.