Part of the Transforming Life as We Age Special Report
Remember Marcus Welby, M.D., the television program starring Robert Young as the kindly family practitioner? The show only aired for seven years, ending in 1976, but the Marcus Welby character has become a durable symbol of a more caring approach to medicine long past.
Now, an emerging movement is trying to bring back the old-school doctor-and-patient relationship. It goes by different names, including concierge care, retainer-based medicine and direct primary care.
“It’s patient-focused medical care,” says Dr. Erika Bliss, a Seattle-based pioneer in direct primary care and co-owner of Qliance, a network of primary care clinics in Washington. “We are good at taking care of people.”
Direct Primary Care: No Longer Just for the Affluent
Whatever the label, patients get to spend more time with, and enjoy easier access to, their primary care physician than is typical these days. Traditional primary-care providers usually see some 2,000 to 2,500 patients, while direct primary care physicians typically see 400 to 600.
Instead of buying insurance to cover primary care, subscribers pay a fee directly to their doctors.
How is this possible? Direct primary care doctors bypass the health insurance system and instead charge their patients an out-of-pocket subscription or membership fee that’s monthly, quarterly or annual. Fees vary depending on the specific menu of services, of course. But patients usually get unlimited office visits, same-day appointments and access to their doctor through email, phone, text and video.
“I find continuity to be unusually important for patients and physicians — access and time,” says Dr. Julie Gunther, a veteran family doctor who started her direct primary care clinic in Boise, Idaho, in 2014.
Direct primary care controversially emerged about two decades ago under the name “concierge care.” Its focus then was on serving wealthy clients. High-end concierge services still charge $10,000 or more annually, but the model has taken a more middle-class turn in recent years.
Today, the membership charge for some two-thirds of direct primary care is $135 a month or less. Physicians who’ve turned to this model recommend that their patients still carry some type of health insurance for care beyond primary care. Typically, patients have a high-deductible catastrophic insurance policy.
Doctors and Patients Want Alternatives
Take a look at the experience of the Rutherfords.
Dr. Molly Rutherford of Crestwood, Ky., was frustrated with the assembly line pace of patient care in her first years as a family physician. Two years ago, she set up Bluegrass Family Wellness with a monthly subscription fee of $50 for people ages 18 to 45; $75 for people 46 to 65 and $100 for those over 65. Her fees top out at $150 a month for a family. She offers almost all generic drugs at wholesale prices and has negotiated low prices with clinics for a variety of services, such as x-rays. Rutherford currently has about 350 patients.
“Direct primary care allows me to do what I want to do” for patients, she says.
Mary Ann Rutherford of nearby Taylorsville, Ky., is a few months shy of 60. She’s no relation to Dr. Rutherford, but likes her arrangement with this physician. “I’m always trying for the family discount, but I don’t get it,” she laughs. A retired entrepreneur, she recently went back to work at Costco as a server. “I retired from running my own business,” she says. “I wanted a no-brainer.”
Rutherford says she calls and texts her doctor when needed and always hears back right away. Dr. Rutherford accompanied her to the hospital last year and acted as her advocate when she needed to spend several days there for a procedure. “Dr. Rutherford listens,” says Mary Ann Rutherford. “It’s much more of a one-to-one relationship.” When Mary Ann’s husband passed away, her doctor “counseled and encouraged me with much compassion.”
The bill for Rutherford’s hospital stay came to $31,000. How did she pay it? Through another alternative to conventional insurance: covered care. She is a member of Samaritan Ministries, a Christian health share plan where members help defray each other’s health care bills. Rutherford negotiated discounts with the hospital and her various doctors in return for paying cash, reducing her bill to $9,000. She submitted that tab with accompanying paperwork to Samaritan Ministries, which reimbursed her for the full amount.
Biggest Benefits Are to Chronically Ill and Elderly
Direct primary care remains a niche business model, with only about 2 to 3 percent of primary care doctors embracing it so far.
From a patient’s point of view, many people balk at taking on another $800 to $1,600 annual bill, even if they can offset some of that cost by reducing the insurance coverage they need. And patients’ out-of-pockets costs can climb when they need tests or specialty treatments.
Health care experts are concerned that direct primary care will exacerbate a nationwide shortage of primary care physicians. They also say there isn’t a sufficient track record yet for making confident statements about accountability.
“I actually think it’s a pretty good way to pay doctors if they have protections in there” for patients, says Robert Berenson, a fellow at the Urban Institute, a Washington D.C. think tank. “The downside is [if] the doctor takes the money and doesn’t provide the services.”
Direct primary care seems best suited for people taking multiple medications or dealing with complex health concerns. That’s when a close relationship with a primary care physician and team pays off big.
“In terms of the elderly, they need the doctor more than younger patients,” says John Deane, chairman of Advisory Board Consulting, which advises health care organizations. “It’s a sustainable model for them.” Adds Guy David, professor of health care management at the Wharton School of the University of Pennsylvania: “With older people and people who have complex medical problems, you need someone who is attuned to their day-to-day-changes.”
A Helpful Move Away From Fee-For-Service?
Advocates may be tilting at windmills, but they make an intriguing case that this business model could be the foundation of genuine health care reform. Including Medicare and Medicaid would be key. Right now, those programs do not cover direct primary care. In fact, not all direct primary care physicians will see patients who are enrolled in Medicare or Medicaid because of legal issues that could raise for their practices. Patients need to ask about this when considering signing up with a direct primary care provider.
As a reform catalyst, direct primary care’s flat-fee structure could shift the health care system away from its current fee-for-service model, whose built-in downside is that it incentivizes professionals to order more procedures.
Another positive is that direct primary care doctors, nurses and other team members are encouraged to practice preventive medicine and concentrate on improving patient health. That kind of focus can reduce patients’ trips to high-cost specialists and hospitals, and make them less reliant on medications.
Sad to say, Washington isn’t wrestling with the kind of transformative, fundamental health care reform that would bring us closer to the “triple aim:” a better patient experience, better health outcomes and lower cost. If reports of what is being contemplated in the Capitol are true, the opposite of that aim may happen.
In the meantime, the experiment with direct primary care will continue. It’s an arrangement with a primary care physician that’s worth investigating. Online directories of providers exist, but their quality is spotty. Your best bet to find a direct primary care physician is to do an online search including “direct primary care” and the name of your state. Before signing up, be sure to read the fine print of the deal and have a good handle on your personal finances.
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