Physicians may indeed have more autonomy and sovereignty in the debacle known as “healthcare in America” than we might think. I am a primary care doc, one who practices under license as a naturopathic doctor, and although you may not be familiar with such a practice, we have many similar challenges.
Maintaining a private practice that meets patients’ needs while remaining ethical and financially viable is no small task—a task that insurance contracts can make more difficult and challenging. Having wrestled with this for a number of years, I began reading more and more about the “direct pay” (DP) movement in primary care (and surgery, as we’ll see later) medicine. This video describes the many advantages of family healthcare working for and with a community, including discounted cost for medications, arrangements with local medical equipment suppliers, and the low-cost practicality for patients.
A recent article in Medical Economics illustrates the financial shift that is occurring with DP. According to data cited in the Journal of the American Board of Family Medicine, there are roughly three times as many DP practices in 2017 than in 2014. Today, there are about 400 practices in 540 locations that use some form of DP, an increase from 141 practices in 273 locations reported in the previous data.
Now, it’s important (for me, anyway) to distinguish “direct pay” from “concierge medicine,” where fees up to $1,500 per month are charged for a 24/7 all-inclusive suite of services bridging the spa and the medical practice. The concierge model is not the type of medical model that will make a difference in the overall health of the population, it is simply too expensive and exclusive in its target patient demographic. What I’m advocating here is medicine for the average person; an affordable ($40-$50 per month, $1.70 per day), sensible partnership with a primary doc who will have the time and practice structure to serve their health needs without an insurance company pulling the strings of what is or what isn’t permitted.
The changes intrinsic to the DP model are very attractive to physicians: more time for patients, no insurance claim hassles, lower overhead, no pre-authorization phone calls, greater satisfaction, and less stress. DP practices have about 30-45 percent lower overhead, due to reduced need for office staff and billing personnel. The average practice has 300-600 people per doc per year versus the 2,000 per doc in insurance-based practices. DP also removes oversight of treatment choices from a corporation distanced from medical care, and brings it back to the individual practitioner who is ultimately responsible and knowledgeable about what is best for that particular patient. People may be treated as individuals rather than fit into diagnostic or procedural categories.
For patients, they attain a great connection to a “family doc” at a very reasonable cost, they know they have the same doc for each visit and thus are more at ease in sharing the details of their situation, knowing they will have the time (typical visits are 30-45 minutes) to fully engage with the physician. They get lower cost medications and lab services and also know that if they need referral, their DP doctor will act as advocate because they have the time to do so.
So, what are the drawbacks of such a practice? Some critics say that there just aren’t enough people that are comfortable with a membership-type arrangement with their doctor. Some feel it is too difficult to do the marketing necessary to promote such a novel system when a physician is just starting area practice.
I’ve shifted my naturopathic medicine practice in Connecticut to DP, but not until a few things were in place. I have been in my region for more than 20 years and established my presence and reputation. There are other practices in my area, but I see more children than the others, so maintaining Medicaid for that population was important to me. I spent about 18 months floating the idea to patients via newsletters, articles, and individual discussions, and my office person acted as a strong advocate of the change.
We have three tiers of service, providing:
- Basic care
- Additional visits/year
- “Swiss Watch” version designed for optimal wellness achievement via labs, ancillary services (massage therapy, mild hyperthermia sauna, etc.), and more frequent visits.
I charge $30, $60, or $90 per month for the different tiers and permit children to be added at an additional $10/month per child. We typically collect membership fees at the end of each quarter. My office assistant loves the change, as she now spends her time connecting with and facilitating patient services instead of being on the telephone with insurance companies.
When changing to DP, we had a few patients that dropped out of the practice, since they felt their copay was less than they’d pay for the monthly fee I asked for membership. For other patients, it didn’t make a difference and they didn’t need to come in that often, so they paid the regular office fees. Medicare does not reimburse for naturopathic services, so I give significant senior discounts.
Having a specialty practice is, I think, a positive attribute when considering DP. For example, The Surgery Center for Oklahoma operates on a DP basis and offers complete transparency on the cost of their procedures. Starting afresh with a new model guaranteeing excellent patient care, and letting people know the reason for keeping insurance out of the equation, does resonate with more and more people who have had ongoing frustrations with the insurance-based system.
So, the bottom line is DP bypasses systemic defects in our current system. Insurance pre-approvals and claim conflicts are mercifully absent. This approach also provides excellent availability and personalized, low-cost medical care to patients, and serves as a trusted first-line intersection with more complex medical services that may be needed. While patients should still have a high-deductible plan for catastrophic illness or accident, it frees patients from the stress and confusion of frequently changing insurance carriers, and yet provides physicians with a living wage for doing the work most of us in primary care always hoped to be doing.
Patients know they have a physician and advocate who understands their medical status intimately. Practitioners find greater satisfaction with fewer hassles in a broad representation of practice types. As physicians take greater control of their own patient populations and continue to practice good medicine, it will become increasingly apparent that such a model gives people what they need and what they want for a lower cost. This is the ultimate goal for making healthcare great. Let us docs take the helm and steer the healthcare ship away from the insurance ‘bergs and towards clear sailing, where we collaborate with our patients and have the time to serve them. Our patients deserve it.
Below are other sites, organizations, and resources that can facilitate the path to a DP practice: