CHAPTER 6

Direct Primary Care

The old adage, “necessity is the mother of invention,” is nowhere more applicable than the experience of Garrison Bliss, MD who describes himself as a “proud Direct Primary Care pioneer,” and served as president of the American Academy of Private Physicians. Dr. Bliss’s journey to embrace Direct Primary Care as a way to bring compassionate care to his patients began when his son was presumed to have a digestive disorder, causing him to endure a month-long episode of vomiting. Dr. Bliss’s son, Michael, was examined by a pediatrician with knowledge of oncology who diagnosed him a with a cerebellar ependymoma (a tumor from the ependymal cells, which line the ventricles of the brain and the central canal of the spinal cord). After it was removed, Michael wanted bacon to satisfy his hunger. Michael’s nurse informed Dr. Bliss that she could not order the bacon “until the doctors finished their rounds.” At the time Dr. Bliss realized his son’s immediate needs were overridden or ignored by the nurses and doctors in the hospital.¹

Soon after this episode, Dr. Bliss began to reevaluate health care in general and his medical practice specifically. He concluded that he needed to focus more on his patients and developed a four-pronged approach. His practice’s new structure included: (1) more time with patients, (2) more room for urgent care, (3) clearer promises, and (4) better patient experiences. In short, the foundation for the Direct Primary Care movement began. Dr. Bliss realized that a relatively low monthly fee—at the time (1990s) estimated between $30 and $50 per patient per month and a patient panel between 600 and 800—would achieve his goal of a new medical practice. His Seattle-based practice opened in 1997 and he filled his patient load in slightly more than 12 months.²

In 2001, Dr. Brian R. Forrest was the first family physician in the country to open a Direct Primary Care (DPC) practice in Apex, North Carolina, Access Healthcare (www.acchealth.com). Dr. Forrest’s inspiration for a DPC practice came from a gym membership. A gym membership includes access to all the equipment instead of having to pay a fee to use dumbbells, a treadmill, etc. Using the equipment in an all-inclusive fee thus makes patrons healthier. He explains that a DPC practice allows him to devote 100 percent of his time meeting patients face-to-face, and he does not “have to do any of the baloney with insurance.”³

Becoming a DPC doctor had a major challenge, namely, facing financial insecurity while building a practice over a year or more. But once the transition is made, according to Dr. Forrest, “the pay is actually better than traditional medicine.”⁴

For Dr. Jeffrey S. Gold, watching his mother care for his grandmother who had dementia was a difficult experience, especially since the family physician had very little involvement. After he became a physician and worked in a major hospital system for nine years, he was disillusioned with “big health care” early on. When he learned about DPC, he decided to open his practice (2015), Gold Direct Care (golddirectcare.com) in Marblehead, Massachusetts. He points out DPC is “real” medicine by not having to deal with paperwork, bureaucracy, and insurance. Dr. Gold believes the American people are “brainwashed” about health care, thinking it is so expensive that they need insurance to pay their medical care bills. And a major reason health care is expensive is because of “having a third party pay for it,” Dr. Gold points out.⁵

Dr. Nate Favini, founder of Forward, a direct primary care service with locations in California, New York City, and Long Island as well as in several other large cities, wanted to be doctor since he was five years old, when his father, an emergency physician, bemoaned the fact that patients in the emergency room (ER) did not have accessible primary care and died prematurely from cancer, heart disease, and other treatable diseases. Young Nate decided he wanted to be a primary care doctor; he began his medical care career at a Bronx, New York, community health center, where patients were packed in the waiting room like sardines and had to wait for hours to see a doctor who typically spent 10 minutes with a patient.⁶ After learning about the history of health care in America, Dr. Favini decided to build from the ground up a primary care practice, Forward (www.goforward.com) that would use high tech to provide preventative care.

The philosophy at Forward can be summed up in its mission: “to radically improve how healthcare works in order to lower costs, improve results and make quality care available to those who need it most”⁷ (emphasis added). Launched in San Francisco (2017), Forward began to use genetic testing to screen for cancer and heart disease, and the following year introduced a body scanner to assist doctors in identifying potential diseases. Innovations since then include an app to monitor a patient’s mental health for anxiety and depression and a Dermatascope to detect skin cancer. In short, Forward uses high tech to diagnose and treat a major illness before it becomes an expensive treatment in a hospital.⁸

Forward is committed to strengthening the doctor–patient relationship by having blood and other tests done in-house so the results can be analyzed by the physician and discussed with the patient instead of the patient having to make another appointment. Forward’s goal, therefore, is to keep patients healthy rather than treating sickness, calling the current system “sick care,” because the doctor only sees you when patients are ill. At Forward, their approach is just the opposite, and working with individuals to achieve optimal health before a major illness or disease strikes. Thus, at Forward, patients are welcome, encouraged to see their physicians often and utilize the services to monitor risks based on a patient’s “unique biology.”⁹

Direct Primary Care (DPC) turns primary medical care on its head by providing virtually 24/7 access to a physician; having no co-pays or deductibles without an insurance company gatekeeper; and patients get more time with a physician, eliminating seemingly endless waiting time in a doctor’s office and other benefits. As of 2018, there were about 20,000 DPC physicians out of approximately 465,000 physicians nationwide, or 4.5 percent.¹⁰ In short, there is substantial growth potential in the number of DPC doctors who could transform primary care into a more “entrepreneurial” model rather than the traditional fee-for-service primary care doctor’s office, where each physician may have as many 2,500 patients.

For patients, the benefits of having a physician “on call” 24/7 is appealing. Not having to wait days for an appointment is another plus in participating in a DPC practice. Getting routine tests in the doctor’s office and the results immediately is also a major benefit, which reduces the anxiety of waiting to learn about a possible illness and receiving treatment ASAP.

For physicians who have a DPC practice, the overwhelming consensus is the feeling they are practicing medicine the way they thought it would be to benefit their patients. Instead of worrying about entering the correct code for an insurance claim and having to hire administrative staff to handle the billing, the reduction in overhead costs makes a DPC practice more efficient than a fee-for-service practice. In short, the “burnout” factor for DPC doctors is virtually nil—a very good thing for patients who want their physicians in the best frame of mind to diagnose and treat their illnesses competently.

Employers and Direct Primary Care

This section is based on a PowerPoint presentation (“The Perfect Health Benefit for Young Companies”) by FreedomDocs.com, a website dedicated to promoting Direct Primary Care for employers, individuals, and physicians. Christopher Habig, CEO and co-founder of FreedomHealthworks.com, created the content and has allowed me to share with you how health care must be based on doctor–patient relationship, “free of barriers,” so patients can obtain value in the health care marketplace.

A major—if not the primary—consideration for individuals in deciding which company to work for is the health benefits package. A health benefits package could be a “deal breaker” for a prospective employee if he or she is not convinced there would be adequate medical care coverage for himself and his family. FreedomDocs provides a solution for startups and mature companies. For example, health benefits must be structured to not only attract talent but retain them as well. Entrepreneurs should devote their efforts on the company’s mission to provide customers with a product or service that has value to them and not spend time on collecting employee data and then send that information to insurance brokers for a quote to determine which carrier is preferable. Instead, a DPC benefit would allow employers to plan better because at a fixed, predictable cost per head (x dollars per month); thus, an entrepreneur would be able to budget new hires much more easily than providing traditional medical care insurance, where the costs could be inflated depending on the number of dependents and other variables. In addition, DPC eliminates the broker, middlemen, undoubtedly a potentially substantial savings.

An employee health benefit has several components.

Thus, beginning with primary care, “the perfect health benefit,” employees would have access to “concierge-level” type customer service, which is valued by patients because it is utilized most often. DPC includes acute and urgent care, chronic condition management, preliminary mental health services, and discounted ancillary services, especially in-office dispensed prescriptions. Examples of usage would include a routine office visit, urgent care, telehealth, navigating downstream care, and pharmaceuticals.

The next “perfect health benefit,” specialty care, would consist of a FreedomDoc℠ affiliate network where employees would get discounted consultations to avoid unnecessary testing and procedures, discounted cash payment procedures, such as surgeries, physical therapy, and other medical care. Also included would be an annual eye exam and dental care membership, which would provide two exams, two cleaning, one set of X-rays, and 20 percent discount on elective services. Accordingly, for example, an insurance-based hospital knee replacement would cost just under $45,000, but at an independent surgery center, the cost would be $15,500. Thus, insurance premiums would reflect the costs of a hospital-provided benefits, which is why the insurance premium for a family of four is now more than $21,000 annually. And if a family is generally healthy, a traditional insurance policy is a very expensive way to obtain medical care.

The next “perfect health benefit” is catastrophic care, based on a health share membership. An employee would receive “self-pay” discounts for all non-primary care. For example, an insurance-based childbirth could cost $42,000 with a maximum out-of-pocket expense of $11,000. A cash-priced OB and delivery would be $7,300 and only a $1,000 out-of-pocket expense.

What would a sample benefits package cost the employer, assuming the company would pay for all the benefits? A total of $380 per month is broken down as follows.

A flat-rate pricing would allow an employer to easily determine the cost of hiring a new employee and possibly lure talent from competitors with an innovative way to provide health care, which would mean a higher salary, allowing the employee to pay out of pocket for medical care expenses at deeply discounted prices.

For example, an employee, let’s call him Phil, would choose a DPC physician of his choice and there would be no co-pays or deductibles or additional cost from an executive physical exam to any treatment that could be handled in an office visit. Urgent care visits would be in the office rather than a hospital ER or an urgent care clinic. Phil would also have the ability to call, text, or have a video chat with his doctor 24/7. Other services that Phil could access include diet/nutrition, exercise guidance, and questions about new therapies. In addition, Phil would get basic dental and optometrist checkups as needed and discounts for non-covered procedures.

What would Phil’s out-of-pocket expenses be? Discounted prescriptions in his doctor’s office and recommendations for discounts at other providers. If Phil needed an magnetic resonance imaging (MRI) scan, a local hospital may charge as much as $4,000 paid by insurance (which drives up the cost of traditional insurance premiums), but an out-of-pocket cost for him may be $400 at an affiliated imaging center. And if Phil needs a lipid panel test, which could cost as much as $300, his doctor’s deep discount affiliated lab may charge only $25.

If Phil needs more costly care, what are his options? His doctor may recommend a podiatrist, for example, if a specialist is needed to assess his condition. Phil could then get a consultation for an independent podiatrist, not just a local provider but also one in another part of the country for a telemedicine session. Prices for all the available doctors would be known beforehand so Phil could make a choice and determine which doctor provides the better value.

Most surgeries are elective, which would allow Phil to do research to obtain the best value for his medical care dollars. And finally, a catastrophic insurance policy would protect Phil and his family from a major illness and thus allay any anxiety about exorbitant medical bills.

At https://freedomdoc.care/business/, businesses “of all shapes and sizes can have a FreedomDoc experience” by first obtaining the information they need to make an educated decision about the health care they want to provide employees. Employees too can learn about the FreedomDoc approach (https://freedomdoc.care/memberships/), which puts them and their doctors at the center of medical care decisions instead of expensive traditional employer-based medical insurance.

Criticism of Direct Primary Care

According to Direct Primary Care’s proponents, individuals and families get quality, relatively low-cost health care. Nevertheless, is there any downside to having employees enrolled in a DPC plan? Yes, asserts management professor Timothy Hoff, who focuses on health care systems and health policy at Northeastern University. Hoff does not believe DPC is a “transformative innovation for making primary care more relevant, responsive, and affordable on a large scale.”¹¹

Thus, Huff points out that “direct primary care is self-limiting in how many patients it can serve.” True. That’s what makes DPC attractive to both doctors and patients, practicing medicine the way it is supposed to be, namely, not bound by a 15-minute office visit and having access to your doctor virtually 24/7. Hoff rightly acknowledges that the country is facing a primary doctor access problem and DPC would exacerbate it. He also asserts “too many sicker or needier patients can also be problematic for direct primary doctors, as they require more contact and management.”

However, the goal of DPC, according to Dr. Favini, founder of Forward, is to help patients get and stay healthy, not just having doctors treat them for illnesses. If optimal health is the goal of every individual, then a DPC practice would be a worthwhile health care option for individuals who have chronic illnesses that can be successfully treated by a primary care physician.

Professor Hoff also asserts that the DPC model has an incentive to limit care. He points out DPC doctors obtain their revenue via a monthly retainer and thus take on the financial risk for lab work and screenings. Thus, Hoff concludes, this “imposes significant pressure to keep service utilization, care management activity, and direct contact per patient lower to maximize the profit margin.” He does not offer any data to support his assertion.

Another criticism leveled by Hoff is that patients could pay more for health care if they enroll in a DPC. The cost of the monthly retainer plus additional insurance, which would require co-pays and deductibles, could exceed the cost of having traditional insurance coverage.

Lastly, Hoff makes an interesting criticism of DPC, namely, patients have to take on greater responsibility for their health care. This is not entirely accurate. No matter what type of health insurance individuals have, they have to read the fine print of their policy the employer has chosen for them or read through different policies if they have to choose from one.

In his conclusion, Hoff attempts to minimize the benefits of DPC, because he claims physicians in this practice downplay the role of hospitals and specialists, which are integral components of the health care system. From the DPC literature I have reviewed, this is far from the truth. DPC doctors and websites like FreedomDocs focus on the benefits of a small panel of patients that direct primary doctors serve and the ability to get specialists’ services at deep discounts. Thus, DPC may, in fact, not be a panacea for every company, but it is an option to pursue that could be in the best interests for both employees and employers.

Conclusion

The DPC model is gaining speed across the country. WebMD published, “More Patients Turning to ‘Direct Primary Care,’”¹² highlighting how DPC employers have determined this benefit makes sense for their employees. For example, Mick Lowedermann, father of two small children and owner of the 12-employee pest control business in Wichita, Kansas, contracted with Atlas MD for a cost of $50 monthly fee per employee and customized major medical insurance policy for which he pays $375 monthly per employee. According to Lowerdermann, traditional insurance policy would be double or triple that cost.

The bottom line from employers is that a well-structured DPC benefit package in conjunction with a major medical/catastrophic insurance policy could eliminate having to navigate the medical insurance maze that is expensive and bureaucratic.