Last week I went to a conference: Primary Care in Internal Medicine (PCIM), a week-long educational bonanza at the Kendall Square Marriott (Cambridge MA) run by Harvard teaching hospitals. For five straight days, specialists from Mass General Hospital (MGH), Brigham and Women’s Hospital (BWH), Beth-Israel Deconess Medical Center (BIDMC) and Mount Auburn Hospital (MAH) circled in and out of the conference auditorium to lecture about a wide range of primary care topics, ranging from the foot to the brain and everywhere in between.
While most of the lectures were on the technical aspects of primary care, one
particular one was unique. In his talk ‘The future of primary care,’ John Goodson, course director, Harvard Medical School primary care doctor and founder of Harvard’s
Center for Primary Care Innovation, described with razor-sharp insight how primary care has become the un-favored, underpaid and overworked specialty that it now is. In brief, he pointed to the corruption of thereal-value unit (RVU) –a unit created by economists to ascribe a monetary value to cognitive work—as the basis for the demise of our primary care system. When in the 1980’s the federal government commissioned a team led by MIT healthcare economist William Hsiao to come up with a new reimbursement strategy for Medicare to contain rising costs, the political mechanics of ascribing a dollar value to a doctor’s time gave preferential authority to quick, procedural specialist-oriented billing codes over the more time-consuming, cognitive primary care codes. This RVU imbalance created in the 1980’s is the reason why the average specialist makes two or three times the amount that a primary care doctor makes, and—I might add—why, among other things, the number of graduating doctor’s entering primary care is declining.
What will the future of primary care be—Dr Goodson asked—when the aging population explodes over the next decade while the country’s supply of primary care doctors implodes? Things will have to change.
Among the new models he brought up as potential gap-fillers in the primary care shortage is direct primary care (DPC)—a low-cost, monthly direct pay set-up between the patient and the doctor. In exchange for flat, up-front fee (usually $50-100 a month), patients have more time with and access to their doctor. This provides the doctor with the opportunity to better focus on the individual patient’s needs without the headache of the 25 patient per day rat-race of traditional insurance-based primary care. It also offers more income flexibility to the doctor (who sees as many patients as needed to make his or her desired income). While this type of arrangement has the potential to attract more graduates into the field, he said, it also can lead to greater healthcare disparity. If providers cherry pick patient’s who might be healthier, sick patients might be left to find care only from doctor’s accepting traditional insurance, or worse, to public care.
This has been a common argument that I’ve come across when explaining the model of my practice to people. As my lawyer warned, DPC could lead to catering to the ‘haves’ and leaving behind the ‘have-nots.’
Having worked with several successful DPC practices all across the country—Qliance (Seattle), AtlasMD (Wichita), Gold DirectCare (MA)—I can say with confidence now that DPC is not just for the wealthy. For $50 (or even $30) to $100 per month for all-access primary care, patients often times are faced with a monthly medical bill cheaper than their cable bill. True, they must pay for insurance as well or—if uninsured—for additional labs or medications, but when all of the cost savings from DPC are added up, the money saved (either on co-pays, cheaper insurance or deductible payments) usually comes out to 30 or 40% less than traditional insurance-based medical care. While paying the fee at present does require out-of-pocket funds, I’ve seen impoverished patients say the fee to have ready access to a doctor is worth it. In fact, Dr Ryan Neuhofel (http://neucare.net/) opened his practice serving a less-advantaged population and has now a thriving medical practice. I would go so far as to say that net income is not the major factor for a patient deciding on joining a DPC practice. So much more is involved in choosing a doctor than income level, and if a patient is so destitute that he or she can’t pay the monthly fee, there is nothing stopping a DPC doctor from offering charity care—care which, unlike most Medicaid-accepting MD’s—many DPC’s offer.
DPC is not a model set up for the wealthy. That is concierge medicine. It is a model set up for those who want more time with their doctor, more accessibility via phone or email and less hassle with insurance companies.
Will DPC surpass traditional insurance as a means of payment for primary care? Who knows. Insurance companies are still very wealthy and have much more money to lobby Congress than DPC doctors do.
One thing is for sure: I’m not letting income alone stand in the way of a patient joining my practice. Catering to the wealthy is not why I became a doctor.