Direct Primary Care - alternative work/life option for FM,IM, Peds

[aaronrodgers]

Hi all,

I've been reading up on direct primary care (DPC) and it seems like a decent alternative payment method/career for primary care providers.

I am wondering what SDN's opinions are based on their own personal experience and anecdoctal knowledge. In summary this is my understanding of DPC:

1. Approximately 600 patient panel (instead of 2500 normally). Because your panel is so small, you see only 6 - 10 patients a day and can give each patient 30-45 mins per visit instead of 15 minutes.

2. Patients pay a monthly membership of 50-100 dollars per month (for example $60*600 pts *12 months= $432,000 per year). DPC overhead costs are extremely low, about 1/3 of net profit. (so 0.33*$432,000 = $142,560) for office space, supplies, hiring 1 MA and 1 office manager. Net profit is thus $432,000 - $142,560 = $289,440.

3. No insurance involved. Therefore no billing, no coding, no prior authorizations. Which is why overhead costs are so low.

Worklife Pros
Slower work pace. Less administrative burden, paperwork, coding. Lower burnout. Be your own boss and set your own schedule. Higher income ceiling. More intimate long-term patient-physician relationships (you know their dog's name). You can serve the poor and underserved

Cons
You have to be available 24/7 to patients via phone, text, and email. You have to create your own network of specialists to refer to patients and manage care coordination (granted this is a normal aspect of private practice anyways). Building up a full panel of 600 takes ~20 months. You have to manage relationships and find wholesale deals for labs, imaging, and medication prescription. You have to deal with advertisments (radio talk shows, billboards, newspapers, local news).

The AAFP endorses this practice model and it seems like it is a legitimate and ethical way to care for the community while cutting out leeching insurance companies so that physicians can escape the administrative burden, pressure to do high volumes, and subsequent burnout.

Direct Primary Care

Read the AAFP's policy statement on direct primary care.

www.aafp.org

In Defense of Direct Primary Care

Direct primary care will continue to grow because it empowers price transparency, quality, and patient satisfaction.

www.aafp.org

Comments from Richard Besser, MD, on Direct Provider Contracting Models

Richard Besser comments in response to the Center for Medicare and Medicaid Innovation's Request for Information on Direct Provider Contracting Models.

www.rwjf.org

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[AMEHigh]

It’s certainly not for me for a variety of reasons....
I take care of uninsured and undocumented patients regularly and that’s what I enjoy so ethically I don’t want to give that up since they often can’t afford a monthly fee. I also do a lot of procedures and ultrasounds so I just don’t think that model would work for me. Lastly and probably most importantly, hell no do I want to be available 24/7. I do give out my cell phone number on occasion, but I love leaving work at work and not worrying about it at all.

Like all jobs in medicine it’s a personal choice.

 

[VA Hopeful Dr]

It’s certainly not for me for a variety of reasons....
I take care of uninsured and undocumented patients regularly and that’s what I enjoy so ethically I don’t want to give that up since they often can’t afford a monthly fee. I also do a lot of procedures and ultrasounds so I just don’t think that model would work for me. Lastly and probably most importantly, hell no do I want to be available 24/7. I do give out my cell phone number on occasion, but I love leaving work at work and not worrying about it at all.

Like all jobs in medicine it’s a personal choice.

When I had a DPC easily half of my patients were blue collar uninsured patients. Honestly that was part of its appeal to me - helping those who made too much for charity care but not enough to have great insurance.

You can also see people for free to your heart's content. Its your practice after all so you make the rules.

DPC is perfect for procedures/ultrasound as you save your patients insane amounts of money doing it as part of the DPC agreement. When I did joint injections, for example, I charged cost for the steroid only. So a knee injection would cost the patient around $15 or so.

I know of a few other DPC practices that do ultrasound, its included in the monthly fee and so are a huge boon to those patients.

Now you're absolutely right about the 24/7 part. It was rarely that bad (I would get 1-2 after hours texts every other day or so), but knowing that it could happen at any time did bug me.

The part I really didn't like was actually running the business. Rent, insurance, payroll, all of that was not something I enjoyed.

 

[aaronrodgers]

It’s certainly not for me for a variety of reasons....
I take care of uninsured and undocumented patients regularly and that’s what I enjoy so ethically I don’t want to give that up since they often can’t afford a monthly fee. I also do a lot of procedures and ultrasounds so I just don’t think that model would work for me. Lastly and probably most importantly, hell no do I want to be available 24/7. I do give out my cell phone number on occasion, but I love leaving work at work and not worrying about it at all.

Like all jobs in medicine it’s a personal choice.

that is a good point about procedures and ultrasound. I don’t know how burdensome 24/7 access can be for a 600 pt panel. Maybe a practicing DPC can comment if there are any on SDN. Edit: just saw the previous post.

ethically, DPC should be satisfactory, but correct me if I am wrong. Low income patients with high out of pocket costs and monthly insurance payments are incentivized to do DPC. It is not concierge medicine catering to the rich.

 

[aaronrodgers]

When I had a DPC easily half of my patients were blue collar uninsured patients. Honestly that was part of its appeal to me - helping those who made too much for charity care but not enough to have great insurance.

You can also see people for free to your heart's content. Its your practice after all so you make the rules.

DPC is perfect for procedures/ultrasound as you save your patients insane amounts of money doing it as part of the DPC agreement. When I did joint injections, for example, I charged cost for the steroid only. So a knee injection would cost the patient around $15 or so.

I know of a few other DPC practices that do ultrasound, its included in the monthly fee and so are a huge boon to those patients.

Now you're absolutely right about the 24/7 part. It was rarely that bad (I would get 1-2 after hours texts every other day or so), but knowing that it could happen at any time did bug me.

The part I really didn't like was actually running the business. Rent, insurance, payroll, all of that was not something I enjoyed.

Overall, did you feel you that there was a notable work/life improvement in DPC as opposed to working at, say, Kaiser? Despite having to be a business owner and providing 24/7 accessibility.

 

[VA Hopeful Dr]

Overall, did you feel you that there was a notable work/life improvement in DPC as opposed to working at, say, Kaiser? Despite having to be a business owner and providing 24/7 accessibility.

I work harder while at work doing FFS for a large health system, but outside the office I am only on call 2 nights/month. I get a handful of calls each night, usually critical labs more than anything else.

With DPC my schedule was more fluid since I wasn't seeing many patients/day (8-12/day versus 20+ in FFS) so there was more down time. But there was also always stuff that needed to be done to keep the practice running - inventory/ordering supplies, keeping up with the office website, advertisement work, paying bills, you get the idea.

 

[AMEHigh]

When I had a DPC easily half of my patients were blue collar uninsured patients. Honestly that was part of its appeal to me - helping those who made too much for charity care but not enough to have great insurance.

You can also see people for free to your heart's content. Its your practice after all so you make the rules.

DPC is perfect for procedures/ultrasound as you save your patients insane amounts of money doing it as part of the DPC agreement. When I did joint injections, for example, I charged cost for the steroid only. So a knee injection would cost the patient around $15 or so.

I know of a few other DPC practices that do ultrasound, its included in the monthly fee and so are a huge boon to those patients.

Now you're absolutely right about the 24/7 part. It was rarely that bad (I would get 1-2 after hours texts every other day or so), but knowing that it could happen at any time did bug me.

The part I really didn't like was actually running the business. Rent, insurance, payroll, all of that was not something I enjoyed.

Yeah I guess I don’t know much of the details to understand the ins and outs of the finances of how a DPC practice could support only uninsured patients.

I just am happy working where I am where I know I can refer my uninsured patients to the specialists that come here and they’ll be seen.

Obviously there’s a lot wrong with our healthcare system in general and there are different options to making access better for everyone.

 

[fldoctorgirl]

Yeah I guess I don’t know much of the details to understand the ins and outs of the finances of how a DPC practice could support only uninsured patients.

Pretty easily. For someone like my father, insurance costs close to $1,000 a month for the crappiest plan with a super high deductible and pretty much nothing covered. Someone like him, who doesn't qualify for free aid but isn't rich enough to pay $1,000/month, can join a DPC practice for even $100 or $200 a month and not have to worry about having to pay a deductible etc whenever he goes to the doctor.

 

[AMEHigh]

Pretty easily. For someone like my father, insurance costs close to $1,000 a month for the crappiest plan with a super high deductible and pretty much nothing covered. Someone like him, who doesn't qualify for free aid but isn't rich enough to pay $1,000/month, can join a DPC practice for even $100 or $200 a month and not have to worry about having to pay a deductible etc whenever he goes to the doctor.

DPC is not medical insurance. Patients who have a DPC physician as their pcp are still going to need insurance if they need more than just basics and that insurance is still not going to cover things. Right now the ACA pretty much mandates that plans cover preventive services. So in general those things are already covered. So your father would still need to pay $1,000/month for insurance in addition to the monthly DPC fee and again that DPC fee doesn't cover fees to see specialists. Sometimes I need to see my primary care patients more than once a month, but that's usually not the case. So where I work like I said patients are able to see us for free or for a few dollars each visit.

Like I said I'm not an expert, but where I work now we take care of patients for free or we take care of them using a slide scale.
Some people can only pay $10 per month for example and the DPC model isn't sustainable for patients that can't pay anything or only a few dollars per month. You would need thousands of patients on your panel, thus then you wouldn't be able to only see 5 patients per day. In addition the DPC model in general doesn't cover more extensive testing, or referrals to specialists. Where I work now we have specialists that see our patients using the free or sliding scale schedule that we use.

There are a lot of problems with healthcare coverage in this country and I do not think DPC will solve that problem on a larger scale, especially for patients who are poor and uninsured. I'm certainly not 100% against the model, but as a primary care physician I do not think it would improve my work-life balance and it doesn't solve the problem of the need of comprehensive coverage for all people.

 

[fldoctorgirl]

DPC is not medical insurance. Patients who have a DPC physician as their pcp are still going to need insurance if they need more than just basics and that insurance is still not going to cover things. Right now the ACA pretty much mandates that plans cover preventive services. So in general those things are already covered. So your father would still need to pay $1,000/month for insurance in addition to the monthly DPC fee and again that DPC fee doesn't cover fees to see specialists. Sometimes I need to see my primary care patients more than once a month, but that's usually not the case. So where I work like I said patients are able to see us for free or for a few dollars each visit.

Like I said I'm not an expert, but where I work now we take care of patients for free or we take care of them using a slide scale.
Some people can only pay $10 per month for example and the DPC model isn't sustainable for patients that can't pay anything or only a few dollars per month. You would need thousands of patients on your panel, thus then you wouldn't be able to only see 5 patients per day. In addition the DPC model in general doesn't cover more extensive testing, or referrals to specialists. Where I work now we have specialists that see our patients using the free or sliding scale schedule that we use.

There are a lot of problems with healthcare coverage in this country and I do not think DPC will solve that problem on a larger scale, especially for patients who are poor and uninsured. I'm certainly not 100% against the model, but as a primary care physician I do not think it would improve my work-life balance and it doesn't solve the problem of the need of comprehensive coverage for all people.

I agree with you that he would still need insurance, but the fact is that many people simply can't afford it. In a perfect world everyone would have insurance, but there are countless people walking around without it because they just can't pay the crazy prices. It's admirable that you are willing to see patients for free or use a sliding scale, but many doctors won't do that. I agree with you that the healthcare system is the problem, and I'm not advocating for DPC being the answer, I just think it's a viable option for a lot of people who simply cannot get insurance. It's attractive for certain populations.

 

[Type2Fiber]

I work harder while at work doing FFS for a large health system, but outside the office I am only on call 2 nights/month. I get a handful of calls each night, usually critical labs more than anything else.

With DPC my schedule was more fluid since I wasn't seeing many patients/day (8-12/day versus 20+ in FFS) so there was more down time. But there was also always stuff that needed to be done to keep the practice running - inventory/ordering supplies, keeping up with the office website, advertisement work, paying bills, you get the idea.

Is the day to day practice of medicine more enjoyable in your current set up? You said you didn't like the business side, which I get, I'm just wondering which environment is more enjoyable in terms of daily clinical work

 

[Espressso]

Super interested in this topic in general so I'm following this.

But I'm pretty naive with this, but for a DPC practice, what happens when your patient has to see specialists? It seems like DPCs are very preventative-focused. But for those patients/clients who need speciality evaluation, is it expected that they all have insurance that would cover that?

 

[AMEHigh]

Super interested in this topic in general so I'm following this.

But I'm pretty naive with this, but for a DPC practice, what happens when your patient has to see specialists? It seems like DPCs are very preventative-focused. But for those patients/clients who need speciality evaluation, is it expected that they all have insurance that would cover that?

Yes it's recommended that you still maintain insurance. DPC doesn't cover ALL expenses such as certain imaging, all prescriptions, hospital visits, surgeries, specialists, etc. If it did, now that would be too good to be true!

 

[Espressso]

Yes it's recommended that you still maintain insurance. DPC doesn't cover ALL expenses such as certain imaging, all prescriptions, hospital visits, surgeries, specialists, etc. If it did, now that would be too good to be true!

Appreciate it. I guess my follow-up would be how exactly does this model limit the scope of health insurance companies, as the AAFP implies.

I admittedly did not watch the OP's posted video from the AAFP, but is the idea to use DPC for preventative and primary care, and only use classic health insurance for more significant stuff such as imaging, expensive prescriptions, surgeries, specialists, etc., as you mentioned?

 

[deleted978973]

Extra pro: You don't have to be board certified.

 

[nimbus]

DPC is not medical insurance. Patients who have a DPC physician as their pcp are still going to need insurance if they need more than just basics and that insurance is still not going to cover things. Right now the ACA pretty much mandates that plans cover preventive services. So in general those things are already covered. So your father would still need to pay $1,000/month for insurance in addition to the monthly DPC fee and again that DPC fee doesn't cover fees to see specialists. Sometimes I need to see my primary care patients more than once a month, but that's usually not the case. So where I work like I said patients are able to see us for free or for a few dollars each visit.

Thank you! This really needs to be emphasized to patients. I saw an ad on FB for a completely online/electronic DPC called SteadyMD that charged $100/mo. Many of the people replying to their ad seemed to think this was the solution to their inability to afford health insurance. Clearly an online DPC doctor can’t help you if you have an MI or break your leg. Heck they can’t even check your blood pressure.

 

[hallowmann]

Thank you! This really needs to be emphasized to patients. I saw an ad on FB for a completely online/electronic DPC called SteadyMD that charged $100/mo. Many of the people replying to their ad seemed to think this was the solution to their inability to afford health insurance. Clearly an online DPC doctor can’t help you if you have an MI or break your leg. Heck they can’t even check your blood pressure.

This is a major flaw that I see in the advertising. Some great examples of DPC I've seen are when the DPC organization actually contracts with businesses or insurance companies to cover employees or insurance customers from the primary care side. It ends up being cheaper on average to have everyone registered with a PCP and to have access to regular doctor's visits, which results in cheaper overall care and improved health, so employers and insurance companies are willing to shell out a little extra per month.

A lot of people will interpret DPC as meaning they don't need insurance, and they'll be devastated when they actually have something that goes wrong or have to pay $4k for an MRI. Primary care, at least in my area, tends to be some of the cheapest aspects of medical care, with many insurances allowing for free or even ~$10 copays for PCP visits. With the exception of offering procedures and being available whenever so people don't have to shell out more money at an urgent care (or an unnecessary ED visit), I don't really see how this saves individual patients much money (at least in a way other than any other family med doc saves their patients money).

I can see why its good for the doctor, obviously, but I don't see how its the solution to all the problems in the American healthcare system.

 

[VA Hopeful Dr]

Is the day to day practice of medicine more enjoyable in your current set up? You said you didn't like the business side, which I get, I'm just wondering which environment is more enjoyable in terms of daily clinical work

It depends on what you like. I enjoy being very busy, so most days I prefer the 20+ patients I see doing FFS.

 

[VA Hopeful Dr]

Super interested in this topic in general so I'm following this.

But I'm pretty naive with this, but for a DPC practice, what happens when your patient has to see specialists? It seems like DPCs are very preventative-focused. But for those patients/clients who need speciality evaluation, is it expected that they all have insurance that would cover that?

Depends. Most DPC offices will negotiate special rates for imaging/specialists in their area. I did that with a fair number. For example: local ENT group would charge my patients a flat $100 for a new patient visit. Local imaging center was $25 for x-rays, $125 for u/s, $400 for CT, $500 for MRI.

 

[VA Hopeful Dr]

Appreciate it. I guess my follow-up would be how exactly does this model limit the scope of health insurance companies, as the AAFP implies.

I admittedly did not watch the OP's posted video from the AAFP, but is the idea to use DPC for preventative and primary care, and only use classic health insurance for more significant stuff such as imaging, expensive prescriptions, surgeries, specialists, etc., as you mentioned?

Yep. There are even a few smaller insurance companies that have created insurance plans geared specifically towards patients who use a DPC doctor.

 

[VA Hopeful Dr]

This is a major flaw that I see in the advertising. The best examples of DPC I've seen done right are when the DPC organization actually contracts with businesses or insurance companies to cover employees or insurance customers from the primary care side. It ends up being cheaper on average to have everyone registered with a PCP and to have access to regular doctor's visits, which results in cheaper overall care and improved health, so employers and insurance companies are willing to shell out a little extra per month.

The truth is that a lot of people will interpret DPC as meaning they don't need insurance, and they'll devastated when they actually have something that goes wrong or have to pay $4k for that MRI. Primary care tends to be some of the cheapest aspects of medical care, with many insurances allowing for free or even ~$10 copays for PCP visits. With the exception of offering procedures and being available whenever so people don't have to shell out more money at an urgent care (or an unnecessary ED visit), I don't really see how this saves individual patients much money (at least in a way other than any other family med doc saves their patients money).

I can see why its good for the doctor, obviously, but its not the solution to problems in the American healthcare system.

In 2 years I never saw a patient who thought DPC meant they didn't need insurance.

As for how DPC saves money, well that's easy:

1. Cheap labs - DPC almost universally contracts with labs to get huge discounts. For example: my usual yearly lab work consisting of a lipid profile, CMP, and CBC if I use my insurance runs around $100-125. With my old DPC pricing, it would be $14. I have patients complain when the bill comes for a PSA as its usually around $70. DPC pricing is $9.

2. Cheap imaging - Many of us did similar with imaging. My patients paid $500 for MRIs, for example. When I did UC work, a simple x-ray, with read, would run people around $150. DPC pricing was $25.

3. Prescriptions - The majority of DPC offices offer in-house medication dispensing. Most generic drugs are surprisingly cheap. I was able to beat the Wal-Mart $4 list by quite a bit. I had about 20-ish meds that I used regularly that were less than $1/month.

4. The days of free/low copay for primary care are quickly coming to an end. Increasing numbers of people have higher deductibles than ever before. That means they are essentially paying cash for primary care.

5. I think you're underestimating the value of avoiding an ED visit. I had a patient a few years ago (before they signed up with me) who had to go to the ED for a laceration one evening (all the urgent cares were closed). Even with insurance, he had to end up paying around $1000 to get that repaired. That $1000 would have covered 2 years of my services.

 

[hallowmann]

In 2 years I never saw a patient who thought DPC meant they didn't need insurance.

As for how DPC saves money, well that's easy:

1. Cheap labs - DPC almost universally contracts with labs to get huge discounts. For example: my usual yearly lab work consisting of a lipid profile, CMP, and CBC if I use my insurance runs around $100-125. With my old DPC pricing, it would be $14. I have patients complain when the bill comes for a PSA as its usually around $70. DPC pricing is $9.

2. Cheap imaging - Many of us did similar with imaging. My patients paid $500 for MRIs, for example. When I did UC work, a simple x-ray, with read, would run people around $150. DPC pricing was $25.

3. Prescriptions - The majority of DPC offices offer in-house medication dispensing. Most generic drugs are surprisingly cheap. I was able to beat the Wal-Mart $4 list by quite a bit. I had about 20-ish meds that I used regularly that were less than $1/month.

4. The days of free/low copay for primary care are quickly coming to an end. Increasing numbers of people have higher deductibles than ever before. That means they are essentially paying cash for primary care.

5. I think you're underestimating the value of avoiding an ED visit. I had a patient a few years ago (before they signed up with me) who had to go to the ED for a laceration one evening (all the urgent cares were closed). Even with insurance, he had to end up paying around $1000 to get that repaired. That $1000 would have covered 2 years of my services.

Fair enough, but I'd wager you probably made it clear to them that insurance was still necessary. There are likely some situations where it could be cheaper, and probably more importantly some regions. I suspect region/competition varies quite a bit with regards to cost of certain labs and imaging, let alone insurance copays.

Fortunately in my area, PCP visits still run ~$10-$20 at most, and no one has ever complained that their PSA was too expensive. People in my area have 2 options for non-medicare insurance, and the ones who would be able to afford $60/mo have the insurance that makes most labs in the $10-$50 range unless its something ridiculously rare. Same with imaging, rarely >$200 unless they have medicare.

How common is the contracting with imaging? I know people that have purchased/rented their own C-arms for fluoroscopy and X-rays, but that also meant that they were reading those images themselves.

I suppose if I could make those types of deals with labs and imaging companies it could be worth it, but it would also mean having to renegotiate with those companies, and potentially losing options or sites periodically if prices change much. I can see why the business aspects would be a pain as well when you still have to see 10 pts a day on top of it.

 

[deleted547631]

I’m glad the DPC model exists and I think it’s a fantastic way for FM docs that might be burned out from working for a large employer to transition into a potentially more lifestyle friendly mode of practice. It’s a viable way out from the medical megacorp rat race.

 

[FluidStaccato]

Interesting thread. I’m a PCP who recently opened up my own practice here in the super saturated market of South Florida. I’ve been trying to credential with the major insurers for > 1 year with virtually no luck outside of Medicare. I actually enjoy running a business and being the “king of my own kingdom” as opposed to a pawn in the corporate machine. In any case, given the circumstances of being essentially locked out of insurance panels, I’ve given DPC and concierge some serious consideration. Ideally this is not the type of practice I would want to run but one that I find myself being forced to consider given the circumstances.

 

[libertyyne]

I agree with you that he would still need insurance, but the fact is that many people simply can't afford it. In a perfect world everyone would have insurance, but there are countless people walking around without it because they just can't pay the crazy prices. It's admirable that you are willing to see patients for free or use a sliding scale, but many doctors won't do that. I agree with you that the healthcare system is the problem, and I'm not advocating for DPC being the answer, I just think it's a viable option for a lot of people who simply cannot get insurance. It's attractive for certain populations.

There are cash based models where the patient only pays the fee when they go to see the doctor. Like 50-100 dollars per visit. There is no monthly reoccurring charge. This already exists and does fill the need for people that cant afford much. But the problem is going to come along when they end up needing expensive testing, procedures or hospitalizations.
DPC in essence provides unfettered access to people to a physician 24/7 for a fixed monthly fee which is appealing to people. And nothing wrong with that. Even some of the people who cant afford insurance or would be spending too much for monthly visits to a cash only practice it would make sense. But it really isnt solving the underlying issues of access for most people. And is giving a nice option to people who can afford insurance with either massive deductibles or more of a concierge feel.

 

[libertyyne]

Interesting thread. I’m a PCP who recently opened up my own practice here in the super saturated market of South Florida. I’ve been trying to credential with the major insurers for > 1 year with virtually no luck outside of Medicare. I actually enjoy running a business and being the “king of my own kingdom” as opposed to a pawn in the corporate machine. In any case, given the circumstances of being essentially locked out of insurance panels, I’ve given DPC and concierge some serious consideration. Ideally this is not the type of practice I would want to run but one that I find myself being forced to consider given the circumstances.

What are some of the barriers for gaining access to major insurers?

 

[FluidStaccato]

What are some of the barriers for gaining access to major insurers?

I can only speak from my experience as an independent primary care physician in South Florida.

In order to gain access you have to go through a credentialing process where the insurers review your credentials as a physician and evaluate that in comparison to their need in a particular market. At the end of he day however it often just comes down to who you know in the insurance company that has the authority to credential you so that you can be reimbursed by the insurer. I have tired credentialing myself with the top 8 major insurers in this area. After a 6-12 month back and fourth, all 8 of those insurers, except for medicare, have rejected my application for credentialing. Mind you I am double board certified, have no criminal hx or pending/past litigations, and attended an accredited medical school in the US. The reason I am unable to be credentialed according to the insurance companies is because, "the panels are full". Mind you there are other physicians with the same or similar credentials joining bigger groups or other corporate entities that become credentialed in this area within a few weeks.

I am now paying a company to do my credentialing for me with the hope that they have more connections with people on the inside of the insurance companies than I do. Time will tell if anything pans out however over the last 2 months I have yet to hear anything positive from them. In short, your ability to become credentialed with insurance companies will be more difficult if you go at it alone and much of it is based on who you know. Of course this can change based on your specialty and the market you live in.