Direct Primary Care Puts Financial Control Back in Physicians' Hands

Concierge medicine and President Obama’s Affordable Care Act may be getting all the headlines, but flying under the radar is the concept of direct primary care (DPC).

With DPC, physician practices charge patients a flat monthly fee — usually around $50 or $60 — for unlimited services in lieu of insurance. The New York Times has called the concept “concierge medicine for the masses,” and according to the Direct Primary Care Coalition, a coalition of direct primary care practices, DPC practices currently serve more than 100,000 patients in 21 states.

Erika Bliss, MD, the chief executive officer of Qliance, a five-clinic DPC practice in Seattle, and co-founder of the Coalition, says awareness of the model has taken off in ways that have even surprised her.

“[The model] has something about it that is very appealing to people,” she explains. “They get that this shows a lot of promise for changing the trajectory of our health care system. And so, word is spreading.”

Making sense

Garrison Bliss, MD, a board-certified Seattle-based physician, is the head of the Coalition. He equates the logic behind DPC to that of consumers and their automobiles.

“Imagine if we relied on auto insurance for primary care for our vehicles — things like fluid changes, tire rotation and wiper blades,” Garrison says. “Think of the paperwork and billing hassles we would endure for each little oil change. The overall cost of auto maintenance would increase to cover the business overhead. Soon, fewer Americans would be able to afford auto insurance, with serious ramifications for liability, setting the stage for a national crisis.”

That logic is not lost on Congress, where H.R. 3315, the Direct MD Care Act, legislation proposed by Reps. Bill Cassidy, MD (R-LA), and Jay Inslee (D-WA), would create a demonstration project allowing Medicare to pay direct monthly fees to practices using the DPC model. A second piece of legislation, sponsored by Sen. Orrin Hatch (R-UT) and Rep. Erik Paulsen (R-MN) would direct the IRS to make DPC fees tax-deductible like other medical expenses, while enabling consumers to use pre-tax health savings account dollars to pay DPC fees.

“We are definitely making headway in Congress,” Erika says. “It’s anybody’s guess what can happen with specific pieces of legislation. But a group of 10 of us providing direct primary care around the country recently convened in Washington and made about 20 congressional visits. And conceptually, everybody got that this is a really good idea, and that we should be enabling it every which way we can.”

Group or individual practices

Erika believes that what is good about the DPC model is that it works for groups of physician practices banding together, or for the individual practitioner. She points out that DPC creates a stable financial model for primary care that allows physicians to do what’s right for their patients without a lot of interference. It also provides a practice with a reliable way to budget.

“A subscription model is probably one of the best business models we can have, because you have a predictable source of revenue, and you can plan for what you’re going to do,” she explains. “You can actually start doing proactive medicine instead of reactive medicine. You can determine what sort of services you can afford to provide for whatever fees you set, and you can promise that to your patients. Then you’re really working for them.”

Erika adds that in primary care, the vast majority of medical practices are one-, two- or three-physician offices, and the key to their success is having enough demand in their respective marketplaces to make it feasible to switch to the DPC model. As such, some practices are starting as a hybrid by offering a DPC option and encouraging patients to make the switch.

Control of your practice

Erika explains that what the DPC model offers is an opportunity for existing independent physicians, whether they’re single provider or multiple provider offices, to control their business in such a way that it functions well and they can remain independent, rather than finding that, financially, they just can’t manage anymore and they have to sell the practice to a hospital.

She also recalls what one of her mentors told her a long time ago that family physicians do whatever their communities need them to do.

“I’ve never forgotten that, because that’s true primary care,” she says. “Every community is different, and physicians need to adapt to the needs of their community. That’s the nice thing about this model, is that it doesn’t treat everybody like they’re the same. It’s the flexibility of this model to adapt to the needs of the purchaser, the patient and the community, that is so great.”