Myth Buster, Cash-Only Medicine Edition

Some people have a knee-jerk reaction when asked about direct primary care: “Only the rich can afford direct primary care” and the end result will be “fewer doctors seeing fewer patients”. These statements are true but ironically only in context with the current dysfunctional system that impairs quality by reducing actual patient care time. It’s this patient mill mentality that drives doctors away from a career in primary care, and further exacerbates the problem. Its leads to efficiency delusions like Meaningful Use Stage 2, and ICD-10 billing codes and fast-talking EMR vendors which all to the red tape that makes healthcare so needlessly expensive.

The current insurance-driven primary care system is underfunded and overburdened and gives poorer quality care than a direct care system would. The top 9 conniptions about direct care are as follows:

  1. “Seeing fewer patients will reduce access to primary care.” This concern is valid but only if applied to the current system which is designed to be like an assembly line. Imagine the famous conveyor belt scene in I Love Lucy. If Lucy and Ethel don’t wrap enough candies then fewer candies will be in supply for kids and chocoholics. However,  medical care and the management of complex medical problems is not an assembly line style process and does not absolutely need to be done with an in-person visit. Many patient care encounters could be done over the phone (such as discussing lab results) or other modern electronic form of communication where the physician allowed to defer to his or her medical judgment as to whether the patient needs an in-office visit. For those patients who do belong to a direct care practice, access to care would actually be increased since these practices offer 24/7 direct access to an MD. In our case, we provide their own cell phone number for direct care patients to call. Direct care docs have time to to communicate freely via phone and email. Patients can generally get a same day appointment when needed. And if our practice model were much more widely accepted and initiated then it could put a tourniquet on the doctors bleeding out financially and retiring early.
  2. “Physicians will have LESS incentive to see patients and perform care since they are paid up front.” Again, this concern might be valid for overworked and underpaid physicians on salary within a socialized government health care system. But this is not the case here at Atlas MD. Physicians in a direct care practice have an ownership stake and added responsibility. We need to ensure that our patients are well cared for and that they are satisfied enough with the care and service provided by the practice to maintain their subscription. It’s called incentive and it is that little ingredient that has made capitalism the most viable economic system to date.
  3. “Only the ‘rich’ will be able to afford Direct Primary Care.” Let’s put this in perspective. The cost of cable TV is about $3-4 per day. Many Americans pay $8-16 per day for private medical insurance and they don’t get anything like the services of a direct care practice with 24/7 MD access, same day visits, and office visits of 45-60 minutes or more — not to mention the discounted labs and Rx, and the free tech visits. Perhaps Americans should start asking their insurance companies why direct care services are not covered given the amounts they are already paying. Not that we want to deal with insurance companies. But, if the companies were smart, they would reimburse people with insurance and save money in the long run. On top of that, direct care physicians are allowed to charge discounted fees to patients depending on their economic need and ability to pay in any way they want. Charging patients less than Medicare rates is actually ILLEGAL under current law for physicians who accept Medicare. How crazy is that?
  4. Direct Primary Care patients get better care.” Yes, this is an actual complaint of the direct care model that comes from people who are well aware that the current system severely underpays primary care providers and limits actual time spent on patient care. We are of the opinion that rushing to do anything increases the likelihood of mistakes. Not being able to follow up with patients increases the likelihood of misdiagnoses. Direct care is a model that mitigates these outcomes. If that makes us bad guys, so be it. Let’s start a revolution and get more direct care doctors and more direct care patients and start making these better outcomes the status quo.
  5. Direct Primary Care patients get better service.” This one is absolutely true and is the number one reason why patients sign up for direct care. I’m not sure why it’s a complaint but it definitely comes from people who are aware of how the current system packs waiting rooms and physician’s schedules, leaves people waiting for weeks to months to get appointments, leaves people waiting hours for a rushed visit that lasts a few minutes, often gives little to no after-hours access, and generally treats patients like cattle and physicians like meat. We’ll accept this as a complaint, but it stems from a terrible place. A majority of people use cell phones that cost $50/month. Getting healthcare for that price should not be absurd.
  6. Direct Care physicians just want to get rich.” Okay, this makes a lot of sense. I want to make more money, so I’m going to see fewer patients. The vast majority of direct care physicians take an enormous financial risk to change to this practice model and do so out of desire to actually practice patient care and improve their lifestyle while MAINTAINING their income levels. Contrast this to some – not all – physicians in the current system who see 40 to 50 patients a day with a total patient panel of 3-5 thousand. Seeing this many patients a day leaves little time to do anything more than a cursory interview, and a 7-minute physical exam, with maybe a few more minutes writing prescription refills, referral orders, and a laughingly inadequate chart notation. They then submit a “medium” office visit charge to Medicare or other private insurance which is not high enough to attract much unwanted attention to their bad documentation and poor medical care but enough at $30-50 dollars a visit to generate a substantial income for minimal effort.
  7. “Direct Primary Care will increase health care costs.” Though the short term costs may be higher, direct care can provide more comprehensive medical care and it is comprehensive primary care that has clearly been shown to reduce costs. It provides thorough care (laceration treatment, MRIs, CT-Scans, stitches, ultrasounds) with better outcomes (Time is a vital resource in primary care) through a combination of preventive care, close management of chronic medical conditions, and counseling. Contrast this with the current insurance driven model which pays only per visit and per test or procedure and essentially encourages over utilization without much regard for actual outcome. Besides that, what are patients going to do when they get shoddy service? Healthcare isn’t like restaurants. If you serve me lousy french fries, I’m never coming back and neither is anyone I know. But with healthcare and the nature of HMOs, and network providers, and the urgency of healthcare needs, mediocre service can become banally tolerated.
  8. Direct Primary Care amounts to patient abandonment. This is in regards to doctors transitioning from fee-for-service to direct care. First, is it abandonment if a doctor retires because healthcare is broken? The logic is that if the subscription fee, out-of-pocket, is higher than what a patients wants to pay, we’ve abandoned them. But what if instead, we continued down a path where we can barely keep our lights on and we make a bad diagnosis? No, we didn’t abandon you. We just didn’t notice that when you said something was wrong post-vasectomy, you might have had early stages of testicular cancer. With direct care, we build the patient-doctor relationship, and bring satisfaction and income back to primary care — motivators for future generations of students to join our ranks.
  9. Direct Primary Care is UNETHICAL. Wait, you want to talk about unethical? Spending quality time with our paying patients, and even some who pay only what they can, is grounds for being unethical? We’re sorry, but you’ll need a second direct care doctor or some serious health insurance to pull your head out of your– First, ask yourself, why do primary care doctors need to see 3,000 patients in total, on average 25 patients per day? That’s because of red tape. That’s because bureaucrats and insurance companies have leveraged the inelastic demand for healthcare and colluded to make prices obscenely high and utterly opaque. Then they’ve made it harder for doctors to get paid for the work they do, meaning the doctors have to spend more money and time just getting paid… Why would a doctor train for a decade to embark on such an unsatisfying career?

So what’ll it be? Direct care anyone?